Hidratos de carbono

Underlying the discussion in this chapter is the understanding that health policy formulation and implementation is influenced and shaped by the interactions between state controlled funding and policy agencies, managers, healthcare professionals, patients, interest groups, and the wider community. Consequently, elements of both ‘top-down’ and ‘bottom-up’ policy development need to be acknowledged in any analysis of the policy process in the field of ART. ART policy in Aotearoa/New Zealand has been formulated using an ad hoc, reactive, and case- by-case approach as new or challenging issues have arisen over ART service provision. Many reports from various committees and commissions have called for public debate and an overseeing organisation to advise and monitor ART practices and developments. However, no such administrative body has been created and the only official bodies involved in the control and regulation of ART practices are the Reproductive Technology Accreditation Committee of Australia (RTAC) and National Ethics Committee on Assisted Human Reproduction (NECAHR). These two committees operate independently and are not accountable to each other. Although the Status of Children Amendment Act 1987 (SCAA) remains the only piece of legislation that explicitly deals with ART, there are many existing regulations and statutes that could be used in relation to legal issues arising from ART practices. These include professional codes of practice and legislation specific to the health and medical sector, as well as legislation relating to adoption and human rights.

During the last five years, two bills have been introduced to Parliament that propose varying degrees of legislative regulation and control over currently practiced assisted reproductive techniques, as well as potentially harmful ART developments. Although these bills have been considered by Parliamentary Select Committees for a combined total of five years, they have had the due date for their report/s extended on numerous occasions and there is no guarantee that they will be tabled before this thesis is submitted.72 _{Delays in reporting on the two bills}

72 _{A check of the Office of the Clerk of the House of Representatives’ website ‘Bills before the Select}

Committees’ (http://www.gp.co.nz/wooc/npaper/select-committee-bills.html), prior to submitting this thesis, indicated that the due date has again been extended and the report is now due on the 31 May 2002.

have been explained as systemic and procedural. However, it is more likely that the delays have been influenced by the fact that the issues are politically contentious and involve state interest in matters that are generally considered private. Although issues surrounding the use and development of ART may be politically difficult to resolve, the lack of action by successive political parties and coalitions has meant that the resolution of many social and ethical concerns remain dependent on the attention and discretion of providers, NECAHR, and RTAC. Embryo donation, sex-selection, and surrogacy are all areas that require further public debate and consideration. Controlling the introduction and application of these practices currently remains dependent on providers applying to NECAHR for approval of their use and then complying with NECAHR’s decisions.

While both the Yates and Graham Bills propose the banning of certain unethical procedures, they differ over the level and structure of oversight for ART practices. The Yates Bill proposes that fertility clinics be licensed and aims to establish a licensing authority which will control and monitor the provision of ART services. However, the Graham Bill proposes a policy structure similar to the one currently in effect and, although NECAHR is given statutory recognition and its role is expanded, the committee remains under the control of the Minister of Health. The bills differ over the level of attention they give to surrogacy and the recognition they give to the Treaty of Waitangi (te Tiriti o Waitangi). They also reflect the polarisation of issues around the clinical applications and the potentially harmful aspects of specific techniques. Some commentators have expressed concern that prescriptive legislation would restrict the use and development of any technological advances in assisted reproduction. They have suggested that the establishment of a government appointed organisation to oversee and monitor such developments and ART practices would provide a more flexible and timely form of control. Although not established as an ART policy organisation, NECAHR has taken on this role by default. Consequently, ethical decisions, which should form the basis of policy in conjunction with other fields of knowledge and experience, have become de facto policy decisions. The ambiguity in NECAHR’s role, combined with difficulties in predicting the future consequences of certain practices, political expediency, limited finances, timeframes, and information, as well as the flexibility offered, have all contributed to a case-by-case decision-making approach, which lacks legislative support. The lack of consumer representation on NECAHR also raises concern over the marginalisation of the experiences of those with fertility problems in the formulation and implementation of policy and ethical decisions. NECAHR has no legislative power to support and enforce their decisions and this has raised concerns with the committee, as well as

other commentators. However, some providers believe accreditation requirements for RTAC are sufficient to ensure compliance. RTAC is an Australian based organisation that is not answerable to any Aotearoa/New Zealand agency or authority and has no statutory ability to enforce its accreditation requirements or sanctions. Although recommended by MCART and supported by many other commentators in the field, a Aotearoa/New Zealand supplement to RTAC’s ‘Code of Practice’ has not eventuated and New Zealander’s involved in ART practices have little assurance that these practices will be monitored and regulated in line with local cultural and political values and principles.

Providers do not appear to be resistant to compulsory accreditation or the creation of some form of policy development body that would oversee and coordinate policy initiatives and developments in ART. However, despite repeated calls for such an organisation, it has not eventuated. If the Graham Bill remains the preferred option for legislating ART practices, it is unlikely that such a body will be established in the near future. It is highly likely that NECAHR will be reconstituted to officially recognise the policy-focused role it has undertaken in the last few years. Consequently, the status quo will be maintained and ethical and policy decisions will be combined and implemented using a case-by-case approach. Alternatively, the establishment of an ART focused policy body would offer oversight to the ART arena and provide a sense of accountability and responsibility in relation to policy decisions. Such an organisation could also co-ordinate the interrelated roles and functions of NECAHR and RTAC in relation to ART and could oversee the implementation of policy and ethical decisions in the clinics. It would enable the voice of consumers and providers, as well as other interested publics, organisations, and individuals, to be heard.

While this chapter has focused primarily on the initiatives and implementation of ART policy from a ‘top-down’ perspective, I do not disregard the consequences and significance of ‘bottom- up’ policy processes. The interpretation and observance of ART policy protocols and guidelines by providers, consumers, and involved groups and individuals has an influential effect on policy formulation and implementation. The following chapter will investigate how the ad hoc development of public funding for ART services has entrenched regional inconsistencies and inequities in funding and access.

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Allocating Resources