# 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

## TL;DR

This paper assesses how sustainability is measured in global health tools and finds they lack focus on long-term outcomes and equity, especially in low-income countries.

## Contribution

The study introduces a qualitative framework for evaluating sustainability in global health tools through expert insights and sectoral differences.

## Key findings

- Experts criticized current tools for focusing on short-term compliance rather than long-term sustainability and equity.
- Sectoral differences highlight varying sustainability priorities, such as workforce in human health and economic continuity in animal health.
- LMIC experts emphasized challenges like donor dependency and weak local ownership affecting sustainability.

## Abstract

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).

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.

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.

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.