Operational intelligence for immunization recovery: mapping system shocks and capacity to zero-dose debt and outbreak...

Immunization services continue to face uneven recovery following the COVID-19 shock, leaving zero-dose children unreached and elevating the risk of measles in many settings. We analyzed a multicountry observational panel spanning 2019-2024 to generate operational intelligence for immunization recovery. Using routinely available indicators, we developed measures of service disruption (including conflict exposure, displacement pressure, and price instability) and indicators of system capacity (governance effectiveness and health financing) and then summarized coverage gaps relative to prepandemic baselines as recovery debt. We identified service delivery archetypes using unsupervised clustering, with stability and interpretability checks, and then assessed whether archetype membership and recovery debt were associated with reported measles activity using negative binomial models with population offsets, regional fixed effects, and clustered standard errors. Four robust archetypes emerged, each characterized by distinct driver profiles and equity gradients. Two of these archetypes accounted for the majority of recovery debt and were associated with substantially higher measles incidence compared to the lowest-risk reference group, with patterns remaining robust across prespecified sensitivity analyses. Countries transitioning toward lower-risk archetypes over time exhibited improvements in predicted measles activity. These findings provide a health services typology that links routinely available indicators to immunization service risk, enabling managers to target high-leverage recovery actions, prioritize catch-up delivery, and monitor service improvements alongside surveillance indicators.