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Australia’s health care providers play a vital role in the success of the National Immunisation Program, write Shevaun Drislane and Associate Professor Katie Attwell
Government policies to tighten vaccine requirements or impose mandates are becoming more commonplace around the world. Before the coronavirus disease 2019 (COVID-19) pandemic, such policies predominantly focused on routine childhood vaccinations.
These policies aim to ensure adequate vaccination coverage and, therefore, to provide community protection, often known as herd immunity. They also seek to combat parental vaccine hesitancy or refusal.
Australia’s policy under the microscope
In our recently published article, we reviewed Australia’s federal “No jab, no pay” policy, which requires families to vaccinate their children in line with the national immunisation schedule to be eligible for certain government-paid financial entitlements. We also reviewed state level “No jab, no play” policies (in New South Wales, Victoria, Queensland, Western Australia and South Australia) that limit childcare enrolment for unvaccinated or under-vaccinated children.
We examined the trajectory of “No jab” policy developments and requirements, finding that the policies are becoming increasingly normalised and more stringent for both parents and providers of early education and care.
Certainly, both the federal and state policies have an impact on parents/guardians of young children, given the financial and childcare access consequences of not vaccinating them. A study published in 2022 found that “No jab, no play” policies also place burdens on the frontline childcare and early education providers who are required to implement them.
The question we address here is what do “No jab, no pay” and “No jab, no play” policies mean for health care providers?
The role of health care providers in vaccination governance
Well before Australia’s “No jab” policies, health care providers were involved in the governance of childhood vaccination. In 1997, coverage rates stood at 53% nationally for children aged 0–6 years. As part of a suite of policies to improve uptake, the Commonwealth government imposed a condition linking immunisation status to federal financial assistance. To be eligible for what were then called “Childcare assistance” and “Childcare rebate”, families needed to provide proof that their children were immunised as appropriate for their age.
Conscientious objection
However, parents/guardians were permitted to register a formal conscientious objection to vaccination based on personal, philosophical or religious beliefs. This would allow them to continue to receive these payments.
To obtain a conscientious objection, parents/guardians had to attend and receive advice from an authorised health care provider about the benefits of vaccination and the risks of refusal. The health care provider could then issue a certificate of objection if, after this counselling, the parent/guardian remained opposed.
The percentage of Australian children aged 1–6 years with a registered conscientious objection grew from 1.1% in 2002 to 2.0% in 2013, highlighting that health care providers engaged with an increasing number of vaccine-hesitant and vaccine-refusing parents/guardians during this period.
In April 2015, the federal government announced its “No jab, no pay” policy, which would put an end to conscientious objections as a valid exemption ground from January 2016.
To continue receiving relevant payments, children now needed to be vaccinated unless they had a medical contraindication or met one of the other narrow exemption grounds.
As state level “No jab, no play” policies rolled out, they aligned with the federal position and did not permit conscientious objections for unvaccinated children to access childcare. NSW, the first state to enact a “No jab, no play” policy in 2014, initially allowed conscientious objections. However, following the federal policy shift, NSW amended its policy to abolish them from 2018.
The impact of policy shifts on health care providers
The removal of conscientious objections to vaccination meant that health care providers were no longer required to provide counselling and issue conscientious objections certificates to parents/guardians.
This likely provided a welcome reprieve – when Berry and colleagues interviewed vaccination providers, almost all described their conversations with vaccine-refusing parents as challenging. Some resented being conscripted into a bureaucratic process whose ultimate focus was money, not health.
And although no interviewed health care providers refused to sign the conscientious objections forms, some felt uncomfortable endorsing vaccine refusal.
However, other consequences have followed from the removal of conscientious objections and the rollout of state “No jab, no play” policies. As we outline in our article, exemption grounds vary but all state policies permit medical exemptions.
Health care providers may now be approached by parents/guardians seeking medical exemptions who previously would have qualified for a conscientious objections.
Increase in exemptions
A 2017 publication recorded anecdotal reports of an increase in the number of families requesting medical exemptions from GPs in Australia.
When the state of California in the United States abolished non-medical exemptions to its vaccine mandates for school entry in 2015, the rate of medical exemptions increased 250% (from 0.2% in total in 2015–2016 to 0.7% in total in 2017–2018).
It is important that health care providers in Australia understand the medical exemption process, including the grounds upon which a valid medical exemption can be granted. Providers must also be eligible to issue a medical exemption, and are required to record the exemption on the Australian Immunisation Register’s centralised database.
Where parents/guardians are reluctant to vaccinate their children but are prompted to do so because of “No jab” policies, health care providers may have to manage challenging conversations with patients and consider their communication style and messaging.
Strategies to help
Leask and colleagues developed a framework of strategies that can be tailored for differing parent/guardian concerns and attitudes. This framework can help to avoid communication that might contribute to vaccine refusal or dissatisfaction with care. The Australian suite of resources Sharing Knowledge About Immunisation includes cutting-edge strategies developed by Professor Leask and her team, and is hosted on the National Centre for Immunisation Research and Surveillance website.
Health care providers will need to arrange catch-up vaccination schedules for children who have been unvaccinated or under-vaccinated and now need to meet the national schedule because they have enrolled in childcare or early education, for example. In these cases, health care providers must confirm whether the child has had any vaccinations (including vaccinations provided overseas, which will not be recorded on the Australian Immunisation Register), determine which doses have been missed, and develop a schedule of vaccinations to be completed. Various resources are available to assist health care providers with this task.
Conclusion
Australia’s health care providers play a vital role in the success of the National Immunisation Program through providing information, addressing concerns and, ultimately, administering vaccinations.
“No jab, no pay” and “No jab, no play” policies have deepened the role of health care providers in implementing policies aimed at increasing vaccine uptake and addressing hesitancy and refusal.
With medical exemptions one of the last remaining options for vaccine refusers to keep their children unvaccinated and still access federal and state entitlements, it is likely that health care providers’ clinical challenges have morphed rather than evaporated. Vaccine refusers’ pursuit of medical exemptions for COVID-19 mandates will have only heightened such pressures.
Our team will study the effects of this through the MandEval project, interviewing health care providers about their experiences with requests for medical exemptions.
Ms Shevaun Drislane is a researcher in the School of Social Sciences at the University of Western Australia.
Associate Professor Katie Attwell leads VaxPolLab in the School of Social Sciences at the University of Western Australia.
The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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