In an era of big global health budget cuts that often demand tough choices, identifying vaccine needs and priorities at national level is increasingly important. As we observe World Immunization Week, it’s time to recognize the pivotal role that National Immunization Technical Advisory Groups (NITAGs) can play in guiding effective, evidence-based decisions – alongside global guidance from the World Health Organization.

From infancy to old age, vaccines are a life-saving tool. Over the past 50 years, vaccines have saved more than 150 million lives. They play a decisive role in keeping us safe from diseases through childhood, strengthening our immune responses in adulthood, and keeping us out of hospital in our older years. 

Immunisation currently prevents 3.5 million to 5 million deaths every year from diseases like tetanus, pertussis, influenza, and measles.

Without vaccines, diseases consigned to the past could resurge in our present. Funding cuts and reduced resources are increasing barriers to vaccine research and development, as well as  equitable access to immunisation – including the routine vaccination of young children in low- and middle-income countries. This reduction in support and resources is forcing organisations like the World Health Organization and Gavi, the Vaccine Alliance, to rethink how they operate. Vaccine decision-making is no longer about access alone; it’s about prioritisation under constraints.

From global guidance to national decision-making

Many countries still rely heavily on vaccine recommendations made by the WHO through the Strategic Advisory Group of Experts on Immunization (SAGE). While being scientifically robust and relevant they do not always reflect the specific needs, challenges or health systems of individual countries. With global health funding undergoing dramatic reductions, countries and regions most affected by infectious diseases are facing difficult decisions about which diseases to prioritise and how best to procure and roll-out vaccines to maintain even fuller vaccination schedules.  

This greater emphasis on country-level decision-making is appropriate – countries affected by diseases are best placed to make decisions on how to tackle them. However, it takes time to build expertise and evidence, and responsibility is being decentralised faster than this capacity can be developed, with experts required to wear multiple hats.   

This is not merely a technical challenge, but a political and operational one. It requires a reshaping of power and accountability in global health structures. filling gaps in infrastructure to support more national and regional decision-making.  

Regional decisions need regional expertise

Building regional sharing of expertise is now as critical as supply chains. This is where advisory groups such as the National Immunization Technical Advisory Groups (NITAGs), can play a pivotal role in guiding effective, evidence-based decisions. Each country’s NITAGs expertise differs, but their aim is the same – multidisciplinary independent experts assess whether international knowledge is applicable and relevant to local contexts, informing appropriate policy recommendations at a national level and bridging the gap between research and policy action.  

The impact of NITAGs can be felt quickly, allowing the introduction of specific vaccines that better suit the regional needs – whether it’s switching from one malaria vaccine to another in Nigeria, or the introduction of a Hepatitis B vaccine given at birth in Lesotho.  

For this model to work effectively, sustained funding is needed not just for research projects but to support policy-relevant expertise, enabling research to be translated into country-relevant recommendations. 

This is why Wellcome is investing in the African-led NITAG Support Hub, or NISH, which helps strengthen NITAGs across Africa. Through local evidence and support, and by sharing expertise and best practice via resource hubs, countries can be better prepared to navigate choices, including which of the increasingly robust array of lifesaving vaccines to prioritise, where, and how – all whilst aid and global health budgets are shrinking. 

Similarly, Gavi, The Vaccine Alliance has introduced ‘The Gavi Leap’ – a new operating model aiming to support country self-reliance to transition away from donor-led systems. Gavi Leap is increasing resources to help countries decide their own priorities, financing and delivery of vaccines with the long-term goal of immunisation sustainability. 

The intervention trade-offs 

Amidst global instability, decision-makers increasingly need to balance the benefits of investing in one vaccine over another, as well as balancing the costs of vaccine procurement and distribution with spending on other interventions such as diagnostics and therapeutics, surveillance and health system strengthening.  

For example, while oral cholera vaccines alone protect individuals against the disease, and water, sanitation and hygiene (WASH) alone reduces the amount of bacteria in the environment, studies suggest that combining the oral cholera vaccine with improved household WASH leads to optimal protection.  

There is a tricky balance to strike, taking into account factors such as available resources; behavioural attitudes to interventions; the benefits and risks of mass immunisation campaigns; and the needs of vulnerable, under-resourced communities. And any public health policies must take a long-term view, with the ability to adapt to changing circumstances – such as the emergence of new outbreaks, new pathogen variants, and new forms of disease resistance. 

Diverse expertise combined with awareness of local needs and barriers is essential to ensure vaccines are neither over-prioritised nor underused. Global health will, and must, be a global effort, and international guidance remains essential. But it cannot replace regional and national judgement and local knowledge of community needs and challenges. 

Investment in expertise means equitable vaccine policies 

With tightening global funding, choices between vaccines and other essential health interventions are unavoidable. Doing so without investment in more localised expertise is not.  

Investing in national and regional advisory capacity, knowledge-sharing and long-lasting expertise is not a luxury, it is the foundation of smarter, fairer vaccine decisions in an increasingly constrained world. 

Charlie Weller is the Head of Prevention in Wellcome’s Infectious Disease team. Since 2016, she has led the team to develop new and improved vaccines and antibodies – from managing the research and funding response to the Ebola epidemic of 2014-2015, to helping the co-founding of the Coalition for Epidemic Preparedness Innovations (CEPI), which is investing in new vaccine development that protects the world from epidemic and pandemic threats. 

Image Credits: University of Oxford/ Tom Wilkinson, Shattock A, Johnson H, Sim S et al.,The Lancet, May 2024, E. Fletcher/Health Policy Watch , Eduardo Soteras Jalil/ WHO.