Willingness to pay for assisted reproductive technologies among individuals with infertility in China.

Infertility is defined as the “failure to achieve a pregnancy after 12 months or more of regular unprotected sexual intercourse” ( Vander Borght and Wyns 2018 , World Health Organization 2023a ). The prevalence of infertility is ∼17.5% globally and 23.2% in the Western Pacific Region ( World Health Organization 2023b ). Infertility not only has negative impacts on patients’ physical and mental health, but also imposes considerable financial burdens on households, frequently resulting in catastrophic health expenditures due to out-of-pocket treatment costs ( World Health Organization 2023a ). As infertility treatment services are a core component in promoting sexual and reproductive health and fulfilling essential human rights, the provision of available, affordable, and high-quality fertility care has been recognized as an important objective of health systems. However, prohibitive costs remain a major barrier to accessing fertility care, particularly assisted reproductive technologies (ARTs) ( Dyer et al . 2013 , Seifer et al. 2018 , Njagi et al . 2023 ). Several high-income countries, such as Australia and the UK, cover some of the costs of ART services through public subsidies or social health insurance schemes, significantly reducing patients’ out-of-pocket expenses for infertility treatment ( Chambers et al . 2009 , International Federation of Fertility Societies 2022 ). However, most low- and middle-income countries (LMICs) lack public financing mechanisms for ART. Consequently, individuals with infertility in these settings face high risks of catastrophic health expenditure ( Njagi et al . 2023 ). The global rise in infertility will increase demand for ART, highlighting the need to implement targeted financial interventions to improve equitable access to fertility care ( Liang et al . 2025 ). It is therefore critical for governments in LMICs to consider public funding for ART. Willingness-to-pay (WTP), the maximum amount an individual is willing to pay for a given service or health improvement ( Lin et al . 2013 ), is a widely used tool to assist healthcare policymakers in determining which health technologies should be prioritized for coverage under public health insurance schemes ( Facey et al . 2017 , Keller et al . 2023 ). It reflects the monetary value individuals place on health technologies and can inform thresholds for health technology assessment. However, a previous systematic literature review found that only limited research was performed to investigate WTP in LMICs ( Fenwick et al . 2023 ). Among 17 empirical WTP studies, most were conducted in the USA, Australia, Israel, Brazil and European countries ( Fenwick et al . 2023 ). Only one study focused on women with infertility in Hong Kong, China ( Lai et al . 2021 ). Research on WTP for infertility treatment in mainland China and LMICs remains scarce. The review also found that there were no standard WTP benchmarks for ARTs, and that factors associated with WTP included treatment outcomes, age, education level, and income ( Fenwick et al . 2023 ). There is an urgent need to estimate WTP thresholds for infertility treatments based on well-defined outcome measures, such as clinical pregnancy or live birth. China, the largest LMIC in the world, has an infertility prevalence of ∼25% among couples of reproductive age ( Zhou et al . 2018 ). The ARTs, including artificial insemination (AI), in vitro fertilization (IVF), and preimplantation genetic testing (PGT), are approved by the National Health Commission of China for the treatment of infertility ( Bai et al . 2020 , National Health Commission of the People’s Republic of China 2025 ). Although the availability, efficacy, and safety of ART in mainland China are comparable to those in the USA and European countries, access to ART in China remains a challenge for patients with infertility due to the exclusion of ART costs from health insurance schemes ( Bai et al . 2020 , Qiao et al . 2021 ). In China, the clinical pregnancy rates for AI, IVF, and PGT are ∼20%, 50%, and 60%, respectively ( Zhang et al . 2022 ). However, the high costs of ARTs—around renminbi (RMB) 5000–8248 ($1253–2067) for AI, RMB 20 000–80 000 ($5013–20 050) for IVF, and RMB 30 000–90 000 ($7519–22 556) per cycle for PGT—are important barriers for individuals with infertility ( Bai et al . 2018 , Qiao et al . 2021 , Wang et al . 2022 ). Over the past decade, both academic researchers and the public have advocated for ART subsidies through public funds or health insurance schemes ( Wang et al . 2022 ). Since 2023, select ART procedures have been included in China’s health insurance benefit package ( Global Times 2025 ). The government has made efforts to identify ART services with high cost-effectiveness for prioritization in health insurance coverage and to determine appropriate reimbursement rates, pricing mechanisms, and coverage ceilings. In this context, assessing WTP for ART among individuals with infertility is crucial to inform health insurance reimbursement decisions. Given the absence of established WTP for ART in China, this study aims to estimate WTP values and identify their determinants, thereby addressing a critical evidence gap to inform future policymaking and health technology assessment.

The data collection process was conducted as planned. The response rate was ∼80%, with the main reasons for refusal to participate being lack of time and the stigma associated with infertility. A detailed overview of the participants’ demographic and socio-economic characteristics is presented in Table 1 . A total of 570 respondents completed the formal survey, with a mean age of 33.0 years and a predominance of female participants (94.4%). Nearly a quarter of the participants had an educational level of middle school or below (26.1%), while more than one-third had attained a university education. Most respondents were covered by basic health insurance (97.2%), although the majority did not enroll in supplementary health insurance (91.9%). With regard to the cause of infertility, female factors (37.5%) were more commonly reported than male factors (22.8%) or unexplained factors (23.0%). Geographically, the largest proportion of respondents were from Shandong (37.7%), while the smallest proportion were from Ningxia (9.8%). Sociodemographic and disease characteristics of study participants. Supplementary health insurance includes private medical insurance, government medical insurance, medical assistance programs, and other employer-based supplementary insurance schemes. SD, standard deviation; URRBMI, Urban and Rural Residents’ Basic Medical Insurance; UEBMI, Urban Employees’ Basic Medical Insurance. The predicted WTP is shown in Table 2 . The mean WTP for one IVF cycle in Scenario A was RMB 30 163 (US $4259, 95% CI: RMB 29 650–30 675), equivalent to 0.34 times the GDP per capita. For one AI cycle in Scenario B, the predicted WTP was RMB 6046 (US $854, 95% CI: RMB 5987–6106), equivalent to 0.07 times the GDP per capita. Notably, the highest WTP among all technologies was observed for PGT in Scenario C, with an average WTP of RMB 47 234 (US $6669, 95% CI: RMB 46 435–48 033), equivalent to 0.53 times the GDP per capita. WTP for ARTs based on pregnancy rate among study participants. ART, assisted reproductive technologies; IVF, in vitro fertilization; AI, artificial insemination; PGT, preimplantation genetic testing; RMB, renminbi; US dollar, 2023 US dollars converted using exchange rate; 95% CI, 95% confidence interval. a Gross domestic product per capita in China 2023. Table 3 presents the results of interval regression analysis examining factors associated with WTP for ART. Notably, respondents’ age was negatively associated with WTP across all scenarios ( P < .05), indicating that older individuals with infertility tended to report lower WTP for reproductive treatment. The relationship between education level and WTP was significant only for PGT. Respondents with a university degree or higher were willing to pay RMB 6609 more than those with a middle school education or lower ( P < .05). The cause of infertility also showed a significant correlation with WTP. For IVF and PGT, respondents with male-factor or unexplained infertility reported lower WTP than those with female-factor infertility. Finally, cost communication with physicians was positively associated with patients’ WTP: compared with no communication, those reporting communication about cost had increased WTP of RMB 613 for AI and RMB 8814 for PGT, respectively. Factors associated with WTP for different ARTs: interval regression results. IVF, in vitro fertilization; AI, artificial insemination; PGT, preimplantation genetic testing; AIC, Akaike Information Criterion; BIC, Bayesian Information Criterion. a Dependent variables captured from CVM were converted into interval-censored data. * P < 0.05. ** P < 0.01. *** P < 0.001.

We found the WTP among individuals with infertility in China was equivalent to 0.34 times GDP per capita for IVF, 0.07 times for AI, and 0.53 times for PGT, respectively. This study helps bridge the evidence gap in WTP for ART in China. These findings indicate strong support for including ART in the benefit package to prevent families from incurring financial catastrophe when accessing fertility services. These findings also inform that the government should establish appropriate cost-effectiveness thresholds and reimbursement ceilings for ART to improve affordability. Furthermore, we confirm that age and education are factors influencing WTP and provide new insights into WTP’s determinants, such as causes of infertility and patient-physician communication about cost. Given the potential overestimation bias in WTP resulting from sampling patients currently undergoing ART, future studies should conduct surveys among the general public and other stakeholders to obtain a broader consensus on the WTP for ART.

This study estimated the WTP for three ART techniques among Chinese individuals with infertility using the CVM, and examined the factors associated with WTP. We found that the WTP varied significantly across the three techniques, ranging from 0.07 to 0.53 times the GDP per capita. Furthermore, age, education level, diagnosis of infertility, and cost communication were significant determinants of WTP for ART. The mean WTP for PGT and IVF was considerably higher than that for AI, reflecting a potential association between WTP and the success rate of each ART. This finding was consistent with previous studies ( Settumba et al . 2019 , Fenwick et al . 2023 , Keller et al . 2023 ). Specifically, the WTP for one IVF cycle among Chinese individuals with infertility was equivalent to 0.34 times the GDP per capita. Several publications have reported the WTP for one IVF cycle in other countries, such as Australia (0.09 times the GDP per capita) ( Ryan 1996 ), UK (0.22–0.96 times the GDP per capita) ( Ryan 1997 , 1998 , 2004 , Abdulrahim et al . 2021 , Skedgel et al . 2022 ), Israel (0.08–0.15 times the GDP per capita) ( Spiegel et al . 2013 , Gonen 2016 ), Brazil (0.69–0.85 times the GDP per capita) ( Lima et al . 2020 ), Spain (0.55 times the GDP per capita), and the USA (0.42 times the GDP per capita) ( Skedgel et al . 2022 ). Generally, the WTP for IVF among patients with infertility ranged from 0.09 to 0.96 times the GDP per capita across different settings (see Table 4 ). As Fenwick summarized, the lack of a standard or consensus on the WTP for IVF is partly due to methodological heterogeneity and variation in the clinical outcome measures (e.g. pregnancy vs. live birth rate) ( Fenwick et al . 2023 ). Comparison of WTP for IVF across countries/regions between 1996 and 2022. IVF, in vitro fertilization; WTP, willingness to pay. a Gross domestic product per capita in the publication year. In our study, the WTP for IVF among individuals with infertility in mainland China was lower than that in Australia but higher than that in Brazil, Spain and the USA. Several potential reasons may account for this variation. First, differences in study design and methodology used to estimate WTP—CVMs and outcome measures—may influence the results ( Fenwick et al . 2023 ). Second, IVF success rates and costs varied across countries and regions. A common trend is that WTP tends to increase with both higher success rates and greater treatment costs ( Neumann and Johannesson 1994 , Settumba et al . 2019 , Abdulrahim et al . 2021 ). Third, respondents’ attitudes toward infertility may have important impacts on WTP. A previous multi-country survey showed that public support for ART in China was significantly higher than in many other countries ( Skedgel et al . 2021 ). Fourth, the coverage or reimbursement of ART costs by public funds or health insurance schemes may also affect WTP. The costs of ART were fully reimbursed in Israel and the UK, partially reimbursed in Australia, Spain and the USA, and not reimbursed in China until 2023 ( International Federation of Fertility Societies 2022 ). Consistent with previous studies, our findings confirmed that patients’ age and education level are significantly associated with WTP. Generally, older individuals with infertility were willing to pay less for ART compared with younger patients ( Fenwick et al . 2023 ), possibly due to the lower clinical pregnancy and live birth rates of ART associated with advanced maternal age ( Vitagliano et al . 2023 ). Moreover, patients with a university education or higher degree were found to be more willing to pay for PGT than those with lower education levels, even after controlling for covariates such as income. Two potential explanations may account for this finding. First, individuals with infertility who have higher education levels usually have more health literacy and knowledge about PGT, which has been identified as an important determinant of WTP for health services ( Steigenberger et al . 2022 ). Second, individuals with infertility with higher education usually exhibit positive attitudes toward the use of PGT ( Steigenberger et al . 2022 ). Notably, although studies from other countries have reported a positive association between higher educational attainment and WTP for IVF ( Fenwick et al . 2023 ), no significant differences were observed among educational groups in this study. This may be attributed to sample characteristics. Participants in this study were individuals with infertility undergoing embryo transplantation or AI. They had not only strong fertility desires but also access to IVF, suggesting that the service was financially affordable for them. Therefore, the individuals with infertility included in this study were likely wealthier than the general public in other studies. Furthermore, the income per capita of the sampled respondents in this study (RMB 44 381) exceeded that of the general Chinese population (RMB 39 218) in 2023 ( National Bureau of Statistics of China 2024 ). This suggests that the participants in our sample may have a relatively greater ability to pay for ART. Furthermore, we found the WTP for ART varied across different causes of infertility. Infertile couples with male factors or unexplained infertility reported lower WTP for IVF and PGT than those with female-related infertility. One possible explanation is that diagnostic testing and treatment services differ by the type of infertility diagnosis ( Katz et al . 2011 ). Couples with male factor or unexplained infertility tend to use fewer diagnosis and treatment services, resulting in lower cost ( Quaas and Dokras 2008 , Carson and Kallen 2021 ). As a result, they may have lower perceived value and report lower WTP for IVF and PGT ( Skwara 2023 ). Finally, we found that patient-physician communication about cost was positively associated with WTP for AI and PGT. As suggested by previous studies, appropriate price communication could increase WTP by providing patients with sufficient information and knowledge about health services and making them recognize the differential value of given services ( Nagle et al . 2010 , Steigenberger et al . 2022 ). Prior knowledge and information may impact WTP by improving perceived benefit and decreasing perceived risk. In addition, cost communication may affect WTP through improving price transparency and increasing patients’ trust in physicians and treatment care ( Roosen et al . 2015 , Morsink 2024 ). This study has several strengths compared with previous research. First, there are marked differences in success rates, costs, and patient comfort across different ART techniques. Our study estimated the WTP for specific ART techniques rather than for general infertility treatment, which provides more detailed information about the perceived value of infertility treatment. Second, to the best of our knowledge, despite the urgent and substantial need for research on the financing of infertility treatment services ( Njagi et al . 2023 ), studies on WTP for ART in LMICs remain scarce ( Fenwick et al . 2023 ). Our findings contribute new evidence to ART financing and have important implications for policymakers in formulating public funding mechanisms or expanding health insurance coverage for infertility services. However, this study has several important limitations. First, since participants were recruited from five provinces, there may be selection bias. The findings should be interpreted with caution, as their generalizability may be limited. Future research is needed to confirm and validate these findings. Second, the CVM used in this study may be subject to starting point bias—a common limitation of this approach. Starting point bias occurs when the initial bid value presented to respondents influences their stated WTP rather than reflecting their true valuation. In this study, the bidding values were set based on the real-world costs and success rates of each ART procedure to improve realism and relevance. However, this approach may have inadvertently anchored respondents’ valuations and led to an upward bias in the estimated WTP. This limitation should be considered when interpreting the findings, especially in the context of policy implications or cost-effectiveness analysis. Future research could reduce starting point bias by randomizing initial bid values across participants. Third, all respondents in this study were individuals with infertility who were currently undergoing ART and thus likely had better knowledge about healthcare costs and higher ability to pay. However, this sampling approach excluded individuals with infertility who did not pursue ART due to financial barriers, potentially introducing an upward bias in the estimated WTP for ART. Therefore, the sample selection strategy may have overestimated the actual WTP. This represents an important limitation in the generalization of our findings. Based on the findings from our study, future research involving all patients with infertility is expected to provide more comprehensive WTP estimations and inform national policies for resource allocation for ART. Fourth, 95% of the participants in this study were female, failing to reflect the actual female proportion in the infertility population. However, according to Fenwick’s systematic review, no significant differences in WTP for ART were observed between male and female individuals with infertility ( Fenwick et al . 2023 ). Thus, the uneven sex distribution is not likely to cause serious bias in the estimation of WTP for ART. Fifth, due to sample size limitations, we did not conduct subgroup analyses in this study. Future studies should recruit a more diverse sample of individuals with infertility, including those who have not initiated ART, to explore disparities in access, affordability, and WTP across different socioeconomic groups. Given declining national birth rates, and the associated social and economic challenges created by an aging population, there is likely an externality value associated with an assisted birth that is not captured in these WTP values. Such analyses are essential to inform equitable fertility care policies and health insurance benefit package design. These findings have several important policy implications. First, China is facing the dual challenges of a low fertility rate and a high prevalence of infertility ( Wang et al . 2024 ). In response, the government has taken measures to build a fertility-friendly society, including the incorporation of ART into the national health insurance scheme and the regulation of prices for ART services ( Global Times 2025 ). Although selecting infertile patients currently undergoing ART may lead to an overestimation of WTP for ART, the values obtained from patients in this study can be used in conjunction with data from the general public and other stakeholders to inform health care coverage decisions. Second, the finding that the WTP for ART among individuals with infertility was not sensitive to economic status suggests strong desires for having children. Setting a higher cost-effectiveness threshold for ART—relative to interventions for other chronic diseases—and raising the reimbursement ceiling in health insurance schemes may help meet healthcare needs and support fertility goals ( Wang 2024 ). Third, patient-physician communication, including discussions about costs and the provision of more information to patients, has been found to influence patients’ treatment decisions and is therefore recommended as part of shared decision-making ( Oshima Lee and Emanuel 2013 , Politi et al . 2023 ).

The data used in this study were obtained from a multicenter cross-sectional survey. We strategically selected five hospitals that provide ART services, which are geographically distributed across China, including Shanghai (municipality), Shandong (East China), Ningxia (West China), Guangdong (South China), and Hubei (Central China). A quota sampling method was used to recruit individuals with infertility undergoing ART treatment. The inclusion criteria were as follows: (i) individuals diagnosed with infertility based on the WHO definition of “a disease of the male or female reproductive system defined by the failure to achieve a pregnancy after 12 months or more of regular unprotected sexual intercourse” ( World Health Organization 2023a ); (ii) individuals undergoing one of the five ARTs approved by the National Health Commission of China; (iii) individuals aged between 18 and 49 years; (iv) individuals with infertility undergoing embryo transfer or AI at the time of the survey, indicating that they were actively completing a full cycle of ART. After giving informed consent, participants were invited to complete the questionnaire while waiting outside the operating room for intrauterine insemination or embryo transfer procedures. Female respondents were selected as the primary respondents for the following reasons: (i) female factors account for the majority of infertility cases ( Liang et al . 2025 ); (ii) ART procedures are primarily performed on the women’s bodies, even in cases of male infertility, making women generally more familiar with the treatment process and related costs ( Webair et al . 2021 ); (iii) males are more likely to decline survey invitation due to stigma ( Webair et al . 2021 , Liang et al . 2025 ). The contingent valuation method (CVM) is a widely used technique for measuring individuals’ stated preferences. Participants were asked to imagine themselves in hypothetical scenarios—such as experiencing a specific disease—and then to indicate their WTP for a service or good that would improve their well-being. The CVM has been widely adopted by researchers worldwide, particularly in WTP ( Klose 1999 ). Moreover, CVM has demonstrated robust validation in estimating WTP for ARTs across different countries ( Settumba et al . 2019 , Fenwick et al . 2023 ). The scenarios in this study were developed based on the guidelines for contingent valuation ( Carson 2000 ). The contingent valuation investigation of WTP in our study included three scenarios: AI, IVF, and PGT. Each scenario was designed based on the real-world efficacy and cost of these technologies in mainland China, as detailed in Supplementary S1 . Since all respondents in this study were individuals with infertility, it was unnecessary to hypothesize that participants themselves had infertility; thus, this aspect was excluded from the scenario descriptions. Each scenario presented participants with information on pregnancy rates, treatment complexity, and related costs for each technology. To assess WTP for ARTs, we used a close-ended dichotomous choice format followed by a payment card technique. Participants were first asked whether they were willing to pay a specified initial bid amount. Those who responded “yes” were presented with a set of higher bid ranges, while those who responded “no” were shown lower bid ranges. Participants then selected the range that best reflected their WTP for the treatment. In Scenario A, participants were asked to state their WTP for IVF, with an initial bid of RMB 40 000. In Scenario B, the initial bid for AI was RMB 7000. In Scenario C, the initial bid for PGT was RMB 60 000. The initial, minimum, and maximum bid values for each scenario were determined based on the cost per cycle reported in previous studies ( Bai et al . 2018 , Qiao et al . 2021 , Zhang and Yi 2021 , Wang et al . 2022 ). The detailed bidding questions for each scenario are presented in Supplementary S2 . In addition to the CVM, the questionnaire also collected information on age, sex, socioeconomic status, and disease-related details. According to previous empirical studies and reviews, these factors may influence WTP for ART among individuals with infertility ( Poder et al . 2014 , Dieng et al . 2020 , Fenwick et al . 2023 ). Specifically, socioeconomic status included educational attainment (1 = middle school and below; 2 = high school; 3 = junior college; 4 = university and above), enrollment in basic and supplementary health insurance, employment status (1 = employed; 2 = non-employed; 3 = other), and economic status. Basic health insurance schemes in China includes the Urban-Rural Residents’ Basic Medical Insurance (URRBMI) and Urban Employees’ Basic Medical Insurance (UEBMI). Enrollment in supplementary health insurance was coded as a dichotomous variable, (0 = No; 1 = Yes). The economic status of the respondents was measured by annual household income per capita in the previous year. Disease-related variables included the cause of infertility (classified as male factor, female factor, combined factor, unexplained infertility, or other), the occurrence of complications during infertility treatment, and the presence of any chronic diseases. Female factors included tubal factors, diminished ovarian reserve, ovulatory dysfunction, and endometriosis. Male factors included oligoasthenospermia, teratospermia, and azoospermia. The occurrence of complications was a binary variable (No/Yes) indicating whether the respondent had experienced any of the following conditions during ART treatment: (i) moderate to severe ovarian hyperstimulation syndrome, (ii) postoperative bleeding (>300 ml), (iii) postoperative pelvic infection, or (iv) other clinically reported complications. Patient-physician communication about costs was measured using a four-category nominal variable ( Rai et al . 2020 ), based on responses to the question: “Has your physician ever discussed the total medical cost of ART with you?” The responses were categorized into four levels: (i) never discussed, (ii) briefly discussed, (iii) discussed in detail, (iv) I do not remember. Prior to the pilot survey, the content of the questionnaire was validated by several experts to ensure the relevance and clarity of each question. Expert consultation was conducted using a focus group discussion approach. Experts were purposively selected to provide multidisciplinary suggestions, including: (i) nurses familiar with the clinical procedures of ART; (ii) financial personnel with expertise in the cost of ART services; (iii) health economists experienced in using CVM to assess WTP; (iv) researchers specializing in infertility-related health policy. Three rounds of focus group discussion were held on 28 June, 3 July, and 5 July 2023. During these sessions, experts reviewed each item in the questionnaire, provided comments on content accuracy and clarity, and suggested revisions. We reviewed and discussed the feedback, and all modifications were finalized through group consensus to improve the questionnaire’s validity and feasibility. Before the formal survey, a pilot survey was conducted in Shandong province with 45 individuals with infertility. Based on the participants’ feedback, we verified the comprehensibility of the questionnaire and the appropriateness of the bidding values. As no substantial revisions were required, the questionnaire remained unchanged. The questionnaire was completed by one member of an infertile couple via a web-based survey platform (Wenjuanxing) and checked by trained interviewers before submission. The formal survey was conducted between August and November 2023. Descriptive statistics were used to summarize respondents’ characteristics, including the number and proportions of participants in each group. Responses from the CVM were converted into interval-censored data. For instance, if a respondent selected a range (e.g. “RMB 5000–5999”), the lower bound (wtp_lb) was set to 5000, and the upper bound (wtp_ub) to 5999; For responses indicating a value “less than RMB 5000” or “more than RMB 10000,” the data were coded as left-censored (wtp_lb=., wtp_ub=4999) or right-censored (wtp_lb=10000, wtp_ub=.), respectively. Interval regression analysis—a well-established method for analyzing interval-dependent variables derived from CVM studies ( Angell et al . 2018 , Xu et al . 2024 )—was performed to estimate WTP in each scenario and explore its potential correlations with demographic, socioeconomic and disease-related factors. The selection of explanatory variables was based on previous reviews and empirical studies ( Steigenberger et al . 2022 , Fenwick et al . 2023 , Keller et al . 2023 ). Mean WTP and 95% confidence intervals (CIs) were expressed in RMB, with conversions to 2023 US dollars using exchange rate ($1 = RMB 7.08). Additionally, WTP was expressed as a proportion of China’s 2023 GDP per capita (RMB 89 424) ( National Bureau of Statistics of China 2024 ). Mean WTP and its associated factors were estimated using maximum likelihood methods with the “intreg” command and robust errors in STATA 15.0 ( StataCorp 2017 ). A two-tailed P -value of .05 was considered statistically significant. All data analyses were performed using Stata 15.0 ( StataCorp 2017 ). This study obtained ethics approval from the Ethics Committee of the Center for Health Management and Policy Research, of the authors’ institute. All respondents provided informed consent before participating in the survey.