“No jab, no pay” pays off

The policy has been effective, albeit with modest closure of coverage gaps, and without substantial backlash

In April 1998, the Australian government linked the payment of childcare subsidies (Childcare Assistance and Childcare Cash Rebate) and the Maternity Immunisation Allowance to childhood vaccination status.1 To receive these benefits, families needed to show that their child was fully vaccinated according to the National Immunisation Program Schedule.2 Further, the Victorian government passed legislation in 2015 that required childcare proprietors to record and regularly update the vaccination status of each child in their care, and to restrict admission to children who were up to date (“No jab, no play”).3 Other states have since followed suit.

The 2016 federal “No jab, no pay” policy expanded the 1998 vaccination requirements for eligibility for the Family Tax Benefit Part A supplement and the Child Care Benefit/Child Care Rebate (from July 2018: the Child Care Subsidy). Under the new policy, exemptions from vaccination requirements for the two family assistance payments were no longer granted on the basis of conscientious objection, and medical exemptions were also restricted. The two means‐tested benefits can add as much as $15 000 per child per year to the budget of lower income families. Australia is possibly the only country that applies fiscal sanctions for non‐compliance with vaccination guidelines.

While there is some indication that parents accept the linkage of welfare payments with childhood vaccination,2,4 evidence of the impact of the “No jab, no pay” policy on vaccination coverage at the population level has not been reported. In this issue of the MJA, a long awaited answer to this key question, following the controversy after the introduction of the “No jab, no pay” policy, is provided. Hull and colleagues5 estimated the impact of “No jab, no pay” on families with children who receive the Family Tax Benefit Part A (means‐tested in 2016–17; about 39% of the more than 4 million families in Australia with children), the Child Care Rebate (not means‐tested at the time) or the Child Care Benefit (about 22% of families).

The study by Hull and his co‐authors,5 based upon data from the Australian Immunisation Register, focused principally on age‐ and vaccine‐specific cohorts in assessing vaccination coverage before and after the “No jab, no pay” policy was introduced. They found that “nearly one in five young people not fully vaccinated against measles were vaccinated during the first two years of the policy.”5 They also found that catch‐up vaccination of children aged 7–10 years with the second dose of the measles–mumps–rubella vaccine (MMR2) was 4.4 percentage points lower in remote areas than among children in major cities (18.3% v 22.7%) and 3.2 percentage points lower than in regional areas (18.3% v 21.5%).

The bottom line, however, is the population‐level result of vaccination‐related policies. Hull and his co‐authors found that MMR2 catch‐up vaccination activity increased coverage of adolescents from 86.6% to 89.0%. That is, increased uptake had only a modest effect on the population coverage gap, recovering about one‐quarter of the difference between the pre‐”No jab, no pay” population level and the MMR vaccination target of 95% coverage. What needs to be done to eliminate the gap entirely?

Hull and his co‐authors provide new evidence of reverse positive discrimination; that is, of “No jab, no pay” having an unequal impact on Australian families, with lesser gains in vaccination coverage among children of higher socio‐economic status. It is gratifying to see evidence of two‐fold higher MMR2 catch‐up vaccination activity among Indigenous than among non‐Indigenous children and adolescents, possibly because a larger proportion of Indigenous families are eligible for family assistance payments. The moderately lower rate of catch‐up activity for children residing in remote areas should be further explored, as it may indicate inequitable access to vaccination services.

On the other side of the coin are the opportunity costs and unintended negative effects of monetary sanction policies. They seem to have been minimal for “No jab, no pay”, but there have been anecdotal reports in connection with “No jab, no play” that some parents avoid institutional childcare rather than being compelled to have their children vaccinated.

The Australian “No jab, no pay” policy could be seen as verging on compulsory vaccination.6 Certainly, the transition from a financial incentive scheme to one based on monetary penalties has attracted criticism and concern that it is inequitable, unnecessary, and even counterproductive. However, the evidence reported by Hull and colleagues4 suggests that the policy has been effective, albeit with modest closure of the coverage gap. So far, there is no evidence of a substantial backlash.