Italys extension of mandatory vaccination in 2017 was a response to a public health crisis many years in the making. Vaccination rates had been in steady decline for half a decade, culminating in a measles epidemic. With existing studies demonstrating the role of vaccine hesitancy, this study sought to understand policy decisions made within the Italian public health bureaucracy between 2012 and 2017 to try and stem the vaccine confidence problem. Semistructured interviews with five key informants inside or close to government were qualitatively analysed using a theoretically informed schema to make sense of governance failures in realms of knowledge (epistemology) and action (the work of governing). Italian public health officials lacked crucial knowledge regarding the population, including how it was getting its vaccine information and what strategies might work to address hesitancy. Limited financial resources also constrained their capacity in a context of austerity. A credibility gap for government ensued, which officials sought to plug by constructing Italians as in need of firm instruction by mandatory vaccination. Mandatory vaccination can be understood as a form of control that modulates peoples access to institutions in this case the pre-school system. The alternative mode of governance is discipline, which uses institutions to educate, communicate and instil social norms. During the study period, Italys vaccination governance employed a disciplinary approach, but ineffectively. The resort to mandates in 2017 can be understood as a failure of this disciplinary approach, triggered by a series of unfortunate events that were thwarted by governance capacity gaps. The explicit control of mandates are improving Italys vaccination coverage rates, but the important work of discipline should not be left neglected. Effective and ethical governance to future-proof vaccine acceptance requires that the unfinished work of discipline be resumed and maintained.
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