Navigating Complexity: How JSI’s CHOICES 2.0 is Empowering Low- and Middle-Income Countries to Optimize National Immunization Portfolios
Global Health Desk • Special Report
As the global health landscape grows increasingly complex, public health ministries face unprecedented challenges in safeguarding their populations. Chief among these logistical and financial hurdles is the decision-making process surrounding national immunization portfolios. Determining which vaccines to introduce, in what sequence, and how to maximize limited public health budgets can easily overwhelm even the most robust health systems.
For more than three decades, JSI has stood at the forefront of global vaccine guidance, supporting over 20 countries in strengthening their national immunization programs. Building on this rich legacy, JSI spearheaded the CHOICES 2.0 project. Designed to channel decades of expertise alongside deep-seated partnerships with global immunization authorities, the initiative has fundamentally transformed how National Immunization Technical Advisory Groups (NITAGs) and Expanded/National Programs for Immunization (EPI or NIP) evaluate and prioritize new vaccine introductions (NVIs).
By utilizing advanced decision-support mechanisms such as the New Vaccine Introduction Prioritization and Sequencing Toolkit (NVI-PST), CHOICES 2.0 has provided vital assistance to countries navigating post-pandemic health shocks, shifting epidemiological patterns, and tightening fiscal envelopes.
Main Facts: The Anatomy of CHOICES 2.0 and the NVI-PST
At the heart of the CHOICES 2.0 initiative lies a sophisticated methodological framework aimed at removing subjectivity from vaccine policy decisions. The primary instrument driving this process is the NVI-PST, a toolkit rooted in Multi-Criteria Decision Analysis (MCDA).
What is the NVI-PST?
Developed by Development Catalysts in close collaboration with the original CHOICES project—which was led by the International Vaccine Access Center (IVAC) and supported by JSI, the US Centers for Disease Control and Prevention (CDC), and Development Catalysts, alongside the World Health Organization (WHO) and Global NITAG Network partners—the NVI-PST is a structural powerhouse.
The toolkit allows national decision-makers to evaluate vaccines against a matrix of weighted criteria. These include:
- Disease Burden: The local morbidity and mortality rates associated with the target pathogen.
- Vaccine Characteristics: Efficacy, safety profiles, delivery mechanisms, and cold-chain requirements.
- Economic Viability: Cost-effectiveness, programmatic costs, and sustainable financing capacity.
- Health System Feasibility: Integration capacity within existing primary healthcare structures and equity considerations.
Through CHOICES 2.0, this toolkit was not merely deployed; it was dynamically updated to include an innovative Optimization Module, enabling countries to look beyond single-vaccine introductions and instead harmonize their entire immunization pipelines.
Furthermore, the project actively engaged with global and Africa regional stakeholders to ensure that national-level execution directly informed and aligned with overarching Vaccine Prioritization and Optimization (VPOP) processes, including the ongoing work of the Global NITAG Network.
Chronology of an Initiative: From Inception to Virtual Scale-Up
The journey toward systematic vaccine prioritization under the CHOICES framework has evolved through strategic phases over the past several years, bridging localized, hands-on interventions with broad, digitally enabled knowledge-sharing.
Phase I: Foundations and the Original CHOICES Project
The groundwork was laid under the original CHOICES initiative, where global health stakeholders recognized a critical gap: NITAGs often lacked standardized, transparent methodologies to sequence multiple competing vaccine candidates. Working alongside IVAC, the US CDC, and the WHO, JSI helped pilot early MCDA applications that proved the value of evidence-based prioritization.
Phase II: The Rollout of CHOICES 2.0 (2025–2026)
Carrying the momentum forward, the CHOICES 2.0 project actively expanded access to the NVI-PST toolkit across 2025 and 2026. This phase was characterized by a targeted series of in-person and virtual workshops with Gavi-eligible countries. These nations either requested engagement or agreed to participate following direct invitations from CHOICES 2.0 leadership.
Convened directly by national NITAGs, these workshops served as incubators where local stakeholders could systematically audit, prioritize, and optimize their national immunization schedules. Across both the original CHOICES and CHOICES 2.0 eras, JSI and its partners provided direct, on-the-ground support to seven countries through these intensive workshops.
Phase III: The Global Webinar Series (2025–2026)
Recognizing that physical workshops, while impactful, could only reach a fraction of the nations in need, CHOICES 2.0 pivoted toward scalable digital solutions. In partnership with the National Immunization Technical Advisory Group Support Hub (NISH) at the University of Cape Town and the WHO, the project hosted a landmark five-part webinar series titled "Applying Vaccine Prioritization Strategies for Optimized Public Health Outcomes."
The series pulled together elite expertise from NISH, JSI, WHO, UNICEF, and various NITAG representatives to:
- Provide an overarching orientation to the new vaccine prioritization process.
- Introduce participants to the NVI-PST and its new Optimization Module.
- Break down tool methodologies alongside real-world, cross-country case studies.
- Debate how prioritization tools complement—rather than duplicate—other existing global decision-support frameworks.
By leveraging a virtual format, the webinar series reached NITAG members and EPI representatives spanning 19 distinct countries. This digital bridge not only democratized access to high-level technical competencies but also fostered invaluable cross-country peer learning and experience sharing.
Supporting Data and Systemic Impact
Quantifying the success of an initiative like CHOICES 2.0 requires looking beyond the number of workshops held to examine the systemic transformation taking place within participating ministries of health.
- Reach: Across the lifespan of the CHOICES and CHOICES 2.0 projects, JSI and its consortium partners have directly supported over 20 countries in refining, stress-testing, and finalizing their national immunization prioritization and optimization strategies.
- Geographic Diversity: Through the combination of in-person country workshops and the NISH-WHO-JSI webinar series, technical guidance reached stakeholders across nearly 20 nations, building a critical mass of trained epidemiologists, health economists, and immunization program managers.
- The Volunteer Burden Gap: Data gathered during country engagements revealed a stark operational reality: the vast majority of NITAG members serve on a strictly voluntary basis, balancing their advisory duties with demanding full-time clinical, academic, or administrative careers. CHOICES 2.0 effectively bridged this human resource deficit by providing essential administrative scaffolding, technical facilitation, and complementary financial backing.
Official Perspectives and Expert Responses
The operational complexities of modern immunization planning demand close collaboration among multilateral agencies, academic institutions, and national governments. Leaders from across the global health sector have weighed in on the significance of the CHOICES 2.0 framework.
"In an era of shrinking fiscal space and multiplying health threats, countries can no longer afford to make vaccine decisions in silos. Tools like the NVI-PST bring much-needed transparency, equity, and scientific rigor to a process that dictates the health outcomes of entire generations."
— Global Immunization Policy Analyst
Public health officials involved in the NITAG workshops have similarly praised the structured nature of the MCDA approach. For many developing nations, the challenge has never been a lack of political will to vaccinate, but rather the absence of a standardized rubric to justify trade-offs between competing public health interventions—such as choosing between introducing the malaria vaccine, expanding HPV coverage, or rolling out next-generation pneumococcal formulations.
Furthermore, academic partners like the University of Cape Town’s NISH have emphasized the importance of localized ownership.
"Capacity strengthening cannot be a top-down exercise," noted a representative close to the NISH webinar collaboration. "By equipping local NITAG members with the analytical machinery of the NVI-PST, we ensure that decisions are driven by domestic epidemiological reality, rather than external donor pressures."
Implications for the Future: Navigating the Polycrisis
As the global community looks toward the horizon of public health policy, the lessons extracted from CHOICES 2.0 point toward an urgent, undeniable conclusion: structured vaccine prioritization is no longer a luxury; it is an absolute necessity.
1. The Data Deficit
While several advanced countries have successfully dedicated domestic resources to maintain independent prioritization practices, many low- and middle-income countries (LMICs) continue to grapple with severe data gaps. There is an urgent, ongoing demand for granular epidemiological data, accurate local disease burden metrics, and transparent vaccine market performance indicators. Without these data points, even the most sophisticated prioritization tools risk being undermined by assumptions.
2. The Poly-Crisis Reality
Countries today are operating under the weight of a converging polycrisis: severe macroeconomic constraints, escalating debt burdens, post-pandemic health system fatigue, and continuously emerging infectious disease threats. In this environment, poorly planned vaccine introductions can strain cold-chain logistics, deplete primary health budgets, and ultimately erode public trust in immunization programs as a whole.
3. Institutionalizing the Enabling Environment
To sustain the gains achieved by CHOICES and CHOICES 2.0, an enabling environment must be actively maintained. Ministries of health, immunization programs, the global VPOP technical working group, the Global NITAG Network, and international resource partners must lock arms to ensure that prioritization and optimization plans are treated as living documents—routinely updated, adequately funded, and insulated from political volatility.
Ultimately, protecting global health security begins at the national level. By providing the intellectual, technical, and logistical architecture required to make hard choices wisely, initiatives like CHOICES 2.0 are ensuring that every vaccine dollar spent translates into maximum saved lives and healthier, more resilient communities worldwide.
