Convergence on Coercion: Functional and Political Pressures as Drivers of Global Childhood Vaccine Mandates

Abstract

Background: Vaccine hesitancy is a global problem with diverse local policy responses, from voluntaristic to coercive. Between 2015 and 2017, California, Australia, France, and Italy increased the coerciveness of their childhood vaccine regimes. Despite this apparent convergence, there is little evidence of imposition, policy learning, or diffusion – the drivers that are usually discussed in scholarly literature on policy convergence. The fact that the four governments were oriented across the political spectrum, with quite different political and institutional systems, further indicates an empirical puzzle. Methods: To better understand the drivers of enhanced vaccine mandates, a crucial issue during the COVID-19 global rollout, this article engages with four case studies assembled from qualitative analysis of semi-structured in-country interviews and document analysis between November 2018 and November 2020. Key informants had specific expert knowledge or played a role in the introduction or implementation of the new policies. Interview transcripts were coded inductively and deductively, augmented with extensive analysis of legal, policy, academic and media documents. Results: The case analysis identifies two key and interacting elements in government decisions to tighten vaccine mandates: functional and political pressures. Policymakers in Italy and France were primarily driven by functional challenges, with their vaccination governance systems under threat from reduced population compliance. California and Australia did not face systemic threats to the functioning of their systems, but activists utilised local opportunities to heighten political pressure on decision makers. Conclusion: In four recent cases of high-income jurisdictions making childhood vaccination policies more coercive, vaccine hesitancy alone could not explain why the policies arose in these jurisdictions and not others, while path dependency alone could not explain why some jurisdictions with mandates made them more coercive. Explanation lies in restrictive mandates being attractive for governments, whether they face systemic functional problems in vaccine governance, or political pressures generated by media and activists. Mandates can be framed as targeting whole populations or localised groups of refusers, and implemented without onerous costs or policy complexity.

Vaccine Mandates in the COVID-19 Era: Changing Paradigm or Public Health Opportunity?; Comment on "Convergence on Coercion: Functional and Political Pressures as Drivers of Global Childhood Vaccine Mandates"

“…1 Department of Public Health Experimental and Forensic Medicine, University of Pavia, Pavia, Italy. 2 Collegio Ca' della Paglia, Fondazione Ghislieri, Pavia, Italy.…”

“…The debate around vaccine mandates has flourished over the last decade, within and outside the scientific community, at the population and political levels, with several countries revising their vaccination policies in recent years, some introducing or extending mandatory vaccinations. 1 Analysing the cases of Australia, California, Italy and France, Katie Attwell and Adam Hannah 2 postulated that functional and political pressures added to public health threats and motivated governments to increase the coerciveness of their childhood vaccine regimes. Does this model apply to the coronavirus disease 2019 (COVID-19) case?…”

“…If that is the case, which setting-specific, epidemiological, functional or political elements determine what to opt for within the spectrum? Attwell and Hannah 2 argue that more coercive approaches are enforced on political grounds and perceived by policy-makers to be “easier and cheaper,” as compared to other forms of intervention for increasing vaccination rates. Was this paradigm maintained during the COVID-19 pandemic?…”

Vaccines, Politics and Mandates: Can We See the Forest for the Trees? Comment on "Convergence on Coercion: Functional and Political Pressures as Drivers of Global Childhood Vaccine Mandates"

“…7 Attwell and Hannah have examined in detail one puzzling aspect of mandatory childhood immunization implementation: the political underpinnings. 9 In their report of four case studies, they delved into the nuances behind Italy, France, Australia, and California choosing to move to more coercive routine childhood immunization policies. These three countries and one state had quite different political orientations, motivation for considering mandating programs, differing contexts at the time of consideration as well as different immunization delivery system practices.…”

“…This route may appear at a glance to be an easier strategy to increase vaccine uptake than many others advanced to address lower than desired vaccine acceptance rates. 9 Of note, none of the four jurisdictions used the same compliance incentives or penalties, covered the same vaccines or age groups. One missing piece in this four-case political puzzle report, is what were the outcomes of these mandates initially, overtime, as contexts changed, and as other health measures competed for public health funding.…”