Integrating One Health into health systems: a systematic review of challenges, opportunities, and strategic directions

Integrating One Health into health systems: a systematic review of challenges, opportunities, and strategic directions | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 3 July 2025 V1 Latest version Share on Integrating One Health into health systems: a systematic review of challenges, opportunities, and strategic directions Authors : Md Shahidul Islam 0000-0001-8984-8689 [email protected] , Nusrat Jahan , and Daniel Teshome Gebeyehu Authors Info & Affiliations https://doi.org/10.22541/au.175153391.11261343/v1 268 views 146 downloads Contents Abstract Abstract Introduction Methods Results Focus areas of the included studies Key challenges in OH implementation Opportunities for strengthening OH implementation Discussion Registration and protocol Declarations Additional files References Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Background : The One Health (OH) concept was introduced to establish a multidisciplinary and integrated health system linking animal, human, and environmental health. However, its implementation faces numerous challenges. This systematic review aims to identify the barriers and opportunities associated with OH implementation and explore possible solutions. Study Design : A comprehensive synthesis of existing evidence. Methods : Relevant studies were systematically identified using predefined criteria from four online databases (ProQuest Medicine, Web of Science, Scopus, and PubMed). The selection process followed PRISMA guidelines, including checklists and a flow diagram. Both review and primary research articles were considered. This review focuses on the key challenges hindering OH implementation and the factors facilitating its adoption. Results : Among 2,606 studies identified, 47 met the eligibility criteria, and 17 were included after successive screenings. The major challenges to OH implementation include lack of awareness, professional dominance, absence of legal and policy frameworks, funding shortages, inadequate infrastructure, power struggles, limited political commitment, high costs of modern technologies, and difficulties in identifying common health priorities. Conversely, factors promoting OH implementation include the growing global burden of emerging epidemics and pandemics, population growth, climate change, urbanization, increasing awareness of OH, involvement of non-governmental organizations, academic and research interest, and increased funding opportunities. Conclusion : While the OH approach holds great promise for addressing interconnected health challenges, its implementation has been limited by financial, legal, political, and infrastructural barriers. Despite these challenges, the growing threat of emerging diseases, climate change, and increased interest from academic, research, and funding institutions provide strong momentum for OH adoption. To advance effective implementation, it is crucial to raise awareness, establish supportive policies, secure funding, build infrastructure, and institutionalize OH through cross-sector collaboration. Integrating One Health into health systems: a systematic review of challenges, opportunities, and strategic directions Md Shahidul Islam 1 , Nusrat Jahan 1 , Daniel Teshome Gebeyehu 1 1 School of Health, University of New England, Armidale, NSW, Australia Corresponding author: Md Shahidul Islam ( [email protected] ) Abstract Background : The One Health (OH) concept was introduced to establish a multidisciplinary and integrated health system linking animal, human, and environmental health. However, its implementation faces numerous challenges. This systematic review aims to identify the barriers and opportunities associated with OH implementation and explore possible solutions. Study Design : A comprehensive synthesis of existing evidence. Methods : Relevant studies were systematically identified using predefined criteria from four online databases (ProQuest Medicine, Web of Science, Scopus, and PubMed). The selection process followed PRISMA guidelines, including checklists and a flow diagram. Both review and primary research articles were considered. This review focuses on the key challenges hindering OH implementation and the factors facilitating its adoption. Results : Among 2,606 studies identified, 47 met the eligibility criteria, and 17 were included after successive screenings. The major challenges to OH implementation include lack of awareness, professional dominance, absence of legal and policy frameworks, funding shortages, inadequate infrastructure, power struggles, limited political commitment, high costs of modern technologies, and difficulties in identifying common health priorities. Conversely, factors promoting OH implementation include the growing global burden of emerging epidemics and pandemics, population growth, climate change, urbanization, increasing awareness of OH, involvement of non-governmental organizations, academic and research interest, and increased funding opportunities. Conclusion : While the OH approach holds great promise for addressing interconnected health challenges, its implementation has been limited by financial, legal, political, and infrastructural barriers. Despite these challenges, the growing threat of emerging diseases, climate change, and increased interest from academic, research, and funding institutions provide strong momentum for OH adoption. To advance effective implementation, it is crucial to raise awareness, establish supportive policies, secure funding, build infrastructure, and institutionalize OH through cross-sector collaboration. Keywords : One Health, Implementation, Challenges, Opportunities, Systematic Review Introduction One Health (OH) is “an integrated, unifying approach that aims to sustainably balance and optimize the health of people, animals, and ecosystems”[1]. While the term One Health is not new, its concept dates back to the mid-1800s when German pathologist Dr. Rudolf Virchow [2] explored the link between human and veterinary medicine. Virchow introduced the term zoonoses - diseases transmissible between animals and humans - during his research on Trichinella spiralis in swine. Beyond Virchow, Hippocrates (400 BCE) also emphasized the importance of considering a patient’s environment alongside their medical condition [3]. Virchow famously stated, “Between animal and human medicine, there is no dividing line - nor should there be. The object is different, but the experience obtained constitutes the basis of all medicine” [2]. The OH approach addresses critical health challenges, including emerging and re-emerging epidemics and pandemics, antimicrobial resistance, food safety and security, climate change, and environmental contamination [2]. According to Jones, Patel (4) 60% of known infectious diseases and 75% of emerging diseases are zoonotic. The World Health Organization [5] reports that many recent deadly outbreaks - such as Avian Influenza (H5N1), Ebola, Pandemic Influenza (H1N1), SARS, and MERS-CoV - are zoonotic in origin, often linked to wildlife. Additionally, antimicrobial resistance is accelerating at an alarming rate, necessitating a collaborative response across human, animal, and environmental health sectors [6-9]. Several global trends further emphasize the urgency of OH implementation, including rapid urbanization, globalization, ecosystem disturbances, increasing human and animal populations, climate change, and escalating socio-economic and food security crises [10-17]. Despite its significance, OH remains largely unintegrated into national health systems [15] with only a few countries making inconsistent progress [16]. Scholars have identified multiple factors hindering OH implementation at global, national, regional, and local levels. A recurring challenge is lack of awareness, which slows the incorporation of OH into health systems [18, 19]. Fasina, Bett (17) highlight that OH is often misunderstood by stakeholders, with some perceiving it as causing professional role overlaps rather than fostering interdisciplinary collaboration [3]. Furthermore, disciplinary dominance within health sectors has been noted as a barrier to successful OH integration [20]. The implementation of the OH approach entails notable challenges but also offers substantial opportunities, as evidenced by several key studies. Frequently cited barriers include inadequate institutional structures, fragmented coordination across sectors, limited financial resources, and weak political support—issues particularly pronounced in low- and middle-income countries [16, 21]. These challenges are intensified by disciplinary fragmentation, ambiguous legal and operational frameworks, and difficulties in integrating cross-sectoral knowledge and evaluation tools [22, 23]. Additionally, top-down OH strategies often fail to reflect local realities, resulting in poor community engagement and overreliance on external support [24]. Despite these constraints, OH holds considerable promise for enhancing the prevention and control of zoonotic diseases, antimicrobial resistance, and health impacts of climate change through integrated and multisectoral collaboration. Opportunities identified in the literature include utilizing existing institutional networks, encouraging community-driven initiatives, adopting participatory policy development, and applying systems-thinking approaches to improve performance evaluation [21, 23]. Scholars recommend embedding OH principles into national policies, establishing supportive legal and educational frameworks, strengthening local leadership, and promoting cross-disciplinary knowledge exchange to ensure sustainable and contextually relevant implementation. Furthermore, OH is receiving increasing global endorsement. International organizations such as WHO, FAO, WOAH, and UNEP have integrated OH into their strategic agendas [1, 11, 25]. Funding agencies are also shifting toward interdisciplinary programs, recognizing OH’s potential to address complex health challenges more effectively than isolated, sectoral approaches. However, much of the existing research remains region-specific and lacks a comprehensive global perspective. For example, a narrative study conducted in Uganda [26] explored national-level OH implementation but did not extend its insights beyond the local context. Thus, this systematic review aims to synthesize available evidence on the challenges and opportunities of OH implementation, offering a comprehensive global perspective and identifying actionable strategies for its advancement. Methods This systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. The review protocol was registered in PROSPERO under registration number CRD42024520269. Data sources and search strategy Studies were identified through online database searches and by reviewing reference lists of relevant articles. The search was conducted in Scopus, PubMed, Web of Science, and ProQuest Health and Medicine using the following keywords: One Health AND (Challenges OR Obstacles OR Barriers OR Defiance) AND (Opportunities OR Advantages OR Benefits OR Enablers) AND (Health Systems OR Program OR Service OR Strategy). Additionally, a broad search was performed using Google Scholar to identify supplementary articles. The search terms were finalized in consultation with a health librarian at the University of New England, Australia. Inclusion and exclusion criteria This review includes peer-reviewed studies published between June 1, 2013, and April 1, 2025, that examine the challenges and opportunities of One Health (OH) implementation in health systems, programs, services, or strategies. Studies providing broader insights into OH implementation challenges and opportunities, even without focusing on specific systems or programs, were also included. No restrictions were placed on study methodology. Only English-language studies indexed in the specified databases were considered. Non-peer-reviewed literature and studies published in languages other than English were excluded. The search was conducted in January and February 2025. Selection and screening process The initial screening was conducted by the first author (MSI) in consultation with the second author to determine eligibility based on the inclusion criteria. Studies from each database were assessed for relevance by both authors, first by screening titles and then abstracts. To facilitate this process, the Covidence online tool was used for screening titles, abstracts, and full texts. All eligible studies underwent critical appraisal by two reviewers (the first and second authors). Any disagreements regarding study selection were resolved through discussion or, if necessary, consultation with a third author. Data extraction and management A standardized data extraction form was developed to systematically collect relevant details from the included studies. Extracted data included publication type, geographical location, study setting, publication year, study duration, objectives, study design, sample size, data collection methods, key findings, and limitations. Any discrepancies between reviewers were resolved through discussion or consultation with the third author. Quality Assessment The included studies were critically evaluated using separate assessment tools for primary studies and review articles. Primary studies were assessed using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Cross-Sectional Studies. This tool evaluated factors such as sample size validity, study subjects and settings, adherence to standard criteria, identification of confounding factors, reliability of outcome measurements, and appropriateness of statistical analysis. Responses were recorded as ‘Yes,’ ‘No,’ ‘Unclear,’ or ‘Not applicable.’ Based on these criteria, studies were categorized as included, excluded, or requiring further information ( Additional file 1 ). Review articles were evaluated using the Critical Appraisal Skills Program (CASP) Systematic Review Checklist ( Additional file 2 ). This tool focused on study validity, key findings, and applicability to local contexts, with responses categorized as ‘Yes,’ ‘Cannot Tell,’ or ‘No.’ The first author conducted the initial assessments, with the second author verifying each study for consistency. Any disagreements regarding risk of bias were resolved through discussion or consultation with a third author. Data Synthesis This systematic review aimed to categorize and analyze the existing literature on the challenges and opportunities of One Health (OH) implementation. A segregated approach was used to summarize findings in a data extraction table, highlighting key aspects of OH implementation. • The challenges and opportunities identified in each study were compiled in tables and textual descriptions. • A narrative synthesis was conducted to interpret the findings, providing a qualitative analysis of OH implementation barriers and facilitators. • Recommended strategies for improving OH implementation was identified and analyzed. • General study characteristics (location, publication type, study design, data collection methods, and sampling techniques) were summarized and tabulated for further interpretation. This structured approach ensured a comprehensive analysis of OH implementation across diverse contexts. Results A total of 2,606 published articles were identified from the databases. The majority (1,305 articles) were retrieved from Web of Science, followed by 1,000 from ProQuest, 172 from Scopus, and 129 from PubMed (Figure 1). After applying a sequential screening process, 47 primary and review articles were deemed eligible, of which only 17 were included in the final review. Figure 1: PRISMA diagram illustrating the process of identifying, screening, and including studies for review Among the published articles, ten were primary research articles [16, 21, 23, 27-33], and the remaining seven were review articles [22, 34-38] (Table 1). All the review articles employed a narrative analysis methodology, while the primary articles utilized cross-sectional study designs in both qualitative and quantitative approaches. The study by Hassan-Kadle, Osman (29) employed a retrospective study design with a specified point in time. The review articles utilized a mix of online literature, grey literature, and printed sources as data sources, whereas the primary articles were based on primary data from participants across various multidisciplinary backgrounds (Table 1). Table 1: General information of the included studies Acharya, Karki (34) Nepal Review article Narrative review Assessing reports, articles and documents related to OH challenges and opportunities Belaynehe, Nguta (27) African countries Primary article Cross-sectional study 214 participants responded for the online survey and 170 were deemed eligible Bera, Thulasingam (28) India Primary article Cross-sectional study 70 OH stakeholders were surveyed, and 10 key informant interviews were administered. A mixed method study was use Buregyeya, Atusingwize (26) Uganda Review article Narrative review Documents related to OH implementations in Uganda were reviewed and narrated Destoumieux-Garzon, Mavingui (22) Global perspective Review article Narrative review Review of existing evidences Gebreyes, Dupouy-Camet (35) Multi-country Review article Narrative review 16 papers presented at ICOPHAI 2011, and 39 papers presented at ICOPHAI 2013 were included Gongal (36) Southeast Asia Review article Narrative review Statuses of OH applications in 7 Asian countries (Bangladesh, Bhutan, India, Indonesia, Myanmar, Sri Lanka, and Thailand) were reviewed Hassan-Kadle, Osman (29) Somalia Primary article Retrospective study The study assessed18 One Health actions implemented over ten years in Somalia (2003 to 2023) Hitziger, Esposito (21) European Union & LMIC policy cases Primary article Qualitative multi-case policy analysis Based on document analysis and stakeholder engagement. Lavilla, Domingo-Calap (37) Spain Review article Narrative review The study reviewed multiple literature focused on phage therapy and its OH challenges and opportunities Okello, Bardosh (16) Uganda, Nigeria, Tanzania Primary article Qualitative case study Purposive sampling of stakeholders from health, veterinary, and environmental sectors. Roopnarine and Regan (30) United Kingdom Primary article Cross-sectional Professionals across the medical, veterinary, and public health faculties were participated in audio recorded focus group discussion about the need of “OH-One Medicine approach.” Ruegg, Nielsen (23) Multi-country (Europe and Africa focus) Primary study Cross-sectional Framework development and case evaluation and election of case studies for systems-based evaluation; not random Standley, Carlin (31) Guinea Primary article Cross-sectional study A 5-step situational analysis conducted from 1 September 2015 to 30 April 2016 that comprises Zoonotic disease prioritization, assessment, validation, and reporting was applied. Tegegne, Freeth (32) Multi-European countries Primary article Cross-sectional study Using OH-EpiCap 11 multisectoral microbiological case studies in 8 European countries (Portugal, France, Germany, Netherlands, Finland, Norway, Denmark, and Sweden) and challenges and opportunities of its application were investigated. Tigistu-Sahle, Mekuria (38) Tropical region Review article Narrative analysis Omics related studies that focus on molecular epidemiology and assessed the common OH issues in the tropical context were reviewed Zhuo, Labbate (33) Australia Primary articles Cross-sectional study Aa survey regarding the improvement of antimicrobial prescribing behaviour was completed by 547 doctors, 380 dentists and 403 veterinarians. ICOPHAI = International Congress on Pathogens at the Human-Animal Interface; OH-EpiCap = One Health epidemiological surveillance capacities and capabilities; OH = One Healt Focus areas of the included studies The studies were conducted with a variety of objectives related to OH implementation. Some focused on the challenges of OH implementation [27, 32, 34] while others examined awareness levels and the views of participants regarding OH [28, 30]. Some studies addressed OH implementation for zoonotic diseases [31, 35], while others explored implementation experiences [36] and analyzed the state, prospects, and difficulties of OH implementation [29]. Another study has focused on the conceptual and global evolution of OH [22], and others were targeted in the integration of knowledge in OH policy [21], the OH implementation situation of Africa [16], and systems approach to OH implementation [23]. Additionally, some studies discussed phage therapy as an alternative strategy for preventing food and waterborne diseases within an OH framework [37], the contribution of omics tools to OH implementation [38], and perspectives on Antimicrobial Use (AMU) and Antimicrobial Resistance (AMR) in the development of OH policy [33]. The included articles also highlighted the key challenges, opportunities, and recommended actions for advancing OH implementation in specific contexts (Table 2). Table 2: Focuses of studies, final findings related to the challenges and opportunities of One Health implementation, and recommended actions forwarded by the researchers Acharya, Karki (34) OH, implementation challenges and available opportunities Lack of OH organizational structure Lack of legal framework and implementation policy for OH Absence of collaboration among government agencies and institutions Lack of trained manpower Limited data sharing practice among sectors Budget constraints and low-level understanding of politician Emergence of multidisciplinary health challenges like AMR, highly pathogenic Avian Influenza, and Rabies enforces to use OH approach Engagement of NGOs in supporting OH and advocating its significance OH, legal frameworks should be created Detailed OH awareness should be created for politicians, policy makers and professionals Adequate budget should be allocated for the implementation of OH Belaynehe, Nguta (27) OH implementation challenges faced by scholars, RECs, and regulatory bodies in Africa Insufficient proposal review time Inadequate knowledge for OH research Lack of emergency protocols Insufficient knowledge of ethical issues specific to OH Lack of legal framework Lack of multidisciplinary review board Creation of multidisciplinary committee Formation of mandatory OH review strategies Formulation of standard OH proposal review procedure Awareness creation for REC members Creation of OH communications channels among researchers OH and emergency research ethics review strategies needs to be timely reviewed and implemented. Bera, Thulasingam (28) Determining awareness levels, attitudes on collaboration, and perspectives among OH collaboration Lack of established guidelines Insufficient political focus Limited cooperation among departments Lack of community awareness Stakeholders understood that intersectoral coordination is crucial for the operationalization of OH By establishing standard guidelines and guaranteeing stakeholder coordination, OH operationalization could be improved. Buregyeya, Atusingwize (26) Describing achievements of OH, identifying its challenges, and making recommendations on implementations of OH Insufficient multisectoral integration In adequate commitment from the government Gaps in awareness creation, advocacy, and research Establishment of national OH platform Memorandum of understanding among sectors Listing of priority zoonotic diseases OH Strategic Plan and communication strategy Activities of academia in OH integration Urgent steps should be taken, with government support, to address present and future issues to ensure systematic and sustainable OH involvement. Destoumieux-Garzon, Mavingui (22) Conceptual and global evolution of One Health Ambiguity in scope- Fragmented disciplines- Legal and operational gaps One Health as a framework for AMR, zoonoses, and environmental threats- Global support from institutions (e.g., WHO, FAO, OIE) Institutionalize One Health in policies- Foster interdisciplinary education and research- Create enabling legal frameworks Gebreyes, Dupouy-Camet (35) Highlighting developments in priority zoonotic disease and OH capacity needs. Zoonotic diseases are complex and related with different genetic, anthropogenic, environmental, ecologic, climatic and socioeconomic factors Lack of concern to zoonotic diseases, especially in less developed regions Presence of integral pushing factors that make difficult to predict and prevent zoonotic diseases Notable advancements have been made in clinical diagnostic techniques, medical practices, and diseases surveillance systems Establishing science-oriented risk management guidelines Skilled manpower capacity building Accredited multidisciplinary diagnostic laboratories Equitable use of existing resources Gongal (36) Addressing the experiences of regional countries to address and early prepared for emerging disease threats. Dominancy and ownership related conflicts Crossing professional boundaries Awareness gaps Lack of political commitment Multi-disciplinary and multifactorial diseases outbreaks like avian influenza, Severe Acute Respiratory Syndrome, Nipah virus and Ebola Presence of shared tasks that necessitates multidisciplinary involvement (AMR, Zoonotic diseases, food safety and security) Establishment of common frameworks Global warming, population growth, increased global trafficking and farming systems Involvement of NGOs in OH implementation Even if OH is becoming more widely recognized, but it still needs to be put into practice through national initiatives that are pertinent circumstances. Hassan-Kadle, Osman (29) Describing the state, prospects, and difficulties of OH in Somalia and offering suggestions for institutionalizing and advancing it Insufficient finances and facilities Inadequate institutional capability and governance Somalia is involving various external funding OH initiatives Projects are currently working on research, capacity development, and community interventions Establishment of University initiative like Somalia OH Centre. The government is suggested to institutionalize and implement OH action plans from federal to district administrative levels Hitziger, Esposito (21) Knowledge integration in One Health policy - Difficulty integrating knowledge across disciplines- Divergent institutional priorities- Lack of metrics - Better policy design using multisectoral knowledge- Strengthening evidence-informed decisions Establish knowledge-sharing platforms- Use participatory approaches in policy design- Develop common evaluation indicators Lavilla, Domingo-Calap (37) Examining the use of phages to prevent foodborne and waterborne diseases in a OH platform Extreme specificity of phages Potential phage resistance formation Phage stability and administration routes Legislative approval Consumer acceptance Resistant gene transmission among bacteria Phage biobanking for immediate trials An excellent antimicrobial alternative Self-dosage Effective to use phages in industries like food safety Future research ought to address the outstanding problems and primary hurdles to support phage-based practical use in the future Okello, Bardosh (16) One Health implementation in Africa Weak institutional frameworks- Low political support- Sectoral silos- Limited resources Potential for integrated zoonotic disease control- Platform for intersectoral dialogue- Use of existing networks Build sustainable policy frameworks- Promote long-term intersectoral collaborations- Support locally driven One Health capacity Roopnarine and Regan (30) Examining the views of academics in the medical, veterinary, and public health fields regarding the necessity, opportunities, and challenges of OH curriculum Absence OH accreditation system in the medical curriculum Resistance of accepting OH among the medical educators OH is recognised as a critical concept OH is the best approach for shared learning and research, more importantly in interprofessional education Strategies for convincing medical educators and students to accept OH in the curriculum and encourage a collaborative learning culture are among the implications for practice. Ruegg, Nielsen (23) Systems approach to OH evaluation Inconsistent evaluation tools- Sectoral fragmentation- Poor communication across disciplines Systems thinking to assess performance- Common language and framework to assess collaboration Apply systems-based tools (e.g., NEOH framework)- Train stakeholders in evaluation methods- Align goals and outcomes across sectors Standley, Carlin (31) Determine and evaluate the structures and procedures currently in place for the detection and management of zoonotic diseases Coordination gaps among key actors Lack of continues training to stakeholders Lack of adequate infrastructure Public awareness gaps Extended research gaps on zoonoses Lack of OH sustainability when the funded project ends Exiting linkage among top level ministries are encouraging New OH platform is launched Excellent future OH financial commitment of ministries Adequate investment and fulfilment of resources are needed for the timely implementation of OH Tegegne, Freeth (32) Summarizing the takeaways from the assessment of OH surveillance, the challenges in implementing OH, the obstacles that impede OH functioning, and potential fixes for them. Poor organization and performance of OH surveillance systems Lack of operational and shared leadership Lack of adherence to fair data principles Limited sharing of methodologies Absence of standardized indicators Continuing health complexities are demanding multidisciplinary (One Health) Creating a formal governance board comprising members from every industry could help to remove obstacles that have existed for a while. It might be easier to establish OH surveillance systems if the effects of surveillance’s OH-ness are demonstrated. Tigistu-Sahle, Mekuria (38) Providing an overview of omics tools and their possible applications in OH applications in tropical diseases The cost of genomics is expensive, and while the cost of metagenomics is more escalation. Bioinformatics needs trained manpower Bioinformatics is an analytical tool that needs sophisticated infrastructure and storage Lack of skilled manpower and necessary infrastructure Lack of proper and multidimensional statistical software Internet and cloud technologies enables remote learning and data analysis The advancement of metabolomic profiling and metabolomic fingerprinting for OH applications Metabolomic application in food safety and toxicity, non-communicable disease and environmental health has a synergetic effect for OH application Capacity building in the tropics is critical to achieving equitable global health. Improving laboratory infrastructure and personal capacity building are crucial Zhuo, Labbate (33) Examine and contrast the information, perspectives, and experiences of health professionals AMU and AMR and exploring OH policy development. Externalizing of responsibilities among different medical professionals (Veterinary, Medical doctors, and dentists) Prescribers are open to accept OH approach Professionals are aware about the ever-increasing antimicrobial resistance When developing policies, consideration should be given to obstacles unique to prescriber groups It will be necessary to develop and introduce interventions with caution in case they are seen as diminishing prescriber autonomy OH = One Health; NGOs = None-Governmental Organization; REC = Research Ethics Committee; AMR = Antimicrobial Resistance; AMU = Antimicrobial Use Key challenges in OH implementation The lack of organizational structure and an inadequate legislative framework were identified as major challenges to OH implementation [27, 28, 32, 34, 37]. Additionally, the lack of budget and infrastructure was reported as a bottleneck across health systems, hindering OH efforts [34, 38]. The complexity of zoonotic diseases, which are influenced by various genetic, anthropogenic, environmental, ecological, climatic, and socioeconomic factors, alongside insufficient attention to these diseases, were highlighted as significant challenges in their prevention and control [35]. Emerging technologies such as OMICS and health informatics also faced challenges, including a lack of trained personnel, high technology costs, and the substantial infrastructure demands required for their integration into OH frameworks [38]. Further, barriers to OH implementation were also attributed to lack of trained manpower [34, 38], a low level of understanding among politicians and key actors [28, 34, 36], lack of cooperation among stakeholders [28, 31], and gaps in awareness within political bodies and relevant stakeholders [27, 28, 31, 34-36, 39] (Table 2). Opportunities for strengthening OH implementation Despite the challenges hindering OH implementation, several opportunities position OH as a promising approach for integration into health systems. These include the emergence of multidisciplinary challenges such as Antimicrobial Resistance (AMR) and the emerging and re-emerging epidemics and pandemics [34, 36]. Additionally, there is an increasing commitment from both governmental [31] and non-governmental organizations [29, 34, 36]. The formation of OH committees [27, 31, 35] and the establishment of OH centres [27, 29] further contribute to the momentum. The creation of OH platforms within various governmental structures [31, 35], along with the growing intersectoral and multidisciplinary cooperation [28, 30], also presents significant opportunities. Finally, the rising awareness levels among actors and stakeholders [27, 30] highlight an important shift toward greater support for OH implementation. Discussion This systematic review summarizes the challenges and opportunities of One Health (OH) implementations as identified by previous studies. Additionally, the review highlights the actions recommended for advancing OH practices. One Health operates within the common agendas of animal, human, and environmental health [3], which encompass areas such as zoonoses, antimicrobial use and resistance, food safety and security, disease surveillance and investigation, health governance, neglected and non-communicable diseases, and socio-economic issues [40]. Despite the concept of OH being introduced in the mid-1800s, this review found that OH is still in its infancy in many parts of the world. Traditionally, the veterinary, public health, and environmental health sectors have operated independently, and progress toward integration has been slow. The review identifies several factors that hinder the advancement of OH, as well as key drivers that can facilitate its broader implementation across various health agendas. One Health implementation challenges As reported by various OH researchers [28, 32, 34], several key challenges hinder the effective implementation of OH and its incorporation into health systems. These include poor organizational structure, lack of funding sources, absence of a legal framework and implementation policies, gaps in intersectoral collaboration, limited data-sharing practices among sectors and professionals, and constraints related to trained manpower. One of the significant barriers to OH implementation is the lack of established OH institutions and multi-professional teams, leading to frequent denial of research ethics approval, especially in African countries [27]. This challenge arises due to insufficient knowledge of OH concepts among ethics reviewers, lack of standardized ethics review protocols, and rejection of OH-related proposals due to limited time and expertise [27]. These issues related to research ethics approval hinder researchers from conducting OH-focused studies. Despite its growing global relevance, implementing the One Health (OH) approach remains hindered by several systemic challenges. Studies consistently identify weak institutional structures, fragmented intersectoral collaboration, limited financial resources, and insufficient political commitment as core barriers, particularly in low- and middle-income countries [16, 21]. These obstacles are further complicated by disciplinary silos, legal ambiguities, and the absence of unified metrics to assess cross-sectoral interventions [22, 23]. Research from Uganda, for instance, emphasizes how national-level strategies often lack scalability or contextual relevance [26]. This highlights a broader issue: many studies on OH challenges remain region-specific, limiting their global applicability and integration into broader policy frameworks. The OH approach involves multiple stakeholders, which can create ethical dilemmas in research procedures and applications [41]. Therefore, research ethics approval guidelines should be formulated in coordination with different stakeholders and carefully designed to satisfy the interests of multidisciplinary actors. Additionally, the slow progress of OH implementation is also linked to inadequate public awareness, lack of political commitment to integrating OH into health systems, and the absence of legal frameworks and guidelines [28, 35, 36]. The awareness gap reported in 2013 [36] remains persistent in 2020 [35], suggesting that OH implementation is progressing slowly due to ongoing challenges. Although 60% of zoonotic diseases and 75% of emerging and re-emerging diseases originate from animals and are transmitted to humans (4), the prioritization of zoonotic diseases is limited, especially in low-resource settings. These settings often lack initiatives to identify common integral factors for such diseases [31, 35]. In countries where OH is being implemented in different forms, challenges persist, such as the dominance of one sector over others, where professional boundaries are crossed in an attempt to unify health disciplines rather than collaborate [36]. [29] examined the state of OH implementation and identified insufficient funding and inadequate institutional capacities as continuing bottlenecks. Implementing OH is not as simple as it might seem in theory. For example, bacteriophage therapy as an alternative to antimicrobial use in food and water safety faces challenges such as high specificity, phage resistance development, issues with the administration route, stability constraints, phage biobanking, community acceptance, and the need for legislative approval [37]. Furthermore, the poor political interest in OH and the lack of an established accreditation system contribute to resistance to the OH approach, particularly among lower-level professionals. Medical doctors, for instance, tend to show more resistance to adopting OH frameworks compared to veterinary and environmental health experts [30]. Beyond individual resistance, data-sharing practices, adherence to fair data-sharing principles, and the lack of standardized organizational indicators remain persistent challenges within the multidisciplinary context of OH [32]. Some professionals may also use OH as a means of externalizing their unintended professional practices to other sectors, leading to an undesired focus on public health issues while overlooking animal and environmental health sectors [33]. One Health is a promising platform for applying emerging health technologies, such as omics, that can address various health sectors simultaneously. However, the implementation of these technologies is challenged by the high cost of genomic and metagenomic products, the need for trained bioinformatics professionals, sophisticated bioinformatics infrastructure, and a lack of multidisciplinary statistical software [38]. While some of the challenges identified in the reviewed studies may no longer reflect the current trends, ongoing challenges include the absence of an OH accreditation system in medical curricula, resistance among medical educators to adopting OH, and coordination gaps among key stakeholders[30, 31]. One Health implementation opportunities Despite various challenges impeding the seamless integration of the OH approach into health systems, several key drivers are advancing its recognition as a vital, multidimensional strategy for health improvement. Major epidemics and pandemics—such as avian influenza, Ebola, and COVID-19—have underscored the necessity for coordinated, cross-sectoral responses, thereby accelerating the acceptance of OH [31, 32, 34, 36]. Beyond these global crises, persistent endemic issues like rabies, zoonotic infections, antimicrobial resistance (AMR), and food safety concerns are pushing policymakers, professionals, and political leaders to advocate for OH as a means to address these complex threats [34]. Despite existing barriers, the OH framework offers powerful opportunities to tackle multifaceted health challenges—ranging from zoonotic disease outbreaks and AMR to the health impacts of climate change—through integrated, multisectoral collaboration. Research highlights the effectiveness of community-based, locally driven models in fostering sustained engagement and adapting to local contexts [24]. Moreover, the use of systems-thinking tools and participatory policy development can enhance the relevance and evaluation of OH initiatives [21, 23]. The growing endorsement of OH by influential global health organizations—including WHO, FAO, WOAH, and UNEP—further reflects mounting institutional support [1, 11]. Funding bodies are also increasingly investing in interdisciplinary efforts, acknowledging both the limitations of fragmented approaches and the effectiveness of OH in addressing interconnected health challenges. The growing focus of politicians and government bodies, along with the active involvement of non-governmental organizations (NGOs), is a significant asset for OH implementation [34, 36]. In some regions, such as Somalia [29], funding for OH initiatives are largely supported by NGOs. In several countries, promising progress is being made, including the formation of multidisciplinary committees, the creation of OH awareness campaigns for research ethics committees and professionals, and the development of OH strategies and communication channels [27, 31]. Compared to previous situations, stakeholders are beginning to recognize that OH can bring wide-ranging benefits if implemented effectively [28, 30, 33]. Academic institutions are also playing a crucial role in advancing OH, engaging in activities such as establishing OH platforms, forging agreements across sectors, prioritizing zoonotic diseases, and designing OH strategies and communication plans [29, 34]. Additionally, these institutions are driving research and innovations in multidisciplinary disease diagnostics, surveillance, and medical practices [29, 35], all of which serve as a foundation for broader OH implementation. Through these efforts, critical issues such as AMR and food and waterborne infections are being addressed. For example, phage therapy has emerged as a promising innovation for combating antimicrobial resistance in food and waterborne infections [37]. In some countries, such as Guinea, the collaboration between ministries and their financial support for OH activities are a positive sign of progress [31]. Finally, technological advancements like cloud technologies and metabolomic profiling and fingerprinting are playing a synergistic role in OH implementation, particularly in areas such as food safety, toxicity, noncommunicable diseases, and environmental health [38]. Limitation of the review One limitation of this review is that the inclusion and exclusion criteria, particularly the restriction to English-language publications, may have led to the exclusion of valuable literature written in other languages. Additionally, the screening process, which involved reviewing titles and abstracts followed by full-text assessment of eligible articles, may have missed potentially relevant evidence [42]. Since the studies included in this review covered different topics and contexts, it was not possible to track the progress of OH implementation over time (from 2013 to 2025). Furthermore, most of the studies employed cross-sectional designs, which provide insights into OH implementation at a single point in time rather than capturing its evolution over time. Conclusion and recommendations Global challenges such as increased human-animal interaction, globalization, technological advancement, climate change, population growth, and rapid urbanization highlight the urgent need to integrate the One Health (OH) approach into national and global health systems. Although the OH concept is not new, its practical implementation has been slow, primarily due to barriers including limited funding, low awareness, governance and coordination challenges, insufficient focus on zoonotic diseases, and the absence of supportive legislative and administrative frameworks. To address these challenges and enhance the effectiveness of OH, several key actions are recommended. First, OH-specific legal and policy frameworks must be developed and implemented across all levels of governance to provide structured and sustainable support for OH initiatives. Second, comprehensive awareness and advocacy campaigns are essential to inform and engage policymakers, political leaders, and funding bodies, fostering stronger political will and financial investment in OH. Third, increasing the number of professionals trained in OH is crucial to build a capable workforce that can champion and implement the approach across sectors. Fourth, investment in multidisciplinary infrastructure—including diagnostic laboratories, research facilities, and collaborative professional teams—is necessary to support integrated action and ensure equitable sharing of responsibilities and resources. Finally, OH activities must be inclusive and participatory, designed to prevent professional dominance and promote shared ownership among stakeholders. This will encourage long-term commitment and trust, which are essential for the success and sustainability of OH initiatives. Moreover, a critical contrast exists between high-level policy frameworks and field-level realities. While national and international strategies emphasize institutional alignment and regulatory reform, local experiences highlight the need for adaptability, community engagement, and bottom-up approaches. Bridging this divide is imperative. Linking policy integration with local empowerment and participation will be key to overcoming implementation gaps and realizing the full potential of the One Health approach in addressing complex global health threats. Registration and protocol The systematic review was registered in PROSPERO under the registrations number CRD42024520269. Declarations Ethics approval and consent to participate Not applicable Consent for publication Not applicable Competing interests The authors declare that they have no competing interests. Funding No funding was gained for this review. Acknowledgement Not applicable Authors’ contributions MSI , as the first and corresponding author, handled the research conceptualization, data curation, formal analysis, funding acquisition, investigation, methodology development, resource provision, visualization, initial draft writing, and review and editing of the manuscript. The second author, NJ , contributed to the conceptualization, data curation, investigation, methodology, project administration, supervision, validation, visualization, and manuscript review and editing. The final author, DTG , was involved in conceptualization, data curation, formal analysis, investigation, methodology, software development, supervision, validation, visualization, and review and editing of the manuscript. All authors reviewed and approved the final version of the manuscript. Data availability statement The authors affirm that the data underpinning the findings of this study are presented in the results section of the article. Additional information regarding the data can be obtained from the corresponding author, [MSI], upon reasonable request. Additional files Quality check of primary research articles (Additional file 1) Quality check of review articles (Additional file 2) References 1. https://www.cdc.gov/onehealth/basics/index.html https://www.emro.who.int/fr/about-who/rc61/zoonotic-diseases.html https://doi.org/10.1016/j.onehlt.2023.100491 https://doi.org/10.1016/j.onehlt.2024.100716 https://doi.org/10.1016/j.onehlt.2023.100666 https://doi.org/10.1016/j.onehlt.2019.100093 https://doi.org/10.1016/j.onehlt.2024.100704 https://doi.org/10.1016/j.onehlt.2019.100101 https://www.who.int/health-topics/one-health\#tab=tab_1 Crossref Google Scholar Information & Authors Information Version history V1 Version 1 03 July 2025 Copyright This work is licensed under a Non Exclusive No Reuse License. Keywords challenges implementation one health Authors Affiliations Md Shahidul Islam 0000-0001-8984-8689 [email protected] University of New England School of Health View all articles by this author Nusrat Jahan University of New England School of Health View all articles by this author Daniel Teshome Gebeyehu University of New England School of Health View all articles by this author Metrics & Citations Metrics Article Usage 268 views 146 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Md Shahidul Islam, Nusrat Jahan, Daniel Teshome Gebeyehu. Integrating One Health into health systems: a systematic review of challenges, opportunities, and strategic directions. Authorea . 03 July 2025. DOI: https://doi.org/10.22541/au.175153391.11261343/v1 If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download. 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