I thank the Chairman and members of the committee for the invitation to discuss the report of the Working Group on Access to Contraception. As the Chairman has noted, I am joined by Ms Kate O'Flaherty, who is head of health and well-being in the Department of Health; and Ms Maeve O'Brien, who is the acting programme head of the HSE sexual health and crisis pregnancy programme. I intend to outline briefly the background and context to the group's work before highlighting some of the key findings of the report and possible policy options the committee may wish to consider.
The Minister established the working group in April 2019 to consider the range of policy, regulatory and legislative issues that arise as he seeks to improve access to contraception. The establishment of the group was primarily a response to the ancillary recommendation of the Joint Committee on the Eighth Amendment of the Constitution that "a scheme for the provision of the most effective method of contraception, free of charge and having regard to personal circumstances, to all people who wish to avail of them within the State" should be introduced. It also reflected the commitment of the Minister and the Department to improving women’s experience of healthcare in Ireland. It should be seen in the wider context of the establishment of the women's health task force and the work the Department is currently undertaking.
The working group comprised officials from relevant policy areas within the Department, including the Office of the Chief Medical Officer and the community pharmacy, bioethics, research, health and well-being, eligibility and primary care units. I emphasise that this was not a closed departmental exercise. Consultation was an intrinsic part of the group's work. More than 5,000 responses were received in response to a public consultation exercise. Approximately 3,500 of these submissions were fully completed. The group directly met several key stakeholders, including the Irish College of General Practitioners and Irish Family Planning Association. I would like to take this opportunity to thank everyone who engaged with the work of the group, especially the stakeholders who met us or submitted detailed submissions to us, or both. They greatly informed the group's work and the report.
The first key finding of the report is that barriers to accessing contraception exist for some people. It identifies the most prevalent obstacles as lack of local access, cost, embarrassment, inconvenience and lack of knowledge. It is evident that contraception use in Ireland is high and stable and that difficulty accessing contraception is a challenge at the margins in overall population terms. The notion that there is a sizable affordability challenge across the population as people seek to access contraception remains unproven. A number of policy levers are available to the Government as it seeks to overcome the barriers that exist. There is considerable support among stakeholders for the introduction of a universal, State-funded scheme for contraception. The cost of introducing such a scheme is indicatively estimated at between €80 million and €100 million. This is a significant sum and leads naturally to the question of whether such investment would represent the best use of resources.
As the committee will appreciate, there is a substantial list of health service development proposals across the spectrum of prevention, primary and community care and the acute hospital system. Strong cases for additional investment can and have been made in respect of such proposals. In addition to this opportunity cost, there is a real risk that making contraception free to end users will simply displace or substitute for private expenditure. Equally, the view that free contraception will lead to a significant reduction in the number of crisis pregnancies may be over-optimistic.
Any policy initiative in this area should be seen as a behavioural intervention and must go beyond the question of cost to address issues of local accessibility, education and workforce capacity, all of which are considered in the report.
In terms of accessibility, the report examined in particular the potential role of community pharmacists in prescribing contraception, seeking to balance the need for easier access to services with the risk of contraindications and the positive health factors associated with continuity of care. The report recommended that oral contraceptives could be prescribed for a 12-month period to improve accessibility while maintaining patient safety, which would have the additional benefit of reducing costs to the State.
Education is highlighted as key to tackling lack of information, misinformation and embarrassment around contraception. The review of relationships and sexuality education, RSE, curriculum is under way and is welcome, but there will also be a need for wider public information campaigns, possibly under the Healthy Ireland banner. Positive steps are being taken in this area, for example, through the sexual well-being website, but it is important that we build on this work to ensure that we are reaching and informing as many people as possible. It also will be necessary to continue to build our workforce capacity to ensure that we have a sufficient number of trained healthcare providers to deliver safe and accessible contraception services.
The report concludes that there will always be some doubt as to whether a State-funded contraception scheme represents the optimal use of funds on a purely cost-benefit basis. However, it is clear that there are considerations beyond the economic that need to be taken into account when formulating policy in this area. These include: the human and women's rights dimension of contraceptive access; the policy context following the introduction of termination of pregnancy services; and the potential health benefits. It is these social or societal factors that led the group to suggest that further exploration of policy proposals to support contraception may be warranted and three possible options for further consideration are identified. These are a universal State-funded contraception scheme based on the current General Medical Services, GMS, scheme but including the copper coil; the expansion of the GMS scheme as it relates to long-acting reversible contraception, LARC, to all women; or a phased approach to the introduction of a free contraception scheme, beginning with younger women, possibly in the 17 to 24 years age range.
The order in which the options were presented does not imply a ranking of preference, and the group intended that they be viewed as possible directions of travel for further consideration rather than as fixed recommendations with set parameters. Clearly, the development of these or other proposals would require further detailed policy and legislative work, as well as consultation with service providers.
It is important to recognise that the issues discussed in the report relate to just one aspect of the wider strategy to support sexual and reproductive healthcare. The Department of Health and the HSE, in collaboration with stakeholders, are progressing work in a number of areas identified by the joint committee in respect of sexual health promotion and education. This includes the expansion of the free provision of condoms to at-risk groups, while the HSE will be repeating the in-depth general population survey on sexual health and crisis pregnancy to provide us with up-to-date information to support policy development and implementation. The development of the national sexual health strategy will also commence in 2020.
The Minister believes that this committee is in a position to make a valuable contribution in charting a path forward that responds to the challenges and cost implications outlined in the report, while seeking to ensure that we can facilitate access to contraception and strengthen sexual and reproductive healthcare in Ireland more generally. Hopefully, the discussion this morning can advance that aim.