Maintaining ecosystem health (EH) in watersheds is crucial for building a national pattern of ecological security. However, a comprehensive diagnosis of watershed EH and an exploration of its driving mechanisms are still lacking. This study proposed an EH assessment model from a vitality-organization-resilience-service-environment (VORSE) perspective. Taking the Yellow River Basin of Shaanxi Province (YRBS), China, as a research object, the spatiotemporal evolution trend of EH from 2000 to 2020 was quantified. At the same time, we also quantified the respective contributions of climate change (CC) and human activities (HA) to the EH dynamics based on residual analysis. The results showed that EH in the YRBS increased by 11.80 % from 2000 to 2020, and the spatial distribution of the EH was higher in the southern region than in the northern part. At the pixel scale, areas with improving trends accounted for 90.57 % of the YRBS, while 9.43 % deteriorated, with the improving areas mainly in northern Shaanxi and the deteriorating areas in the Guanzhong region. The correlation between the EH and precipitation was primarily positive, while the correlation between the EH and temperature was mainly negative. The residual analysis showed that the contribution rate of CC to EH changes was 78.54 %, while that of HA was 21.46 %, indicating that CC was the dominant driver of EH changes in the YRBS. Specifically, 82.64 % of the improvement in EH was attributed to CC and 17.36 % to HA. Conversely, 65.30 % of the deterioration in EH was attributed to CC and 34.70 % to HA. Furthermore, CC, HA, and CC&HA dominated EH changes in 26.85 %, 3.77 %, and 69.38 % of the YRBS area, respectively. In addition, the Hurst exponent analysis identified six types of future EH development scenarios, each requiring different restoration strategies. This study provides valuable insights for future EH diagnosis, EH restoration efforts, and the formulation of sustainable development goals in other watersheds.