As a vaccine advocate, I encourage vaccination and support vaccination programs without hesitation. However, I fear that rallying calls for compulsory vaccination will only entrench vaccine opposition, and I want to explore what is known about people who don’t vaccinate and what evidence exists for strategies to improve vaccination. Getting more people vaccinated is a fundamental social priority, but implementing a strategy to raise vaccination rates is not as straightforward as it first appears.

The Australian federal government have recently announced a ‘no jab, no pay’ policy which will come into effect in 2016. Under this policy, the option to register as a ‘conscientious objector’ will be removed as an exemption category for government child support payments (specifically, the Child Care Benefit, the Child Care Rebate, and the Family Tax Benefit Part A). Additionally, the Victorian government has announced their inventively named ‘no jab, no play’ policy which requires children to be fully vaccinated to enrol in childcare or kindergarten, likewise through tightening exemption categories so that only medical exemptions are accepted . These policy announcements have been met with cheers (and predictable derision), and are similar in intent to the recently passed law in California, USA where children must now be fully vaccinated to enrol in kindergarten or school. Only medical exemptions are allowed under the new Californian law.

In Europe, vaccination policies stipulate a mix of mandatory and recommended vaccines – sometimes both in the same country (for example, Belgium has mandatory polio vaccination, whereas other vaccines are only recommended). Countries such as the UK and Germany currently have no mandatory vaccines, and other countries such as Slovakia, Czech Republic and Italy have most of the childhood vaccine schedule mandatory. There is little data available on whether mandatory vaccination results in higher vaccination rates, with the ease of obtaining vaccines and the types of penalties imposed for non-compliance (if any) would be influential in determining whether a mandatory vaccination policy is effective. The reasons for variability in vaccine policy (and in subsequent vaccination rates) are not simple to unravel, but it is safe to say that there is little empirical evidence used in developing or revising vaccine policy anywhere in the world.

While the introduction of financial incentives for parents to vaccinate their kids has been linked with moderate increases in vaccination rates in Australia, there is little evidence that the imposition of financial penalties works to improve vaccination rates in all settings. Improvements in vaccination rates have been seen following personal reminders – for example, phone calls or letters, however the impact of reminders varied by target population and vaccine type. Even amongst healthcare workers, a mandatory vaccination policy against common infections such as measles, hepatitis B and whooping cough in NSW showed variable impacts on vaccination rates after 2 years, although mandatory influenza vaccination was successful in raising vaccination rates in a large US medical care organisation.

It is worth having a closer look at unvaccinated and under-vaccinated children. In Australia, 7-8% of children are not fully vaccinated at age 1-2. These children can be categorised into three groups. The first and biggest group are those who have faced barriers to getting fully vaccinated. These barriers range from moving house, to being in a larger family or being socially or geographically isolated. Children who are not fully vaccinated are more likely to come from families with low incomes, although most children in this category do not have parents who object to vaccination. The next, smaller group of children who are not completely vaccinated are those whose parents object to vaccination – either completely, or on a vaccine-to-vaccine basis. A minority of parents are completely opposed to any vaccination, while most parents who are hesitant about vaccination do not oppose vaccines outright, but hold concerns about the side effects and consequences of certain vaccines. The final group of incompletely vaccinated children are those who, for genuine medical reasons, cannot be vaccinated with certain vaccines. Medical exemptions are designed to accommodate these children.

Mandatory vaccination policies such as ‘no jab, no pay’ and ‘no jab, no play’ do not directly address the reasons that children are not fully vaccinated, and may increase the paranoia of staunch vaccine opponents. Without increased support for vaccine access, families who do not vaccinate their children due to social or financial barriers are unlikely to go and vaccinate. Families dependent on the government payments, or who absolutely need childcare, may find themselves cut off from payments or unable to enrol in childcare if vaccines are difficult to access. Parents who hold strong anti-vaccination stances and who don’t access government payments or organised childcare can remain blissfully untouched by these policies, and may even use the call for mandatory vaccination as further evidence for a government/pharma conspiracy.

Creating a system where vaccines are widely and easily accessible, along with checkpoints for reminding parents about their children’s vaccines, may be a more effective way of raising vaccination rates than a strong-arm approach. We will have to wait and see.