In an increasingly complex global health landscape, governments and public health ministries face profound challenges when deciding how to structure and optimize their national immunization programs. Determining which vaccines to introduce, the optimal sequencing for rollout, and how to allocate scarce financial and logistical resources can be an exceptionally complicated process. For more than three decades, JSI has played a pivotal role in shaping global vaccine guidance, providing technical assistance to more than 20 countries to strengthen their national immunization systems. Building upon this extensive legacy, JSI recently spearheaded the CHOICES 2.0 initiative, a landmark project designed to support National Immunization Technical Advisory Groups (NITAGs) and Expanded Programs on Immunization (EPI) or National Immunization Programs (NIP). By leveraging sophisticated decision-support tools and fostering international collaboration, the project has transformed how low- and middle-income countries approach vaccine introduction and portfolio optimization.
The Genesis of CHOICES 2.0 and the Evolution of Vaccine Prioritization
The modern global health architecture is confronted by a convergence of crises—ranging from enduring post-pandemic economic strains and severe funding constraints to shifting infectious disease patterns and a rapid influx of novel vaccine technologies. In this environment, traditional, ad-hoc methods of vaccine introduction are no longer sustainable. Recognizing the need for systematic, evidence-based decision-making, JSI channeled decades of institutional knowledge into the CHOICES 2.0 initiative.
Working in close partnership and coordination with global immunization experts, technical working groups, the World Health Organization (WHO), UNICEF, and the Global NITAG Network, the initiative aimed to guide Vaccine Prioritization and Optimization (VPOP) processes. The primary vehicle for this endeavor was the New Vaccine Introduction Prioritization and Sequencing Toolkit (NVI-PST). The NVI-PST was originally born out of the first iteration of the CHOICES project—led by the International Vaccine Access Center (IVAC) in collaboration with JSI, the U.S. Centers for Disease Control and Prevention (US CDC), and Development Catalysts—alongside inputs from the WHO and global NITAG partners.
Grounded in a Multi-Criteria Decision Analysis (MCDA) framework and refined through rigorous country-level learning, the NVI-PST provides a structured, transparent methodology for evaluating competing public health priorities. MCDA allows advisory groups to weigh multiple qualitative and quantitative factors simultaneously, including local disease burden, vaccine efficacy, cost-effectiveness, programmatic feasibility, equity, and supply chain constraints. By transitioning from subjective evaluations to a reproducible, data-driven methodology, NITAGs can formulate recommendations that command greater confidence from Ministries of Health and external donors alike.
A Chronology of Engagement: Workshops and Capacity Building in 2025 and 2026
The implementation phase of CHOICES 2.0 rolled out across a critical two-year window spanning 2025 and 2026. During this period, the project focused on expanding access to the NVI-PST toolkit primarily among Gavi-eligible countries that formally requested engagement or accepted invitations extended by project leadership.
These interventions took the form of intensive, highly structured in-person and virtual workshops. Convened directly by national NITAGs, these workshops served as operational laboratories where stakeholders could systematically evaluate, prioritize, and optimize their national immunization programs. Across the combined lifespans of the original CHOICES initiative and CHOICES 2.0, JSI and its core partners directly supported seven countries through these specialized country workshops, guiding local experts through the nuances of the MCDA framework and helping them apply the NVI-PST to their unique epidemiological contexts.
However, recognizing that in-person workshops, while deeply impactful, could only reach a limited number of jurisdictions, the project team devised a complementary strategy to scale its reach. In collaboration with the National Immunization Technical Advisory Group Support Hub (NISH) at the University of Cape Town and the World Health Organization, CHOICES 2.0 launched a comprehensive five-part webinar series. Entitled Applying Vaccine Prioritization Strategies for Optimized Public Health Outcomes, the series was engineered to democratize access to advanced decision-making tools.
Reaching Beyond Borders: The Five-Part Webinar Series
The webinar series featured subject-matter expertise from NISH, JSI, WHO, UNICEF, and various national NITAG representatives, creating a dynamic forum for knowledge exchange. The curriculum was meticulously designed to take participants through the entire lifecycle of vaccine prioritization:
- Session 1: An overarching orientation to the modern landscape of new vaccine prioritization processes and public health optimization.
- Session 2: An in-depth introduction to the NVI-PST framework and the newly developed Optimization Module, which allows countries to model different portfolio combinations over time.
- Sessions 3 and 4: Technical deep-dives into the methodologies underlying the tools, supported by concrete, real-world case studies from countries that have successfully implemented the toolkit.
- Session 5: A critical discussion on how the NVI-PST and optimization modules complement existing global decision-support resources, ensuring that countries do not operate in a fragmented advisory ecosystem.
The virtual format proved to be a resounding success in terms of participation and geographic diversity. NITAG members and EPI representatives from 19 countries participated in the series. By removing travel barriers, the webinars not only disseminated critical technical knowledge to a wider audience but also fostered an invaluable culture of cross-country learning, allowing advisory groups facing similar economic and epidemiological hurdles to share best practices and lessons learned.
Overcoming Systemic Hurdles: The Reality of NITAG Operations
Despite the sophistication of tools like the NVI-PST, implementing evidence-based prioritization at the national level is fraught with structural challenges. A fundamental hurdle identified by the CHOICES 2.0 project is the human resource and capacity constraint under which most NITAGs operate.
Globally, the vast majority of NITAG members serve on a voluntary, part-time basis. These individuals are typically leading clinicians, academic researchers, epidemiologists, and public health officials who maintain demanding full-time responsibilities within their primary institutions. Asking these experts to review vast quantities of global and local data, conduct complex modeling exercises, and draft nuanced policy recommendations without dedicated administrative support is a recipe for burnout and delayed decision-making.
Furthermore, many low- and middle-income countries struggle with data gaps. While the NVI-PST provides an exceptional analytical framework, it requires robust inputs. Ministries of Health frequently report a pressing need for more granular epidemiological data, localized disease burden studies, timely vaccine market intelligence, and performance metrics drawn from peer nations with similar socio-demographic profiles. Without these localized data points, tailoring global recommendations to local realities becomes exceedingly difficult.
The Role of CHOICES 2.0 in Creating an Enabling Environment
To counteract these systemic limitations, CHOICES 2.0 functioned not merely as a software training program, but as an institutional facilitator. The project provided vital administrative bandwidth, technical facilitation, and complementary financial support where national budgets fell short. By shouldering the heavy logistical burdens associated with evidence synthesis and workshop facilitation, the project helped cultivate essential political buy-in. This institutional backing ensured that national experts were granted the protected time and resources required to dedicate themselves to the prioritization process.
Experts note that creating an enabling environment is a prerequisite for sustainable immunization governance. Ministries of Health, immunization programs, international technical working groups, the Global NITAG Network, and global donor partners must continue to align their efforts. Without ongoing institutional support, individual advisory groups will struggle to routinely update their prioritization and optimization plans as new vaccine innovations emerge onto the global market.
Implications for the Future of Global Immunization
As the global health community looks toward the remainder of the decade, the implications of initiatives like CHOICES 2.0 are profound. The convergence of tightening public health budgets, shifting donor priorities, and a burgeoning pipeline of novel vaccines—ranging from next-generation pneumococcal conjugate vaccines and malaria immunizations to RSV preventatives—means that countries can no longer simply "add all" available interventions to their national schedules.
Prioritization is no longer a theoretical exercise; it is an economic and ethical necessity. By embedding structured prioritization practices into national policy-making, countries can maximize their return on investment, protect the most vulnerable populations, and safeguard the long-term financial sustainability of their health systems.
Through the combined efforts of CHOICES and CHOICES 2.0, more than 20 nations have taken decisive steps toward mastering their national immunization portfolios. While significant challenges remain—particularly regarding data availability, funding volatility, and volunteer burnout—the methodological groundwork laid by JSI and its partners has established a resilient blueprint for the future. Sustaining this momentum will require continued international solidarity, robust domestic resource mobilization, and an unwavering commitment to evidence-based public health policymaking.
