As governments worldwide grapple with an increasingly complex global health environment, determining how to optimize national immunization portfolios—deciding which vaccines to introduce and in what precise sequence—has become an exceptionally challenging task. Over the past three decades, JSI has played a foundational role in shaping global vaccine guidance, providing crucial technical assistance to more than 20 countries in strengthening their national immunization programs. Building upon this extensive legacy, JSI spearheaded the CHOICES 2.0 initiative, an ambitious project designed to guide National Immunization Technical Advisory Groups (NITAGs) and Expanded or National Programs for Immunization (EPI or NIP) through evidence-based decision-making. Utilizing the New Vaccine Introduction Prioritization and Sequencing Toolkit (NVI-PST), the initiative has sought to streamline how low- and middle-income countries select and sequence life-saving immunizations amidst tightening fiscal constraints and evolving epidemiological threats.
The urgency of this work cannot be overstated. In an era defined by overlapping economic pressures, resource limitations, and lingering post-pandemic health system strains, public health officials must make highly strategic choices. The CHOICES 2.0 project directly addressed these realities by channeling decades of institutional expertise and fostering deep collaboration with global immunization experts and working groups. By engaging closely with stakeholders at both global and regional levels—particularly across Africa—the initiative helped inform and guide evolving Vaccine Prioritization and Optimization (VPOP) processes, working in tandem with vital entities such as the Global NITAG Network to ensure that country-led decisions are grounded in robust, peer-tested methodologies.
The Evolution of the New Vaccine Introduction Prioritization and Sequencing Toolkit
At the heart of the CHOICES 2.0 methodology is the New Vaccine Introduction Prioritization and Sequencing Toolkit (NVI-PST). Developed through a sophisticated Multi-Criteria Decision Analysis (MCDA) framework combined with extensive country-level learning, the toolkit was originally created by Development Catalysts in collaboration with the inaugural CHOICES project. That foundational phase was led by the International Vaccine Access Center (IVAC) with vital support from JSI, the U.S. Centers for Disease Control and Prevention (CDC), and Development Catalysts, alongside critical partnerships with the World Health Organization (WHO) and Global NITAG Network partners.
The MCDA framework embedded within the NVI-PST allows national decision-makers to move away from ad-hoc vaccine selection processes. Instead, it provides a transparent, structured mechanism to evaluate multiple variables simultaneously, including disease burden, vaccine efficacy, cost-effectiveness, programmatic feasibility, and equity. By weighing these diverse criteria systematically, NITAGs can construct immunization schedules and introduction roadmaps that maximize public health impact while respecting financial and logistical boundaries.
A Structured Chronology of Country Engagement and Workshops
The operational rollout of the NVI-PST through CHOICES 2.0 followed a carefully structured timeline, spanning intensive country-level engagements across 2025 and 2026. Recognizing that theoretical tools must be paired with practical, hands-on capacity building, the project organized a series of targeted in-person and virtual workshops. These sessions were specifically offered to Gavi-eligible countries that formally requested engagement or agreed to participate following invitations from CHOICES 2.0 leadership.
Convened primarily by national NITAGs, these workshops served as collaborative forums where local experts could systematically prioritize and optimize their national immunization portfolios. Across the lifespan of the original CHOICES and the subsequent CHOICES 2.0 initiatives, JSI and its consortium partners successfully supported seven countries through these intensive, localized workshops. These sessions enabled multidisciplinary teams of epidemiologists, health economists, pediatricians, and immunization program managers to apply the NVI-PST to their unique domestic contexts, translating global technical standards into actionable national policies.
Expanding Reach Through Digital Collaboration and Webinar Series
Understanding that in-person workshops, while highly effective, could only reach a limited number of nations directly, the CHOICES 2.0 leadership adopted a hybrid capacity-building model. To scale its impact globally, the project partnered with the National Immunization Technical Advisory Group Support Hub (NISH) at the University of Cape Town and the World Health Organization to produce a comprehensive five-part webinar series. Titled Applying Vaccine Prioritization Strategies for Optimized Public Health Outcomes, the series drew upon the specialized expertise of representatives from NISH, JSI, WHO, UNICEF, and various national NITAGs.
Running across multiple sessions, the webinar curriculum provided NITAG members and EPI representatives with a thorough orientation on the modern vaccine prioritization workflow. Participants received detailed introductions to both the NVI-PST and the newly developed Optimization Module, examined the underlying methodologies through real-world case studies, and explored how these instruments complement existing global decision-support resources. By leveraging a digital format, the series successfully engaged NITAG members across 19 countries. This virtual outreach not only democratized access to critical technical tools but also catalyzed cross-country learning, allowing immunization experts from diverse geographic settings to share best practices, discuss common hurdles, and compare strategic solutions.
Confronting Systemic Hurdles: Data Gaps and Human Resource Constraints
Despite the proven utility of tools like the NVI-PST, the path toward sustained, independent vaccine optimization remains fraught with operational challenges. Through both phases of the CHOICES initiative, JSI has provided direct support to over 20 countries, helping them refine their introduction roadmaps. While a subset of these nations has successfully integrated these methodologies into routine governance and allocated domestic resources to maintain them autonomously, a significant majority still encounter substantial hurdles.
Chief among these obstacles is a persistent scarcity of granular data. Many countries report an urgent need for more robust local epidemiological profiles, precise disease burden assessments, and reliable data on vaccine market dynamics and real-world performance—both from within their own borders and from comparable socio-economic settings. Without these empirical inputs, decision-makers face heightened uncertainty when projecting the long-term clinical and economic impacts of introducing novel immunization products.
Compounding these informational deficits are severe human resource and financial limitations. The vast majority of NITAG members serve on a voluntary basis, balancing their advisory duties with demanding full-time clinical, academic, or administrative careers. Expecting volunteer experts to independently execute complex evidence syntheses, economic evaluations, and multi-criteria analyses without dedicated institutional backing is increasingly untenable.
To bridge this gap, CHOICES 2.0 played a vital intermediary role by supplying essential administrative bandwidth, technical facilitation, and complementary financial assistance. By lifting the heavy operational burden associated with evidence gathering and stakeholder coordination, the project helped cultivate the necessary political buy-in from national authorities, ensuring that medical and public health experts had the protected time required to perform this vital advisory work.
The Broader Implications for Global Health Security and Sustainable Immunization
As the international community confronts a convergence of structural pressures—including escalating sovereign debt burdens, shifting donor landscapes, and the continuous emergence of novel infectious disease threats—the structured optimization of vaccine portfolios has transitioned from a technical luxury to an absolute necessity. The introduction of advanced vaccine innovations, such as new malaria, RSV, and pneumococcal formulations, offers unprecedented opportunities to save lives, yet it also strains existing health budgets and cold-chain capacities.
Experts emphasize that navigating this polycrisis requires a permanent shift toward institutionalized, evidence-based prioritization practices. For this practice to take root sustainably, an enabling environment must be continuously nurtured by Ministries of Health, national immunization programs, the global VPOP technical working group, the Global NITAG Network, and international resource partners.
Ultimately, the success of initiatives like CHOICES 2.0 demonstrates that while technical tools like the NVI-PST are indispensable, their ultimate value lies in their ability to empower local leadership. By combining rigorous, transparent analytical frameworks with dedicated administrative and financial scaffolding, the global health community can help nations make informed, equitable, and resilient choices that safeguard public health for generations to come.
