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Health Objectives for the Nation
This issue of the MMWR introduces a new series, "Health Objectives for the Nation." Future articles will address efforts by health agencies at all levels to meet national objectives and by the public and private sectors to develop and implement comparable prevention and health promotion objectives. This first article provides background to the origin of national health objectives, outlines the process used to develop the objectives, lists the broad categories of objectives, and describes an approach to implementing the objectives. Year 2000 National Health Objectives
In July 1979, the publication Healthy People: The Surgeon General's Report on Health Promotion and Disease Prevention described for the first time a national public health agenda. This report established five quantifiable goals for improving the health of all Americans and documented the importance of disease prevention and health promotion in achieving these goals (1). In 1980, a companion piece--Promoting Health/Preventing Disease: Objectives for the Nation--set forth 226 specific, measurable health objectives in a plan of action for reaching these goals (2). These objectives, referred to as "the 1990 health objectives," called for improvements in health status, risk reduction, public and professional awareness, health services and protective measures, and surveillance and evaluation.
Successes in attaining these objectives have been documented in areas such as hypertension, childhood infectious diseases, and injury prevention (3-5). However, many of the objectives will not be met by 1990, and new public health problems and challenges have arisen. Therefore, in 1987, the Public Health Service (PHS) began developing the Year 2000 Objectives for the Nation.
The planning process for these new objectives has taken into account the need to 1) involve as many groups as possible in early stages, 2) set objectives addressing high-risk minority populations and specific age groups when appropriate, and 3) emphasize the roles for citizens, the private sector, and the public sector in meeting the objectives. Process
To ensure a broad base of input, PHS and the Institute of Medicine invited more than 300 national organizations and the state and territorial health departments to join a consortium to develop the year 2000 objectives. Regular mailings and meetings are used to sustain the participation of these organizations. Twenty-five public hearings provided a forum for persons and organizations in different areas of the country to participate in the process and make recommendations; PHS narrowed the list of recommendations to 21 priority areas (Table 1). Specific PHS agencies then drafted objectives in each priority area using work groups made up of subject-area experts from federal, state, and local agencies and from academia. Each work group used the testimony from the public hearings in writing the objectives.
In January 1989, a draft of the objectives developed by the work groups was sent to other experts, both within and outside the federal government, for critical review. The revised objectives were then sent to the Office of Disease Prevention and Health Promotion, Office of the Assistant Secretary for Health (which is coordinating the process), for incorporation into the draft publication Promoting Health/Preventing Disease: Year 2000 Objectives for the Nation (6). More than 7000 persons and organizations have participated in developing the draft now available for review.
On September 18, PHS solicited public review of and comment on the objectives, with a November 15 deadline (7). A national conference is planned for July 1990 to release the final Year 2000 Objectives for the Nation and to begin the decade-long implementation effort. Goals and Objectives
The draft Year 2000 Objectives proposes five specific, measurable goals--similar to those set forth in Healthy People in 1979--that the comprehensive set of objectives in the 21 priority areas is designed to achieve by the year 2000 (6): oReduce infant mortality to no more than seven deaths per 1000 live births (baseline: 10.4 per 1000 in 1986). oIncrease life expectancy to at least 78 years (baseline: 74.9 years in 1987). oReduce disability caused by chronic conditions to a prevalence of no more than 6% of all persons (age-adjusted baseline: 8.9%). oIncrease years of healthy life to at least 65 years (baseline: an estimated 60 years in 1987). oDecrease disparity in life expectancy between white and minority populations to no more than 4 years (baseline: 5.8 years in 1987).
The 21 priority areas have served as a framework for drafting the year 2000 objectives. These priority areas include many of the 15 areas established for 1990 and extend into additional areas, such as human immunodeficiency virus (HIV) infection, cancer, and the vitality and functional independence of older people (Table 1). The priority areas and the specific objectives under each are grouped into four major sections in the publication: Health Promotion, Health Protection, Preventive Services, and System Improvement Priorities.
The year 2000 draft contains 339 objectives (compared with the 226 objectives established for 1990) characterized by 1) an increased emphasis on prevention of disability and morbidity, 2) greater attention to improvements in the health status of specific groups at highest risk for premature death, disease, and disability, and 3) inclusion of more screening interventions to detect asymptomatic diseases and conditions early enough to prevent early death or disability.
Specific targets for special populations were developed for groups demonstrating higher risk than the general population for a particular disease or condition. These groups start at a lower baseline for the health condition and thus are at a disadvantage in attaining the same target level as the general population. For example, the draft objective on the initiation of smoking aims to reduce the proportion of youth who start to smoke from 29.5% in 1987 to no more than 15%. However, a special-population target of 20% is set for youth of low socioeconomic status whose baseline rate was 40% in 1987. Implementing the Objectives
Because many states and communities may wish to develop and attain their own health objectives relating to the year 2000, PHS is working with the Model Standards Project through the American Public Health Association to develop a community implementation workbook. The workbook will integrate the national health objectives with the approaches of the publication Model Standards: A Guide for Community Preventive Health Services (8) to enable state and local health agencies to tailor the national objectives to their specific local health and demographic needs. The work book is scheduled for release in the fall of 1990, as a companion to the Year 2000 Objectives for the Nation. Reported by: Office of Disease Prevention and Health Promotion, Office of the Assistant Secretary for Health, US Dept of Health and Human Svcs. Office of Program Planning and Evaluation, Office of the Director, CDC.
Editorial Note: The 1979 publication Healthy People is a landmark in the history of public health. At the time, the Secretary of Health, Education, and Welfare characterized this report as a document "to encourage a second public health revolution" (1) and suggested that it reflected an emerging consensus among the health community that the nation's health strategy must emphasize the prevention of disease.
Public health efforts at the local, state, and national levels have resulted in documented progress toward meeting many objectives, but improvement is still needed in others. For example, by 1987, considerable progress had been made toward the objectives related to childhood vaccines even though the goal of immunizing children by the earliest appropriate year (age 2) had not been reached. Five of the eight objectives addressing morbidity reduction from childhood vaccine-preventable diseases appeared to have been attained, including those for diphtheria (1990 target, 50 cases; 1987 level, three cases), poliomyelitis (target, 10; level, no cases), and tetanus, rubella, and congenital rubella syndrome (all of which fell below the 1990 target in 1987). In contrast, immunization targets for adults were not likely to be achieved. The 1990 objective for influenza vaccination targeted immunization of at least 60% of high-risk populations annually. However, the 1985 U.S. Immunization Survey showed that only about 20% of high-risk persons had received the vaccine during the preceding year (4).
The draft Year 2000 Objectives affirms the commitment to addressing public health problems that persist, as well as problems that have appeared or intensified since the inception of the national health objectives in the late 1970s. For example, the current document contains a section on HIV, which was unknown when the 1990 objectives were developed.
The extensive participation by representatives of state and local governments, academic institutions, business and labor, and community and professional organizations at each step in the process is helping to establish the broad network needed for successful implementation of programs. This network is vital to the efforts to meet the objectives, as well as to achieve the goal of the World Health Organization of "Health for All by the Year 2000." PHS welcomes comments on the draft objectives. The draft is available for public review from ODPHP National Health Information Center, P.O. Box 1133, Washington, DC 20013-1133; telephone (301) 565-4167 or (800) 336-4797. Comments should be sent by November 15, 1989, to: Deputy Assistant Secretary for Health (Disease Prevention and Health Promotion) U.S. Department of Health and Human Services 330 C Street, S.W., Room 2132 Washington, DC 20201
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