Exploring measures of sustainability in the WHO Joint External Evaluation and the WOAH performance of veterinary services tools—A qualitative assessment of perceived usefulness and acceptability to one health and global health security experts
PMCID: PMC12959694
PMID: 41779720
Abstract
Introduction Amidst global policy reforms including the 2024 amendments to the International Health Regulations (IHR) and the ongoing Pandemic Agreement negotiations, there is a renewed emphasis on sustainability, equity, and multisectoral coordination in global health security. However, the operationalization of sustainability in core assessment tools—such as the WHO Joint External Evaluation (JEE) and the WOAH Performance of Veterinary Services (PVS)—remains poorly defined and underdeveloped, particularly as they relate to low- and middle-income countries (LMICs). Methods We conducted a qualitative study involving semi-structured interviews with 29 global experts across human, animal and environment health from both high and low/middle income countries affiliated with the One Health High-Level Expert Panel, the World Bank Pandemic Fund Technical Advisory Panel, and technical focal points from Quadripartite institutions. Using thematic analysis grounded in the Social Construction Framework and an adapted Schell et al. sustainability model, we explored how sustainability is conceptualized and measured across human, animal, and environmental health domains. Results Participants critiqued existing tools for framing sustainability narrowly, including their focus on short-term processes and compliance, rather than long-term outcomes, equity, or resilience. Sectoral and contextual differences emerged: human health experts emphasized workforce and financing; animal health experts stressed economic and institutional continuity; environmental health experts highlighted ecosystem resilience and intergenerational equity. LMIC respondents underscored the impact of donor dependency, weak local ownership, and limited transition planning. Several determinants of sustainability—such as financing, governance, workforce retention, and community engagement—are already measured in existing reporting tools but are not explicitly or coherently framed as sustainability indicators. Discussion We recommend that future iterations of JEE and PVS incorporate a clear definition of sustainability and explicitly integrate sustainability metrics, aligned with the revised IHR, the One Health Joint Plan of Action, relevant SDG targets and national planning cycles. Tools must also reflect sectoral and contextual nuances and integrate long-term monitoring frameworks that promote domestic accountability. In the field of One Health and GHS, strengthening the sustainability components of these tools is essential to build equitable and resilient health systems globally.
Full Text
Global health security (GHS) encompasses the proactive and reactive measures taken to prevent, detect, and respond to infectious disease and other public health threats that transcend national borders [1]. Its modern origins can be traced back to the 19th-century International Sanitary Conferences (ISC), where the primary objective was to safeguard the health of populations in imperial centers from diseases perceived to originate in the colonies. These conferences sought standardized quarantine measures to protect trade and prevent the spread of diseases such as smallpox, cholera, plague, and yellow fever [2]. The ISCs laid the groundwork for the creation of the World Health Organization (WHO) and subsequent international health agreements and other institutions, embedding colonial attitudes and priorities into the fabric of global health governance. The International Health Regulations (IHR), first adopted in 1969 to address ISC-focused diseases were revised and expanded in 2005 to an all-hazards approach and represent a legally binding framework for GHS [3,4]. Despite their importance and a further revision in 2024, critiques persist regarding the IHR’s efficacy, enforceability and equity, particularly concerning the capacities of low- and middle-income countries (LMICs) to comply with and benefit from the regulations [5,6].
The COVID-19 pandemic exposed and exacerbated these systemic weaknesses, underscoring the need for a more robust, inclusive, and sustainable GHS architecture. In response, WHO Member States initiated negotiations in 2021 for a new Pandemic Agreement, yet deep divisions persist between high-income countries (HICs) and LMICs, on equitable access to vaccines, pathogen sharing, and intellectual property rights [7–9]. The parallel IHR revision process in 2024 has placed greater emphasis placed on incorporating One Health principles, sustainability, and equitable access to medical countermeasures and financing [4,6]. These developments mark a critical policy shift in global health governance: equity, multisectoral collaboration, and long-term resilience are now central pillars of health security.
The integration of sustainability into GHS discourse grew after the publication of the Brundtland Report in 1987, which defined sustainable development as that which “meets the needs of the present without compromising the ability of future generations to meet their own needs” [10]. That report kickstarted an international process to harmonize and unify efforts around three pillars of development – society (including health), economy and environment – culminating with world leaders committing in 2015 to achieving 17 Sustainable Development Goals (SDGs) by 2030 [11]. Sustainability in GHS implies the enduring ability of health systems to manage and recover from shocks, particularly in resource-constrained environments. However, achieving sustainability is increasingly jeopardized by a contraction in donor funding. Significant reductions by major donors such as the United Kingdom and the United States have led to programme closures, workforce reductions, and risks to disease control efforts in several LMICs [12–14]. UNAIDS has announced workforce cuts exceeding 50%, while WHO has warned that several countries may soon run out of HIV medicines [14–16]. Only 17% of assessable SDG targets remain on track for 2030 [17]. In this context, sustainability is both a strategic and ethical imperative for GHS.
The One Health approach offers a promising avenue to advance sustainability by recognizing that the health of humans, domestic and wild animals, plants, and the wider environment (including ecosystems) are closely linked and interdependent. The approach encourages multisectoral collaboration, transdisciplinarity and resource-sharing, and is predicated on principles of equity, inclusiveness and responsible stewardship [18–20]. Its application is particularly valuable in LMICs, where human health is often deeply interwoven with agricultural practices, livestock management, and environmental change. Moreover, One Health can enhance program efficiency in resource-limited settings by enabling integrated surveillance, shared infrastructure, and joint emergency response mechanisms [21–23]. In the current funding climate, such cross-sectoral integration can provide a buffer against systemic fragility and promote better health and well-being outcomes for humans, animals and ecosystems at lower cost.
Nevertheless, sustainability remains variably defined and inconsistently measured across One Health and GHS frameworks [24]. In One Health, sustainability is often understood in ecological and systems terms whereas in GHS it is more closely tied to institutional capacities and functional continuity [25,26]. This conceptual divergence poses a challenge for standardized monitoring and evaluation. Existing assessment tools for the IHR and health security—particularly the WHO Joint External Evaluation (JEE) and the World Organization for Animal Health (WOAH) Performance of Veterinary Services (PVS) Pathway—are central to the IHR Monitoring and Evaluation (M&E) Framework and are widely used to assess national preparedness and response capacities [27,28]. Although they assess may elements of preparedness capacities comprehensively, they lack robust indicators of long-term resilience and sustainability across sectors despite aiming to adopt a One Health approach [29].
[29] Moreover, they do not consistently account for how One Health coordination, environmental degradation, or donor dependency influence the durability of health systems.
Social constructionism posits that knowledge—especially in the policy realm—is not a fixed or objective entity, but one co-produced through social processes, institutional practices, power asymmetries, and professional narratives [30–32]. In this view, concepts such as “sustainability,” “health security,” and “One Health” are not objective realities that are universally understood the same way, but constructed in different ways in different contexts, and by different disciplines and governance arrangements. A social constructionist lens enables researchers to analyze not just what is said, but how meanings are framed and legitimated through institutional and sectoral discourses.
Alternative paradigms were considered. Critical realism offers value when investigating generative mechanisms or causality within systems, while positivism assumes measurable, objective realities. However, both orientations aim to discover generalizable objective truths, while the main focus of our study was exploring diverse, subjective constructions of meaning [33]. For example, when trying to understand the impact of a health intervention like a new vaccination program, a critical realist approach might analyze its effectiveness in the context of wider determinants of health, such as access to healthcare, education levels, or income levels, and uncover how structural inequalities can undermine the intervention’s intended outcomes. A social constructionist approach might focus on how people perceive and understand the vaccine, its benefits, and the social meaning they attach to being vaccinated. They might explore how cultural beliefs, personal experiences, and social norms shape people’s decisions about vaccination. They would examine how the intervention is understood and interpreted within different social groups, potentially revealing how societal factors, like distrust in government institutions, can influence vaccination decisions. On balance, social constructionism aligned more directly with the study’s aim to examine how actors from different sectors, regions, and institutions construct, contest, and negotiate the idea of sustainability within global health security governance and the use of tools like the JEE and PVS [34,35].
OHHLEP, a multi-disciplinary group established by the Quadripartite (WHO, WOAH, FAO, UNEP) to provide independent technical and policy guidance on One Health [36];
The World Bank Pandemic Fund Technical Advisory Panel (TAP), composed of global experts who review and score funding proposals based on their technical quality, sustainability plans, and adherence to One Health principles [37];
Global One Health technical focal points from the Quadripartite institutions, responsible for operationalising the Joint Plan of Action (2022–2026) on One Health at national and international levels [38].
A small number of additional subject matter experts outside of these three groups were identified and recruited via snowball sampling (N = 5). Three invited experts were unavailable due to scheduling conflicts. No one declined to participate once invited. All interviewees were selected based on their cross-sectoral experience, with backgrounds spanning at least two of the human, animal, or environmental health domains. For descriptive purposes of the study, however, we classified interviewees based on their self-identified primary sectoral background. The final sample included 29 participants, with balanced representation across disciplines, sectors and income settings; 11 individuals with predominantly human health expertise, 11 with backgrounds in animal health, and 7 specialising in environment/ecosystem health. Alongside clinical and scientific disciplines such as human medicine, veterinary medicine, and the biological sciences, participants collectively brought knowledge from fields including epidemiology, statistics, health emergency response, logistics, social sciences, environmental engineering and management, political science, conservation, health economics, and mathematical modelling. The sample represented all major world regions—Africa, Asia, Europe, Oceania, and North and South America—and included professionals from both high-income settings and low- and middle-income countries (see Table 1). Gender was balanced across the sample frame with 15 female and 14 male participants. We do not report specific numbers by each category to assure the anonymity of interviewees. Environment specialists with combined global health security as well as One Health expertise were underrepresented in the sample despite concerted effort to recruit suitable participants, and reflects the wider underrepresentation of environment and ecosystem health specialists – particularly those hailing from LMIC settings – in global health security and One Health international policy fora.
Data collection was conducted between July 2023 and March 2024. Informed consent was obtained verbally and in writing. All participants received, at least three weeks in advance, a 5-minute summary briefing derived from a prior document analysis of the JEE and PVS tools, conducted by the study team and published separately [29]. This document analysis applied an adapted version of the Schell et al. sustainability framework, identifying where and how sustainability was referenced across both tools [39]. A summary was also presented at the start of each interview via a PowerPoint slide set (Supplementary information 1; Appendix 2) to provide a shared entry point for reflection and discussion.
Interviews were conducted in English by two researchers experienced in qualitative research (OAD, MC) jointly, via Zoom or MS Teams video. Calls lasted 40–50 minutes and followed a semi-structured interview guide (Supplementary information 1: Appendix 3). All interviews were audio-recorded, transcribed verbatim and anonymized. MS Excel was used as a matrix-management tool to organise transcripts, codes, and mapped themes, while analysis followed Braun and Clarke’s reflexive thematic approach, enabling iterative comparison and theme development across sectors [40]. Three researchers (OAD, MC, HZ) independently reviewed transcripts and performed initial inductive open coding, identifying recurring patterns and emergent categories. This enabled multiple interpretations to surface and be captured – coding differences were discussed and resolved through consensus-building analytic meetings, with codebooks refined iteratively. In the second phase of analysis, we applied a structured coding frame that integrated constructs from both the Schell et al. sustainability framework and the Social Construction Framework (SCF) which support analysis through a social constructionist lens [34,35,39]. This dual-framework approach enabled us to link more tangible sustainability domains (e.g., financing, workforce, institutional infrastructure etc.) with discursive and power-related dimensions such as deservingness, framing, and narratives of accountability.
The COREQ 32-item checklist was used to guide the reporting of this study’s qualitative methods and findings (Supplementary information 1: Appendix 4 in S1 File) [41].
As shown in Table 2, process versus outcome orientation, financing, and timeframes were framed by interview respondents differently across sectors, and between HIC and LMIC settings. Differences in perceived “deservingness,” power, and visibility or accountability across sectors align with the SCF, influencing which capacities are prioritised for sustained investment.
This qualitative study reveals that the current framing of sustainability within GHS assessment tools – namely the JEE and PVS – remains narrowly process-oriented and insufficiently aligned with long-term outcomes, contextual realities, or One Health imperatives. Across all sectors, experts critiqued the absence of robust mechanisms for capturing the durability of capacities, particularly in LMICs where donor dependency, workforce attrition, and institutional fragility undermine sustainability. These insights resonate with critiques from the existing literature, which note that although revisions of the JEE and PVS have incrementally improved in scope, they still fall short in embedding sustainability as a structural goal rather than a procedural achievement [24,25,42]. Notably, several participants argued that sustainability cannot be divorced from the global political economy of health security governance. The severe funding contractions from major donors — including the UK FCDO and USAID — since 2020, and the increasing securitisation of global health under “national interest” doctrines, were viewed as existential threats to the durability of capacities in LMICs. This reflects a recurrent criticism of IHR implementation: without guaranteed, long-term, and sovereign financing, sustainability remains aspirational [12–14,42].
Sustainability was widely understood by participants not merely as the continued existence of systems, but as the enduring capacity of those systems to adapt, function, and deliver meaningful outcomes across human, animal, and environmental health. In contrast, earlier iterations of the JEE and the PVS Pathway were designed primarily as snapshots of technical capacity and legal compliance, reflecting a technocratic model of preparedness [43,44]. Although the 2024 amendments to the IHR acknowledge One Health and sustainability explicitly for the first time, operationalising these commitments through measurable, sector-specific indicators remains a gap [6,45].
A key contribution of this study is its detailed elucidation of sectoral and contextual divergences in how sustainability is understood. Human health respondents from LMICs foregrounded issues such as workforce retention and local ownership, while environmental health participants underscored ecological resilience and intergenerational equity. Experts in the animal health sector stressed economic externalities, such as the fiscal vulnerability of veterinary services in agricultural economies. These differences are consistent with the findings of sustainability literature captured in recent systematic reviews, which report that determinants of sustainability are often domain-specific but converge on broader systemic enablers such as leadership, institutionalization, financing, and stakeholder alignment [24,46,47]. These divergences also align with the SCF, wherein certain sectors (particularly human health) are socially constructed as more “deserving” of sustained investment than others. The relative marginalisation of environmental health capacities — despite their foundational role in zoonotic prevention — exemplifies how power dynamics shape which determinants are prioritised.
The 2024 amendments to the IHRs, alongside the drafting of the Pandemic Agreement, represent a watershed moment for reform and redefining sustainability in GHS. The inclusion of equity, access, and One Health principles reflects a broader shift toward structural resilience, rather than merely response readiness [45,48]. However, integration into national systems and evaluation tools remains underdeveloped.
Parallel to this, the One Health Joint Plan of Action (OH JPA) and its Implementation Framework—spearheaded by the Quadripartite collaboration (WHO, FAO, WOAH, UNEP)—offer a blueprint for operationalising sustainability via intersectoral coordination, community engagement, and environmental stewardship [38]. Interviewees noted that OH JPA’s emphasis on capacity building, governance, and integrated service delivery aligns well with the proposed sustainability constructs emerging from this study, yet there is currently no formal mechanism linking JEE or PVS indicators with OH JPA implementation benchmarks.
The ongoing negotiations around the Pandemic Agreement provide both opportunity and caution. On one hand, the agreement could institutionalize global commitments to sustainable preparedness financing, thereby enabling LMICs to transition from donor dependency to fiscal autonomy. On the other, failure to establish equitable financing mechanisms may entrench existing disparities [7,48]. The widespread funding cuts to global health and development over the last four years since the COVID-19 Pandemic—documented across the UK FCDO, USAID, and other bilateral donors—have already led to the closure of programs, disruption in medicine supply chains, and collapse of key capacities in LMICs [49–51]. These conditions reinforce the urgency of integrating sustainability indicators that account for financing pathways, national co-investment, and budgetary resilience within the assessment frameworks of global health security. Several LMIC participants further highlighted the need to re-balance global governance structures so that sustainability priorities are not externally imposed but generated through domestic political processes. This includes strengthening fiscal sovereignty, integrating sustainability into national legislation, and resisting conditionalities that undermine long-term planning. The recent launch of the America First Global Health Strategy underscores the importance of the issue with a major global donor now overtly predicating significant financing of global health on the use of its own products – no different in essence from a government subsidy for industry – through transactional bilateral arrangements that potentially undermine both data and specimen sovereignty as well as the development of homegrown manufacturing in LMICs of medical countermeasure products like diagnostics, vaccines and therapeutics [52].
Drawing on both interview data and systematic review literature, we propose a high-level schema of sustainability determinants that can be more explicitly embedded into future iterations of JEE, PVS, and related IHR M&E tools and framed as such. These are outlined in Table 3 below. Importantly, several of these indicator categories—particularly those related to financing and investment (e.g., existence of budget lines for health security), workforce and capacity retention (e.g., tenure and turnover rates), institutionalization and governance (e.g., presence of multisectoral coordination bodies and legal mandates), and community engagement (e.g., mechanisms for community input and feedback)—are already being collected in routine surveillance systems, national health plans, and WHO’s JEE and SPAR mechanism. PVS Pathway reports also routinely capture institutional and workforce capacities but do not necessarily explicitly refer to these indicators as relating to sustainability [3,27,28,44]. Systematic reviews confirm that these determinants are traceable and have been repeatedly highlighted as core pillars of sustainability [46,47]. The World Bank/WHO Global Preparedness Monitoring Board (GPMB) has similarly emphasized the need to leverage existing data sources and national planning instruments to reduce the burden of measurement while improving accountability [44].
The findings from this study point to three key policy implications. First, GHS frameworks must shift from short-term process audits toward long-term sustainability planning, particularly in LMICs where external support often substitutes for systemic resilience. Second, multisectoral equity must be structurally embedded in evaluation criteria—ensuring that environmental and animal health perspectives are not marginalized in ostensibly One Health assessments. Third, international financing facilities, such as the Pandemic Fund, should explicitly link disbursements to progress in sustainability planning and locally owned capacity transitions. This is especially important given emerging shifts toward more transactional, donor-interest-driven global health — evidenced by recent strategies prioritising national gains over collective risk reduction which further challenges assumptions that external financing can be relied upon to sustain core capacities [52].
To support these implications, WHO and WOAH could revise the JEE and PVS tools to include a dedicated “Sustainability and Equity” technical area, tied more closely to benchmarks derived from the OH JPA and the GPMB’s calls for systemic preparedness investments [35,41]. Indicators could be co-designed with country partners, reflecting context-specific priorities, financing capacities, and data availability. For example, several interviewees in our study noted that indigenous and other local knowledge systems remain largely absent from current sustainability indicators. Ensuring that environmental and zoonotic surveillance systems capture — and protect — indigenous knowledge could support more community-owned, context-appropriate sustainability measures and enhance data systems for future digital and AI-enabled tools [53].