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THE No Jab, No Pay policy has failed to consider refugee and migrant families, say experts, and GPs have been left to try and work around a logistical “mess”.
Associate Professor Christine Phillips from the Refugee Health Network of Australia told MJA InSight that the policy impacts on almost all recently-arrived refugee families, as well as immigrant children whose families rely on family income support.
“It has hit the refugee health sector hard, in terms of the extra work. In order to respond to the fear refugee families have that they will lose benefits, all of us in our services have had to commit extra resources to entering data into the Australian Childhood Immunisation Register (ACIR).
“It’s not that there’s a hump of extra work that will settle over time; the inequities in this will continue unless there are some changes to the policy and to the ways the policy is implemented.”
Associate Professor Phillips was commenting on an article, published today in the MJA, which argued that while the No Jab, No Pay policy offers an opportunity to improve immunisation coverage rates, it excludes thousands of disadvantaged refugee and migrant families from Centrelink payments due to system issues, rather than conscientious objection to vaccination.
The workforce challenges regarding the No Jab, No Pay measures are also substantial. There have been large numbers of people inundating services, and an increased demand for providers to clarify previous vaccination history, and provide catch-up vaccines where needed.
The MJA authors highlighted several strategies that could help reduce the impact of the policy on these families, including ongoing funding for catch-up vaccination in those aged 10 years or older, and extending the period before Centrelink payments are affected to allow adequate time for catch-up vaccination.
Associate Professor Phillips said that due to the fact that there was no way for GP services to claim all the extra time put into the extended catch-up and paperwork required under No Jab, No Pay, it would have made business sense for GPs not to engage with the process.
“The wonder of it is that GPs and practice nurses actually do put in the time required for No Jab, No Pay compliance.
“They should be congratulated for this, because it’s an act of patient service. They are doing it to avoid patients being financially disadvantaged, even though it certainly means that the practices will be.”
Dr Margaret Kay, GP and senior lecturer at the University of Queensland, said that there had been little recognition of just how difficult this has been for practices.
She said that when refugee families came to GPs wanting to know what vaccinations they were missing, this was not information that could be provided by a clinic.
“People had to physically leave our practice and go to Centrelink to find out what was missing. Some families we saw got distressed.”
Dr Kay provides training at private practices to upskill GPs in managing refugee health, and has heard similar stories across the board.
“Practices told us that GPs were getting so stressed about [this process] and trying to calculate what was needed. Some GPs have had to take a day off to deal with the stress of it.”
Lead author of the MJA article, Dr Georgia Paxton, head of Immigrant Health at the Royal Children’s Hospital in Melbourne, said in an MJA podcast that there was no quick and easy fix.
“The bottom line is that people need to clarify what’s happened before, figure out if they need to catch up, get the catch-up vaccinations if they are outstanding, and put all of that into ACIR.”
Dr Paxton said that an inherent difficulty was that health providers were often chasing histories that date back to 10 years and may cross international borders.
“The other complexity here is that when families first arrive in Australia, they’re often actually mobile and they may change providers in the early period or down the track, and it’s pretty hard to keep track of records.”
Associate Professor Phillips said that in order to try and fix this situation, she would “prioritise improving ACIR’s ability to handle catch-up immunisation quickly, incentivising catch-up immunisation for those over 7 years, and an online catch-up calculator for those under 20 years”.
Dr Kay added that data capture must also be improved.
“We need to recognise that for people of a refugee background, almost no one is adequately immunised when they come here.
“So, we must ensure that they are given documentation, a piece of paper to show their GP. This is particularly important when they don’t speak English – this piece of paper is empowering,” Dr Kay said.
Professor Phillips highlighted that the predicament the health sector finds itself in could have been prevented.
“In this case, if the policy and its administration had been trialled against the most vulnerable population for this policy – refugee children – some of the fixes could have been introduced at once, and others prepared for.
“Software designers always simulate before they release policy. Health care policy makers should do the same.”
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I do not think any payments child care subsidies etc should be a manipulation point to make people vaccinate. I think this is immoral and manipulative and unethical. This policy impacts everyone who has a conscientious objection or religious exemption.
I am a GP with greater than 35 years in practice. Our group practice has had considerable experience in managing the health of refugee children. I agree that the difficulties experienced by GPs are real and expensive. This is not aided by the lack of written health history documentation. In particular, history of immunization. However, we were able to make use of our practice nurses to do some of the “spade work” with the ACIR and other bodies. None of Refugee medicine is easy and it does not fit well normal day to day General Practice. I disagree with the comments in the lead article that Paediatricians are the lead group in childhood immunization. I agree that Paediatricians need to be able to access ACIR. Most GPs that I know are in support of the policy of “No jab-No pay”. I certainly believe that a policy to support herd immunity is needed, and that this particular policy has been successful. Of course, the very successful former policy of support of GP immunization by incentive payments was ceased by government. We need fewer exceptions for non compliance, not more.
The other problem is those who are fully immunised but on a schedule different to ours. Children get additional jabs for no reason other than to satisfy bureaucracy. There is no problem that cannot be made worse by the heavy hand of government.
In response to Robert Hall, I would report that there is already good information available on the Benefits of NJNP, as described here: http://www.abc.net.au/news/2016-07-31/government-labels-'no-jab,-no-pay'-policy-a-success/7675172>
While vaccination rates may be quite good nationally, there are pockets of low rates, where outbreaks can – and do – begin.
There are various different reasons for failure to immunise – including having a chaotic life with competing priorities – not just refusal.
Of course we must do everything to facilitate our refugees being supported – by ironing out this glitch in an otherwise effective policy. Few – if any – areas of public policy benefit 100% of the target population without any side-stream effects. That’s why public policy needs audit and review.
Rules, regulations and their supporting bureaucracy may be necessary parts of the ‘machinery of Healthcare Systems both public and private, but should be no more extensive than necessary. As a ‘rule of thumb’ they should be constrained so they impede neither efficiency nor patient care. Likewise, objections to ‘rules’ also need to be constrained – or subject to discipline – lest they serve merely as opportunities to advance of a political agenda or ideology, both of can also impede efforts to be efficient and to care for the whole community. Immunisation is a vital arm of preventative health and it is essential that there is strict adherence to rules supporting universal vaccination in order to secure the health and well-being of the individual as well as the community. It may be necessary for an incentive, positive motivation or deterrent, to ensure refugees are welcomed and high standards of protection against vaccine-preventable illnesses maintained.
If these refugees are coming into Australia via immigration, why isn’t their immunisation status checked then, as well as checking for any communicable diseases, before they are let out into the general population?
Australia has such strict laws on quarantining animals coming into the country, yet they usually have full documentation of their health. When will the health of humans living in Australia get the same level of protection?
My view is that in Australia there is currently no need for a ‘no jab no pay’ policy. We have high immunization coverage and I see no need for demonizing some sections of the community. The evidence we have is that high-income highly educated parents are the main risk group for non-participation in the immunization programme, and ‘no jab no pay’ is less effective at achieving high coverage among this group.
I think we would do better to look at, or create, the evidence.