Currently, the decision-making capacities of the child in question are not taken into consideration, and parental consent is always required – another area in which the ministry finds it necessary to clarify the rights and obligations of parties at a time of falling vaccination rates.

In a development document released by the ministry — currently a statement of intention and not yet a bill — an unequal situation is highlighted: schoolchildren who would like to be vaccinated but whose parents forbid it are compared with their peers whose parents give their consent.

To address this imbalance, the ministry wants to permit vaccination without parental consent if the child themselves desires it and if a school nurse deems the child's level of comprehension sufficient to be able to make that decision.

Under current law, parents who consent to have their child vaccinated must send confirmation to the school nurse. However, practical issues often interfere. It is not unheard of, for instance, that come spring, after 'flu season has ended, a parent finds a crumbled scrap of paper in a schoolbag or pocket which turns out to be the vaccination consent form, left unsigned – or the parent signs it but the form never reaches the school.

Minister of Social Affairs Karmen Joller (Reform) said: "We have had parents saying their child missed vaccination because they couldn't sign [the form]. So let's do it the other way around: The minority who do not want their child vaccinated should give a signature."

Alongside the proposed change to consent procedures, the ministry also proposes in its development intention to clarify school nurses' tasks, rights, and obligations when it comes to vaccination, including assessing a child's decision-making abilities.

Legal clarity is another area of concern. Current law, critics say, does not provide a clear and uniform procedure for vaccinating minors in schools, which creates confusion when applying various legal acts. The ministry document stated that this "does not best serve the interests of the child," adding that: "Differences of opinion between the child and the parent regarding vaccination can also lead to conflicts, which in turn may reduce trust in vaccination."

Expanding on the legal nuances in a radio interview, Joller told Vikerraadio show "Uudis+," for instance, that school nurses have already had the right to assess children's decision-making abilities, as affirmed by the Chancellor of Justice, but since the current regulation does not explicitly state that, the legal phraseology needs clarifying.

To streamline implementation, parents could for instance receive a notification stating that vaccinations will take place at school, during the upcoming week, the minister suggested.

Age and comprehension are also key factors. Other factors include a child's age; reasoning will be different for seven- to eight-year-olds compared with those aged 16–17, Joller noted.

"If the healthcare worker finds that the child is capable of making a decision, understands why a vaccine, painkiller, or other medicine is needed, and this means we don't offer it to the child as a reward or incentive /.../, then the child must understand what it is for, what the risks and benefits are, and the child can decide on their own," she said.

Joller also pointed to inconsistencies in notification procedures. "Sometimes this [is] done by email, sometimes on paper," Joller – both a parent and a medical doctor – went on, describing her own experiences with granting consent at the last minute.

"It was so inconvenient: you had to download a file; I couldn't fill it out on my phone, had to sign a PDF on the computer and send it back. In a fast-paced life, that was a very lengthy process," Joller said.

"The second change we'd like to make is the one that many parents have pointed out — that a school nurse has to ask the parent for consent to vaccinate the child," she added.

To illustrate inconsistencies in healthcare policy, Joller noted that with regard to administering painkillers, for instance, parental consent is not required. With other health decisions in general, the guiding principle in Estonia is that a child's consent and opinion must be obtained and considered, in line with their developmental level. If the child is not capable of making the decision, the parent or guardian decides for them, with an exception being if this decision clearly harms the child's interests – in which case medical professionals will not follow it.

The first vaccines school-aged children get come at age 13, against measles and mumps. This is an appropriate decision-making age, she added, though this also depends on the individual child in question.

The legislative initiative is part of a broader reform. The Ministry of Social Affairs has prepared a development intention for the Communicable Diseases Prevention and Control Act (known in Estonian as NETS), which, among other things, also addresses children's vaccinations.

A major issue is that the number of vaccinated children in Estonia has been declining for over ten years, and if this trend continues, the risk of disease outbreaks and epidemics will increase.

As of 2023 in Estonia, more than 27 percent of young people had not received booster vaccinations for measles, mumps, and rubella. Among two-year-olds, the vaccination rate for these diseases had fallen to 84 percent.

The intention awaits discussion and analysis from stakeholders before being implemented as a full bill, which would then have to be voted on at the Riigikogu.

The World Health Organization (WHO) recommends vaccination coverage among children of a minimum of 95 percent, falling to 90 percent in the case of some diseases, in order to combat the spread of communicable diseases.

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