(This blogpost has been updated from 11 April because government announced on 12 April that it would also remove eligibility for Child Care Benefit and Rebate along with Family Tax Benefit Part A Supplement)
The Australian government announced on 12 April 2015 that it will “end the conscientious objector exemption on children’s vaccination for access to taxpayer funded Child Care Benefits, the Child Care Rebate and the Family Tax Benefit Part A end of year supplement from 1 January 2016. They called the move “No jab – no play and no pay for childcare”.
The Family Tax Benefit Part A supplement represents up to $2178 per child. It is means tested and 73% of families are estimated to be eligible. The Child Care Benefit is worth $200-a-week and the Child Care Rebate worth $7500-a-year, reported one newspaper.
Many have welcomed this decision. They are rightly motivated to see immunisation rates improve. On an emotional level it has appeal because it appeases anger about parents who reject vaccines. However, there are some downsides to this policy that are much less obvious, but need to be considered.
In summary, it is unlikely to make a meaningful difference to improving vacation rates. It amounts to a form of mandatory vaccination for lower income families, but without a no-fault vaccine injury compensation system implemented alongside. Some children from lower income families will no longer be able to attend childcare. It almost certainly won’t shift entrenched vaccine rejectors. As a monetary sanction it comes with insufficient evidence of its impact on vaccination rates, whereas Australia’s current system of incentives comes with strong evidence for their impact on vaccination rates.
The system we have now works well – maximising procedural complexity for non-vaccinators while encouraging late parents to be up to date. It is fair and proportional to the contribution that vaccine rejectors make to under-vaccination which is at 2%. A report stated that 14,000 families of the 39,000 registering objection to vaccination would be affected. Assuming the 39,00 is the 1.77% who register objection, this equates to 0.6% of children. In a best case scenario where the policy convinced half of them to vaccinate, it would increase child immunisation coverage overall by 0.3%.
Quality engagement with a health professional is a much more ethical and satisfactory approach to non-vaccinators than monetary sanctions. To increase vaccination rates there are areas where much greater gains could be made with fewer unintended negative consequences.
Here is a Q and A about the proposal to help readers consider the impact.
“There are disease outbreaks and people get sick and die. How can we stop people shunning vaccines?” Australia definitely could improve its vaccination rates, its disease control and even the effectiveness of some of its vaccines. But removing family assistance payments for vaccine rejectors will make very little impact on this problem. It won’t touch the 1% who have no vaccines at all – entrenched objectors are very hard to shift. It might motivate some in that 1% of registered objectors who have at least one vaccine, indicating they are not totally averse to vaccination. But these selective vaccinators tend to be in a higher income bracket, and many will be untouched by the policy. The remaining 5% who are not fully vaccinated fall into the motivated but disadvantaged category. Most of them have vaccines but they tend to be late or miss some. Already, these parents have the requirement to be fully vaccinated to get payments. And since they are still not vaccinated, clearly other things need to be done for them (see later). Some children are recorded as being partially vaccinated but are actually fully vaccinated. This is a common recording error. The Australian Childhood Immunisation Register (ACIR) once sent me a letter saying I needed to get my daughter up to date. She was up to date, but the data had not transferred from my GP to the register. Primary care providers spend far too much time correcting ACIR data transfer glitches.
“When did Australia start linking payments to vaccination?” In 1998 the federal government started linking existing parent payments to vaccination status. Then they included the Maternity Allowance ($200 per fully vaccinated child) and the Childcare Rebate ($20-$122/week). Children had to be fully vaccinated for age for parents to receive the payment or parents had to prove a medical or ‘conscientious objection’. In July 2012, government removed the Maternity Allowance altogether and began linking vaccination to eligibility for Family Tax Benefit Part A supplement. This was linked to completed age appropriate vaccination at 1, 2, and 5 years of age for the child and paid in three instalments. Children either had to be fully vaccinated within a certain window or to have registered an exemption – medical or ‘conscientious’. It was worth up to $726 per child per age milestone.
“Isn’t it easy for parents to register ‘conscientious objection’?” The registration process is inconvenient enough to sort the prevaricating from the committed. Parents must take this form to their doctor or immunisation nurse and both must sign it to say they have discussed the risks and benefits associated with immunisation. In one of our surveys, 18% of GPs said they would never sign the form. So some parents must then ‘shop around’ to find somebody who will. They then must submit the form to the Department of Human Services.
“Is it fair that vaccinating parents have to front-up at three visits to get their payments while objectors only once?” It would be fairer to have vaccine objectors have to submit a form at the 1, 2 and 5 year old milestones, not just once. Vaccine objectors should be asked to carefully consider then reconsider their decision, for it affects not just themselves but the wider community.
“How much money is saved by removing FTB-A from objectors?” Reports have estimated this to be about $50 million per year. Ideally the money saved would go into innovative programs to prevent vaccine refusal and respond to parental hesitancy and to improve access to timely vaccination for the disadvantaged.
“Should parents who fail to abide by the social contract not get benefits?” The payments were not introduced as a vaccination incentive originally. They were introduced with the express purpose of supporting Australian families and were later linked to vaccination. Child care payments support the participation of women in the workforce. No other health behaviours are linked to welfare payments. The vaccine incentives system we have now works well – maximising procedural complexity for non-vaccinators while encouraging all parents to be up to date. It is fair and reasonable.
“Would mandatory vaccination help in some respects?” This has prima facie appeal, but what do we mean by mandatory and what would happen if a child were not vaccinated? No country legislates the forcing of vaccination onto a child, unless there is an immediate danger to them. For example, hepatitis B vaccination was required for an infant born to a vaccine-refusing mother who was surface antigen positive. Media occasionally report rare instances of jail for vaccine refusing parents in some countries. The US has school entry vaccination requirements with exemptions. Until now, Australia had vaccination requirements to access welfare payments, with exemptions available for vaccine rejectors and those with a medical contra-indication. Our exemption system amounts to what US experts have advocated for some time because it has sufficient procedural complexity, but stops short of full removal of rights. While a recent Galaxy poll commissioned by Newscorp indicated 86% support for compulsory vaccination, it is unclear how large and representative the sample was and what respondents had in mind for “compulsory”. If it means removing FTB-A supplement, as is planned, then government will effectively introduce a mandatory vaccination system for lower income families without any robust consultation and the public will not have the opportunity to consider the full range of issues.
What would need to be considered if we did have a form of mandatory vaccination? Vaccination is different to other public health measures where mandates have been successfully imposed. Vaccination is a more invasive intervention that comes with common and minor, and rare serious side effects. Because of these risks, governments that mandate vaccination are obliged to bring in a no fault vaccine injury compensation system. However, there are no indications this will occur.
“How do heath professionals feel about having to sign these objector forms?” Clinicians can feel quite ambivalent about signing the forms. My team just completed 26 in-depth interviews with immunisation providers on this topic and I have run workshops with hundreds of GPs and nurses. Many clinicians find these consultations challenging. They feel torn between wanting to see children vaccinated and wanting to retain a relationship with the parent/s. While some dislike having to sign the forms, most will do so, seeing it as an opportunity to discuss vaccination and keep the door open for the future. Sometimes these discussions lead to the child being partially vaccinated. At other times, parents come back when they are about to travel overseas or the child is older. Quality engagement with a health professional is a much more ethical and satisfactory approach to non-vaccinators than monetary sanctions. Removing the incentive for those families to discuss their decision removes an important opportunity.
“Aren’t vaccine objectors at ‘record levels’?” This is simply wrong. A readily accessible website indicates that objector levels actually dropped from 1.79% in September 2014 to 1.77% in December. Between 1999 and December 2014 there was a slight absolute increase in registered objector levels from 0.23% to 1.77%. Unpublished data suggest that this is likely a shift from those who previously did not register refusal now doing so as they became more aware of their capacity to claim or being more motivated to claim objector status. See this blog. Australia will also stop being able to monitor objector levels if the government ceases to measure them. Should this occur, the states will need to implement their own registration system for their existing childcare and school entry requirements.
“What is happening to vaccination rates?” They are holding steady at around 92% and have done so for years. The false reporting of our childhood immunisation rates as being on the decline is harmful if it influences parents to believe that this is a trend. Regardless, the gap between ideal and actual vaccination rates has persisted and needs to be addressed.
“Vaccine objectors cluster in regions. What can we do about this?” This clustering is a persistent problem, creating a critical mass for outbreaks to be more likely and sustained. Non-vaccination travels with other social norms and group identities. Public health needs to better understand and engage with these communities. Punitive policies will almost certainly make that job more difficult, as they further alienate such communities from the government and medical system.
“If this policy won’t do much for vaccination rates, what will?” The following actions would bring bigger marginal returns than penalties:
• enhanced support for doctors, nurses and Aboriginal Community Controlled Health Services providing vaccines
• implement quality control measures in the ACIR to identify and detect recording errors
• having a national vaccine reminder system
• home visiting programs for homebound families
• funding for migrant and refugee catch up programs
• enhancing the cultural respect of immunisation services.
We could also do with a focus on adult vaccination rates, which can be very low. A whole of life register would enable providers to know if the person sitting in front of them is due for a vaccine and adults to keep track of their own vaccinations.
“But these practical measures don’t solve vaccine refusal.” They probably do more for vaccination rates, but it is true that they don’t target refusal. This has been challenging ever since Edward Jenner developed the smallpox vaccine in the nineteenth Century. The solutions need to focus on touchpoints where views about vaccination are shaped: in high school, antenatal care, primary care, and in communities who influence each other. We also need to shore up our readiness for a vaccine safety scare that could be just around the corner. You can hear more about this challenging area in my recent presentation.
In conclusion, the proposal to stop vaccine objectors from getting family assistance payments seems inevitable. However, I feel it’s important that people are aware of its intentions and consequences, and of the less obvious impacts. Also, vaccination advocates can take the opportunity to also propose solutions that are likely to have a bigger impact on improving vaccination rates.