Objectives-Setting for Improved Health:

The Public Health Service Healthy People Program

This case study was developed by Ashley Coffield, Deborah Maiese, and Earl Fox in the Office of

Disease Prevention and Health Promotion (ODPHP), Office of Public Health and Science,

Department of Health and Human Services. ODPHP would like to thank the American Society

for Public Administration Task Force on Government Accomplishment and Accountability for the

opportunity to participate in this important project of identifying and describing strategic planning

and outcome measurement efforts in the Federal government. 

The Department of Health and Human Services, U.S. Public Health Service, has been monitoring,

tracking, and publicly reporting progress in meeting national health goals and objectives for over

16 years. In collaboration with States, communities, and the private and voluntary sectors, the

U.S. Public Health Service (PHS) has established a framework for action based on realistic

opportunities to improve the health of the American people. Published in 1979, Healthy People:

the Surgeon General’s Report on Health Promotion and Disease Prevention, laid the foundation

to continue the process of seeking improvement in health. In 1990, the PHS established year

2000 targets in Healthy People 2000: National Health Promotion and Disease Prevention

Objectives.

As the Nation’s prevention agenda, Healthy People 2000 lays out a 10-year plan of what is

possible for Americans to achieve in improving health and quality of life for all. As overall

coordinator of Healthy People 2000, the Office of Disease Prevention and Health Promotion

(ODPHP), a program office in the Office of Public Health and Science, works with the PHS

agencies, other Federal agencies and departments, and members of the Healthy People 2000

Consortium to reach all Americans with effective disease prevention and health promotion

messages and activities. The goals and objectives are unifying in that they provide the Nation

with a sense of what can and ought to be achieved in health when we work collectively. In

addition they have been used by Federal health agencies to provide direction and measure

performance in a variety of program areas.

The key elements of this case study that may be of interest to other Federal agencies include
PHS’s collaboration with the private sector and the States in setting the objectives and 

achieving the targets; the accountability process established within the PHS to help ensure that

momentum toward meeting the objectives is maintained; and the methods used to expand interest

and participation in Healthy People 2000 activities. While this case study illustrates the use of

strategic planning and outcome measurement, it should be understood that Healthy People 2000

is not a system for assessing the performance of PHS as a whole or of PHS agencies.

I. Context 

Applying private sector objective-setting principles to public health began at the Federal level in

1979 when the PHS set the first national health goals. With the publication of Healthy People:

the Surgeon General’s Report on Health Promotion and Disease Prevention, PHS established

national mortality reduction goals for four age groups. Goals to be achieved by 1990 included a

35 percent reduction in infant mortality; a 20 percent reduction in childhood deaths; a 20 percent

death rate reduction for adolescents and young adults; and a 25 percent death rate reduction for

adults ages 25 to 64 years. For persons over age 65, Healthy People set a target in reducing the

number of disability days, with the goal of improving the quality of life for older adults.

The development of these broad goals and the subsequent development of specific and

quantifiable objectives necessary to attain these goals was precipitated by a recognition in the

Department that a “second public health revolution” should be encouraged. While the first

revolution in public health controlled many infectious diseases (e.g., eradication of smallpox

worldwide), there was a need to move the focus of the Nation’s health system away from the

costly cures of medical care toward prevention of death and disability from chronic illnesses, such

as heart disease, cancer, and stroke. New knowledge from research has increased the capacity of

public health officials to develop effective prevention strategies in these areas.

To identify specific objectives for obtaining the goals, the PHS examined factors that determine

health status and have the potential to prevent disease and premature death. PHS officials

developed analytical background papers on 15 disease prevention/health promotion priority areas,

focusing on biological, behavioral, environmental, and social risk factors as well as interventions
and services proven in the scientific literature to reduce morbidity and mortality. These papers

were then reviewed by 167 experts, including health care providers, academicians, State and local

health officials, and staff of voluntary health associations. These experts participated with PHS

officials in a 1979 conference to create the first draft of objectives for 15 priority areas. The

papers and draft objectives were published in the Federal Register and circulated to more than

2,000 organizations and individuals for review and comment.

The result of this collaboration was Promoting Health/Preventing Disease: Objectives for the

Nation. This 1980 publication set 226 objectives with targets for achievement by 1990. The

objectives addressed: improvement in health status; reduction in risks to health; increases in public

and professional awareness; improvement and expansion of health services and protective

measures; and enhancement of surveillance measures and research efforts.

II. Strategic Planning and Development of Healthy People 2000 Goals and Objectives

The 1990 objectives-setting effort laid the foundation for a prevention agenda for the year 2000. 

Over a three-year period beginning in 1987, a collaboration was launched to develop a prevention

agenda for the year 2000. The Institute of Medicine of the National Academy of Sciences (IOM),

under a cooperative agreement with the PHS, invited national membership organizations from

across the country to join in the development of the Nation’s health promotion and disease

prevention objectives through participation in the Healthy People 2000 Consortium. At the

outset of this planning process, the Consortium consisted of 157 organizations including all State

and Territorial health departments.

Consortium members were invited to present testimony at seven regional hearings hosted by

schools of public health in Los Angeles, Birmingham, Houston, Seattle, Denver, Detroit, and New

York City. A panel consisting of PHS regional health administrators, other PHS officials, and

members of the Association of State and Territorial Health Officials heard the invited testimony

and other public comment. Another 18 hearings were held in conjunction with the annual

meetings of Consortium member organizations. Through these hearings, the IOM collected some

800 pieces of written and oral testimony.
PHS lead agencies used this testimony to draft the year 2000 prevention objectives. 

Objectives-development was based on the following principles: the objectives had to be credible,

reflecting available scientific evidence; it was preferred that they continued to track the 1990

objectives; they had to be compatible with the goals already adopted by federal agencies and

health organizations; they had to be relevant and understandable to a wide audience; and the

primary criterion was that the objectives had to be measurable.

A draft of the objectives was released in September 1989. Public comment continued to flow to

PHS and was used by the lead agencies to create a consensus document. Released in September

1990, Healthy People 2000: the National Health Promotion and Disease Prevention Objectives,

launched a 10-year national initiative to improve the health of all Americans. This collaboration

of States, academics, private and voluntary organizations, and interested individuals ensured that

the goals and objectives of Healthy People 2000 are not simply those of the Federal government,

but are national in scope. The combined efforts of the public and private sectors are requisite to

these targets being achieved.

While the construct as a whole has few detractors, there are critics of specific objectives, targets,

and measures. Some who were involved in the 1987-1990 objectives development process

remember the “battles” over the wording of objectives and claim that staff made modifications

over their objections. A comparison of the 1989 draft of the objectives with the final 1990

publication does show that substantial revisions were made based on public comment. The best

example of a measurement dispute is with the first goal of Healthy People 2000--increase the

years of healthy life for all Americans--which is a summary measure of a person’s perceived health

status and activity limitations juxtaposed with life expectancy data. This measure moves the

public health community from measuring mortality and years of potential life lost to a measure of

quality of life years. This first attempt to move into the realm of morbidity assessment has been

met with skepticism by statisticians who believe that a summary measure masks the details. 

Continuation of this goal in the next century remains an open question.

III. The Healthy People 2000 Strategic Plan and Indicators of Outcomes/Results
The three goals of Healthy People 2000 are to: 

Increase the span of healthy life for all Americans;

Reduce health disparities among Americans; and 

Achieve access to preventive services for all Americans. 

The 300 Healthy People 2000 objectives are organized into 22 priority areas (see Table 1). 

The order of priority areas and the assignment of numbers does not reflect a ranking or

hierarchy. The priority areas are one of three types: health promotion, health protection,

or preventive services. Health promotion relates to individual lifestyle choices, such as

exercise, diet and other behaviors. Health protection relates to environmental and

regulatory measures, such as occupational safety and food and drug safety. Preventive

services includes counseling, screening, and other interventions in a clinical setting. 

Surveillance and data systems, priority area 22, monitors the ongoing efforts to track the

objectives and provides the foundation for knowledge about all of the priority areas.

The age-related mortality objectives for children, adolescents and young adults, and adults

set in 1979 continued to be tracked. For older adults, a new measure seeks to preserve 

independence by reducing the proportion of people aged 65 and older who have difficulty

in performing two or more personal care activities.
Table 1

Healthy People 2000 Priority Areas

Health Promotion

1. Physical Activity

2. Nutrition

3. Tobacco

4. Substance Abuse: Alcohol and Other Drugs

5. Family Planning

6. Mental Health and Mental Disorders

7. Violent and Abusive Behavior

8. Education and Community-Based Programs

Health Protection

9. Unintentional Injuries

10. Occupational Safety and Health

11. Environmental Health

12. Food and Drug Safety

13. Oral Health 

Preventive Services

14. Maternal and Infant Health

15. Heart Disease and Stroke

16. Cancer

17. Diabetes and Chronic and Disabling Conditions

18. HIV Infection

19. Sexually Transmitted Diseases

20. Immunization and Infectious Diseases

21. Clinical Preventive Services

Surveillance and Data Systems

22. Surveillance and Data Systems
Healthy People 2000 explicitly recognizes that “progress toward a healthier America will depend

substantially on improvements for certain populations that are at especially high risk.” High risk is

defined in terms of worse rates or a differing trend than for the overall population. Racial, ethnic,

gender, and age-specific special population targets (“subobjectives”) were set to focus the

attention of the Nation on eliminating disparities and thereby move the country toward achieving

the second goal of Healthy People 2000. Targets for people with low-income and people with

disabilities were also established. An example of a special population target can be found in the

Maternal and Infant health priority area addressing infant mortality (see Figure 2). 

Table 2 - Special Population Targets - Sample

Maternal and Infant Health

14.1 Reduce the infant mortality rate to no more than 7 per 1,000 live births.

 (Baseline: 10.1 per 1,000 live births in 1987)

Special Population Targets

Infant Mortality (per 1,000 live births) 1987 Baseline 2000 Target

14.1a Blacks 18.8 11.0

14.1b American Indians/Alaskan Natives 13.4 8.5

14.1c Puerto Ricans 12.9 8.0

The third goal of Healthy People 2000 is monitored with the objectives in priority area 21,

Clinical Preventive Services. These objectives monitor the number of Americans with health

insurance coverage as well as the number receiving preventive health services at intervals

recommended by the U.S. Preventive Services Task Force.

Because Healthy People 2000 is a national plan and not just a Federal one, the plan explicitly

recognizes that it will require collaboration between the public and private sectors and levels of

government to achieve the objectives. Many factors contribute to the outcomes identified in the

plan (e.g., teenage pregnancy is affected by a multitude of social and behavioral factors in addition

to Federally-funded interventions). Progress in meeting the objectives does not translate directly
to Federal credit for successes, but to the Federal contribution to health improvement.

IV. Use and Impact of Strategic Planning and Information on Outcomes/Results

To coordinate the tracking and attainment of the 1990 objectives, the Assistant Secretary for

Health assigned an agency of the Public Health Service with lead responsibility for each of the 15

priority areas and required them to report regularly on their efforts to achieve the 1990 targets. 

With overall guidance provided by ODPHP, lead agencies in the PHS continue to coordinate each

Healthy People 2000 priority area, presenting a progress review on each priority area to the

Assistant Secretary for Health (ASH) approximately every three to four years. 

Most lead agencies have formed work groups for each priority area with representatives from

other Federal agencies and departments, State governments, and private and voluntary agencies. 

In collaboration with the Centers for Disease Control and Prevention’s National Center for Health

Statistics (CDC/NCHS), the work groups explore data sources, assuring that surveillance systems

are in place to track the objectives. The Office of Minority Health has also designated lead staff

for each priority area and cross cutting group to ensure that special population targets are

appropriately addressed. In preparation for the progress reviews, the work groups identify

problem areas and strategies for improving prevention efforts. At the progress reviews, the lead

agency head reports to the ASH on the status of the objectives and is available to answer

questions regarding the agency’s current efforts. The baseline data are presented as well as the

most current information available to show whether progress is being made or whether the Nation

is losing ground. Interagency and interdepartmental representation at the progress review ensures

that the lead agency collaborates with others at the Federal level. The private sector and State

and local representatives are in attendance as further assurance that problems will be addressed

and collaborative strategies identified.

Following each progress review, the ASH sends a memo to the PHS agency head outlining

strategies identified in the progress review and deadlines for actions. The lead agency head

addresses the specific steps they will take to pursue the strategies and meet the deadlines. Issues

addressed in the ASH’s memo include programmatic initiatives, surveillance improvements, and

interagency and programmatic collaborations. Ideally, these memos serve as platforms for action
and direction in planning next steps toward achieving the objectives. A Progress Report

summarizing the meeting with the ASH is prepared and publicly distributed. Progress Reports

give the current data on the objectives and the strategies PHS and its partners will pursue to

overcome barriers and make progress in reaching the targets (see sample in Exhibit I). 

Although critical to maintaining the relevance and usefulness of Healthy People 2000, the

engagement of lead agencies in this process varies, with some agencies investing higher levels of

effort in the process than others. While preparation for a progress review is the only motivation

for convening a work group meeting for some agencies, others use the work groups to

collaborate on an on-going basis on prevention efforts. For example, some agencies engage only

their own employees in the process, while others go to great lengths to include other Federal,

State, and local government agencies and the private sector making use the work group a forum

for communication and action. 

In addition to managing the progress reviews, ODPHP convenes quarterly meetings of the

Healthy People 2000 Steering Committee. Originally made up of representatives from each of

the lead PHS agencies, the membership was expanded in 1995 to include representatives from the

Health Care Financing Administration, the Administration on Children and Families, and the

Administration on Aging. These additions reflect the reorganization of the Department of Health

and Human Services and draw in partner agencies in health finance and social services. The

Steering Committee engages in information-sharing, addresses data and tracking issues, and

provides feedback on Healthy People 2000 initiatives. 

PHS agencies have utilized Healthy People 2000 to strengthen their programs and services, to

develop new data sources, and to refine existing data sources. The expansion of data sources

since Healthy People was released in 1990 has enabled the PHS agencies and others to identify

significant disparities in health status and receipt of health services between minority populations

and the total population. Because of this new knowledge, it was possible to identify more than

100 subobjectives for special populations as part of the 1995 midcourse corrections to Healthy

People 2000 (the publication, Healthy People 2000 Midcourse Review and 1995 Revisions, is
described in more detail in the next section). The assumption underlying Healthy People’s 10-

year targets is that information will change during the course of the decade, which requires the

agenda to be flexible enough to accommodate those changes. Through the Healthy People

process, data has driven the development of new objectives and objectives have driven the

development of new data. This dynamic has given the Nation a wealth of new knowledge about

health and has ensured the relevancy of the agenda as the decade progresses.

At the National Institutes of Health (NIH), the largest of the PHS agencies, Healthy People 2000

has served as a strategic guide to what needs to be accomplished in research. At the same time,

the research process at NIH has resulted in the development of new objectives. For example, the

Healthy People objective related to overweight prevalence is moving away from the targets for

adults and adolescents of both sexes. In the 1996 reauthorization for NIH, the National Cancer

Institute, National Heart, Lung and Blood Institute, and National Institute of Diabetes and

Digestive and Kidney Diseases cited these data as evidence that further research is needed on

overweight, which can often lead to chronic illness.

NIH also holds consensus conferences for the practicing health community and the public to

inform them of the new advances in the delivery of health care. As new research findings become

available, this information drives service delivery change in other Federal agencies as well as

information dissemination to the private sector and consumers. Information on effective therapy

for prevention of the recurrence of peptic ulcers became available in the 1990s through NIH’s

research process. Peptic ulcers affect 6 million known patients per year, of which 240,000 are

hospitalized. New information on the costs and benefits of prevention of peptic ulcers resulted in

a new objective being added to Healthy People through the Midcourse Review, which calls for

reducing the prevalence of peptic ulcer disease by preventing its recurrence. 

HHS Strategic Planning. As part of the implementation of the Government Performance and

Results Act, the Department of Health and Human Services initiated a strategic planning process

in 1995 which will serve as the superstructure for specific agency plans. The agencies have

initiated their own strategic planning efforts tied specifically to their missions and roles. In the
Department-wide plan, which is currently being refined, many of the success indicators

correspond directly to Healthy People 2000 objectives. For example, success indicators include

rates of tobacco use, percentage of children uninsured, and rates of low birthweight babies.

The PHS agencies in the Department, whose missions are tied most closely to the goals of

Healthy People 2000, have strategic goals and objectives that reflect and support the Healthy

People 2000 agenda. For example, the Center for Food Safety and Applied Nutrition at the Food

and Drug Administration states in the text following its goal on nutrition and food labeling that,

“(FDA) is also concerned with maintaining FDA’s leadership in nutrition science and effectively

supporting Departmental health promotion and disease prevention goals for nutrition as

articulated in the Healthy People 2000 initiative.” The FDA strategic plan also includes objective

statements under that goal that specifically call for FDA’s continued leadership toward achieving

the Healthy People 2000 nutrition objectives and further evaluating the impact on health of

changes in food and nutrient intakes using national survey data.

The Center for Disease Control and Prevention’s (CDC) Strategic Thinking paper, which is the

forerunner to its strategic plan, states that, “Healthy People 2000 was a key factor in motivating

CDC’s strategic thinking process.” Also, the paper states that the words used in CDC’s vision

statement, “Healthy People in a Healthy World--Through Prevention,” reflect two ideas. They tie

the vision to the Healthy People 2000 objectives, and they convey the idea that people and their

health are the highest priority for CDC.

The President’s Council on Physical Fitness and Sports (PCPFS) developed “The PCPFS

Strategic Plan: Meeting the Healthy people 2000 Objectives for Physical Activity and Fitness”

and presented it at it’s 1995 Progress Review on the physical activity and fitness priority area. 

The Strategic Plan provides an analysis of activities and programs in support of Healthy People

2000; an overview of organizational roles and strategies; and a synopsis of ongoing public and

private grassroots activities in support of increasing participation in physical activity and

improvement in fitness. Setting the physical activity and fitness objectives played a major role in

elevating the public health role of physical activity in the nation, as well as highlighting gaps and

barriers, and ultimately led to the landmark release in July 1996 of the first Surgeon General’s
Report on Physical Activity and Health.

Information for HHS Customers. A critical part of the PHS role in Healthy People 2000 is to

monitor, track, and report to the Nation on a periodic basis the health status of the American

people and the results of the Nation’s prevention efforts. PHS began its public reporting with the

publication in November 1986 of The 1990 Health Objectives for the Nation: A Midcourse

Review. The preface to this review states that “having passed the midpoint of the decade, we are

in a position to take our bearings, to assess our progress to date, and to consider necessary

midcourse corrections.” The review provided a report card on each of the 226 objectives,

celebrating the successes in health improvements and calling attention to the bad news in

increasing incidence of preventable conditions that could be reduced, if not eliminated, by further

action.

The 1980s ended with successes and with some important challenges for the upcoming decade. 

In June 1992, Health United States, 1991 and Prevention Profile provided the results of the 1990

objectives:

32 percent of the 1990 targets were attained;

Progress was made on another 30 percent;

15 percent moved in the opposite direction or showed no progress; and

23 percent could not be evaluated due to insufficient data.

To keep customers better informed on the status of year 2000 objectives, an annual

statistical report is released by CDC/NCHS. Healthy People 2000 Review provides a

section for each priority area and presents the baseline, target, and most current data

available for the objectives. Data issues, such as proxy measures, differing tracking

systems, and operational definitions, are also discussed. 

In 1994, the PHS undertook a midcourse review of the Healthy People 2000 objectives. 

PHS work groups met to consider new data, new information, and new science that had

become available since the release of Healthy People 2000 in 1990. The result of these
deliberations was a draft of the proposed midcourse revisions, which was released to the

public for review and comment in October 1994. Revisions were proposed where the

target had already been met and needed to be made more challenging. Also, new special

population targets were added where new data showed increased health risk or disparity

between the total population and people with disabilities, people with low income, or

people in age, gender, racial, or ethnic groups. Finally, some revisions were made to the

language of existing objectives and new objectives were added to fill gaps and to reflect

new preventive interventions.

The final document, Healthy People 2000 Midcourse Review and 1995 Revisions, shows

that of the 300 objectives:

50 percent are moving toward the target;

18 percent are moving away from the target;

3 percent show no change; and

29 percent have insufficient data with which to measure progress.

Published in October 1995, the Midcourse Review added 19 new objectives and more than

100 special population targets. For example, in the priority area for Tobacco, a new

objective seeks the enactment of laws to make cigarette vending machines inaccessible to

minors. The report also provides the mid-decade status on the three goals, the objectives,

and the subobjectives of Healthy People 2000. 

The Midcourse Review shows that the lack of data with which to measure progress is

significant. Of the 29 percent that had no data, with which to measure 8 percent of the

objectives had no baseline data and 21 percent had no update beyond the baseline. 

However, significant improvements have been made. When Healthy People 2000 was

published, 23 percent of the objectives lacked baseline data compared to 8 percent that

have no data at midpoint of the decade. This change is evidence that focusing attention on

important objectives has driven the development of needed information. Also, in the
midcourse review of priority area 22, Surveillance and Data Systems, progress was

reported in meeting six of the seven targets for the objectives. There has been particular

progress in States’ use of the set of consensus health status indicators that are available at

both the national and State level.

To further serve the many customers of the Healthy People process, ODPHP prepares

other products including Progress Reports (described earlier in this report), which

summarize the progress reviews with the ASH. These two page summary reports (see

Exhibit I) provide the most current data on the objectives, a review of the strategies that

appear to be making a difference, as well as a list of follow-up actions to propel further

progress. Also, Healthy People 2000 Resource Lists for each of the 22 priority areas

offer a summary of the objectives as well as Federal, State, and local resources. To

stimulate programs for high-risk groups, ODPHP provides lists of the objectives for

specific populations, such as Black Americans, Hispanic Americans, Asian and Pacific

Islander Americans, People with Disabilities, and People with Low Incomes. ODPHP also

provides an introductory fact sheet on Healthy People 2000 and includes Healthy People

2000 information on the ODPHP home page, which is available over the Internet at

HTTP://ODPHP.OSOPHS.DHHS.GOV/PUBS/HP2000. (A sample Resource List,

specific population objectives, and the fact sheet are included in Exhibit I)

State Action. As of 1995, 43 States, the District of Columbia and Guam had published

Healthy People 2000 plans, each tailoring their objectives to meet their needs. Some

States have drafted documents that parallel the 22 priority areas at the national level, while

other States have adopted only selected priority areas and national objectives. In some

instances, States share the same year 2000 targets as the Nation, while in other States they

have set their own targets to seek greater change or to pursue a slightly less ambitious

result. The multitude of approaches States have pursued, using the Nation’s prevention

agenda as a framework, speaks to the versatility and flexibility of Healthy People 2000.

PHS established a network of Healthy People 2000 State Action contacts to serve as
liaisons between the PHS and the States, to foster communication among the States, and

to serve as the point of contact for the public on year 2000 activities. In some States, the

State health official serves as the primary contact, while in others contacts are in the health

statistics, planning, or policy branches of the health department.

Healthy People 2000 efforts are also reflected in State aging plans. In Tennessee, the

Commission on Aging in conjunction with area agencies on aging and service providers is

working to promote good health among older Tennesseans by pursuing a number of

Healthy People 2000 objectives. These include increasing pneumonia and influenza

immunization levels and other clinical preventive services recommended by the US

Preventive Services Task Force for older adults; reducing overweight prevalence and

cigarette smoking; and increasing physical activity. The plan specifically states that “these

objectives are based on Healthy People 2000 in order to encourage coordination and to

maintain focus on patient outcomes rather than particular methods of delivery.”

In North Carolina, the Division of Aging is pursuing 17 health promotion/health status

strategies. These include the expansion of exercise programs, nutrition screening,

glaucoma screening, oral health education programs and adult immunization

awareness--all areas of Healthy People objectives for older adults.

HEALTHY PEOPLE 2000 Consortium Action. All 50 States and the more than 300

national membership organizations in the Healthy People 2000 Consortium are working

with local governments, their local chapters, and their members to meet the goals and

objectives of Healthy People 2000. Organizations such as the American Medical

Association, the Association for the Advancement of Retired Persons, the Girl Scouts, and

the National Association of Hispanic Health and Human Services Organizations are

examples of Consortium members who are using their expertise, contacts, and resources

to contribute to national efforts of improving health for all Americans.

At annual meetings of the Consortium, progress and successes in prevention, barriers, and
ways to overcome them are discussed. The theme for the 1995 Consortium meeting,

“Healthy People in Healthy Communities,” focused on Consortium members’ experiences

in building broad-based, local initiatives. As local objectives-setting is taking place in

cities and communities across the country, participants explored lessons learned in

establishing community coalitions and the challenges of sustaining project momentum. 

Participants also explored how Healthy People 2000 serves as a framework for

communities to use in identifying their own health problems and for effectively bringing

together their resources to make a difference in health.

ODPHP keeps Consortium members abreast of each other’s activities and those of the

Federal government through Consortium Exchange, a quarterly newsletter highlighting

activities related to Healthy People 2000. In a recent newsletter, two national

organizations were highlighted for tobacco-related activities. The National Medical

Association has implemented a second-hand smoke awareness initiative in predominantly

African-American communities, and Oral Health America, a dental health foundation, has

developed public service announcements communities can use to discourage use of spit

tobacco among adolescents. The State of Kansas was also featured for its recent release

of Healthy Kansans 2000: State Health Objectives for the Year 2000, and Maine was

spotlighted for its midcourse review of the Healthy Maine 2000 objectives. (The most

recent edition of Consortium Exchange is included in Exhibit I)

Both the strength and the weakness of the Consortium lies in its size and diversity. On

one hand, the Consortium effectively brings together a broad range of interests, forming a

powerful alliance for prevention. On the other hand, its scope makes it difficult to ensure

that every member remains engaged. While some members are actively involved in annual

meetings and share information about their health promotion activities, others have not

participated since the release of Healthy People 2000. The challenge for ODPHP, which

provides liaison to the Consortium, is to renew the interest and support of Consortium

members as the year 2000 approaches and plans begin for development of a prevention

agenda for 2010.
The 16 years of experience in objectives-setting has produced a healthier nation and

numerous lessons in the value of strategic planning for public health. For the public health

community, policymakers, and the public, Healthy People 2000 remains a useful vehicle

for reporting the current status of health indicators, trends in health, and ultimately

whether success or failure has been achieved in reaching agreed-upon objectives. It is also

the vehicle by which the Federal government has forged relationships with the States and

the private sector to promote health. The objectives have unified the public health

community and others and has served as a stimulus for complimentary long-range planning

efforts at the State and local level in the private sector.

Perhaps most importantly, objectives-setting has provided a framework for holding

government accountable for its actions. Because the agenda for public health has been set

collectively through the participation of more than 10,000 people nationwide and the

mechanisms are in place for reporting and sharing information, there is some assurance

that public health agencies are directing their resources at the most preventable and

serious health problems. All grant applications submitted to the PHS agencies must

identify the Healthy People 2000 objective(s) being addressed. However, because

Healthy People 2000 is so broad and inclusive, almost any activity can be ascribed to

promoting the Healthy People 2000 agenda. A major challenge is to ensure that these

associations with Healthy People, whether in grant applications, marketing tools, or

budget justifications, have substance behind the attribution.

Through both the management and active use of Healthy People 2000, the ODPHP and

the PHS agencies have learned to examine shortfalls, improve processes, and undertake

innovative approaches. Three laws that incorporate Healthy People 2000 objectives

include the Maternal and Child Health Block Grant which requires reporting on the

national objectives for maternal and infant health annually to Congress. The Indian Health

Care Improvement Act directs the Indian Health Service to report annually on 61

objectives on the health status of Native Americans. Finally, the 1993 authorization of the
Preventive Health and Health Services Block Grant linked activities undertaken by the

States with these grants to year 2000 health objectives. Healthy People 2000 also inspired

HHS’s recent recommendation to develop “performance partnership grants” for federally

funded public health programs, which could shift accountability for these programs away

from process measure to outcome-based accountability.

Healthy People 2000 has also served as the basis for the Oregon benchmarks process,

which provides measurable indicators that the State uses to assess its progress toward

broad strategic health goals. In addition, it has provided four of the nine preventive health

service measures adopted by the National Committee for Quality Assurance for the Health

Employer Data and Information Set (HEDIS20) that assesses the performance of managed

care organizations. Since the HEDIS instrument is the only standard tool by which

purchasers can compare health plans, managed care organizations focus their efforts

toward those areas being measured. Federal government produces a significant ripple

effect with modest investment in innovative efforts such as Healthy People 2000.

Healthy People 2000 is also part of a larger international movement of health promotion

and disease prevention based on the World Health Organization’s Health for All by the

Year 2000 agenda. Countries including the United Kingdom, Australia, Canada, Spain,

New Zealand, and Russia have health goals and objectives similar to Healthy People 2000. 

The Pan American Health Organization, which serves the Regional Office for the

Americas of the WHO, reports annually on U.S. efforts to promote health and prevent

disease in the context of its other 38 member countries on a defined set of indicators.

In many countries, national efforts have been translated into community action. The

Healthy Cities movement, promoted globally by the WHO, is based on the assumption that

local structures and policies can have a profound effect on the physical and mental

well-being of people in communities. The movement is based on a philosophy that places

equal emphasis on the process of promoting change as well as the ultimate consequences

of that process. It is taking root in the U.S. with Statewide Healthy Cities coalitions in

California, North Carolina, South Carolina, and New Mexico. The Healthy Cities process
brings objectives-setting and the pursuit of quantitative targets to the local level. 

V. Costs of Healthy People

Despite political changes in the executive branch of the Federal government, there has

been continuous support for the Healthy People initiative at the national level. In

contrast, not all states have been able to sustain their published health goals and objectives

as administrations have changed. The first Healthy People was released during the Carter

administration in 1979, while the 1990 objectives were published in 1980 after Ronald

Reagan was elected to the presidency. The Reagan administration, through the leadership

of Assistant Secretary for Health, Edward Brandt, found the objectives framework to be a

useful public health improvement tool and perpetuated the use of the objectives,

publishing the Midcourse Review in 1986. The develop- ment of Healthy People 2000

began in 1987 and was continued through the Bush administration with the objectives

being released in September 1990 by Secretary Louis Sullivan. Healthy People 2000

continued in the Clinton administration paralleling the Arkansans 2000 process in which

Hillary Rodham Clinton served as the honorary chairperson.

Healthy Kansans 2000, which follows the structure of Healthy People 2000, was

published in winter, 1996 and lead by the State’s Republican administration. The Healthy

Kansans 2000 Steering Committee with representatives from business, non-profit

organizations, hospitals, academia, and State and local government, identified seven “high

priority” health issues for Kansas residents: 1) alcohol and drug abuse, 2) cancer, 3) heart

disease, 4) HIV infection and other sexually transmitted diseases, 5) infectious diseases

and immunizations, 6) injuries and violence, and 7) maternal and infant health. The

Committee also identified four disease risk factors of concern to Kansans: 1) access to

preventive care, 2) tobacco, 3) nutrition, and 4) physical activity. The Committee

evaluated health data, sought expert opinion, conducted an opinion survey of residents,

and obtained public comment. 
With Kansas added to the list, 43 States, the District of Columbia and Guam have

developed Healthy People 2000 plans. Among the remaining 7 States that have never

published year 2000 objectives, Hawaii and New York are actively working on the

development of plans. Also, Georgia and Illinois have published health status assessments

using Healthy People 2000 as a framework. And all 50 States are using a consensus set

of Healthy People 2000 objectives to conduct health status assessments under the

Preventive Health Services block grant program.

Because HHS/PHS has been pursuing the attainment of national health promotion/disease

prevention objectives for almost 17 years, there is a long history of government employees

being held accountable for health improvements. For example, employees in the Maternal

and Child Health Bureau of the Health Resources and Services Administration are

working toward the year 2000 target of reducing infant mortality, and workers in the

Substance Abuse and Mental Health Services Administration are seeking to increase

adolescents disapproval of tobacco, alcohol, or other drugs. Although these targets

illustrate that the task of improving the Nation’s health extends beyond the reach of any

one program or agency, Federal workers are willing to use the objectives framework to

measure both the successes and failures of their programs. Healthy People 2000 is cited

as the yardstick for success by Federal workers and other authors in hundreds of articles in

journals such as Morbidity and Mortality Weekly Report, Public Health Reports, and

other peer-reviewed publications. Both within and outside the government, Healthy

People 2000 has become part of the fabric of public health.

The total costs associated with Healthy People 2000 are extremely difficult to measure

given the scope of the effort. Because Healthy People 2000 is a national set of objectives,

it is used by Federal agencies and the States in pursuing their policies and programs and by

localities in their development of healthy cities/communities initiatives. In the private

sector, Healthy People 2000 objectives are used in worksite health promotion and in

product development (e.g., low fat foods, sporting goods). And in the nonprofit sector,

organizations such as the American Association for Retired Persons, the Girl Scouts,
American Cancer Society, the National Mental Health Association, and others are using

Healthy People 2000 to shape their programs and publications.

ODPHP, as the coordinator of the initiative, spends less than $1 million annually in direct

support of the Healthy People 2000 Consortium and in information exchange with Federal

colleagues engaged in the effort. A staff of three people--a Healthy People 2000

coordinator, a Consortium coordinator, and an analyst--provide the nucleus of support. 

They are assisted by the nutrition, environmental health, worksites, schools, healthy

communities, clinical preventive services and communications staff team members in

ODPHP. 

The Division of Health Promotion Statistics at CDC/NCHS provides the statistical

expertise for this initiative. With a staff of 7 people working on national data and 6 people

working on state and local data activities, they provide on-going daily support for the

priority area work groups in their measurement activities and produce the annual statistical

report Healthy People Review. In addition they produce two series of reports devoted to

year 2000 issues--”Statistical Notes” and “Statistics and Surveillance.” They have also

supported a 5-year assessment initiative in 7 States designed to improve capacity for

measuring health risks and health status. Considerable resources in other NCHS programs

have been devoted to designing, fielding and analyzing data in the National Health

Interview Survey and in convening panels of experts to develop the consensus set of

health status measures and the measure for years of healthy life. The division devotes 9.5

FTE’s to Healthy People 2000 related work.

While these are the only two staffs devoted to Healthy People 2000, there is a circle of

people in HHS who perform Healthy People 2000 roles in addition to their own duties. 

Sixteen people serve on the Healthy People 2000 Steering Committee, which represents

all agencies in HHS and meets quarterly to discuss and guide policies in the initiative. 

From 1993 to 1995, the Steering Committee guided the development of the Midcourse

Review and grappled with the fact that baseline or updated data may not be available for
certain objectives. This group has begun work on objectives development for 2010 by

hearing from Environmental Protection Agency and Administration on Aging

representatives on their efforts to develop milestones for environmental goals and an

initiative for redefining retirement.

In addition to convening meetings of their works groups, over the past three years the

priority area work group coordinators have been included in the meetings of the Healthy

People 2000 Steering Committee. This has ensured broader participation in the

decision-making processes that surround Healthy People 2000 publications, the annual

Consortium meeting, and monthly progress reviews. Because Steering Committee

members and work group coordinators have other duties in their agencies, it is difficult to

estimate the annual salary costs of their efforts. Furthermore, the level of effort put forth

by work group coordinators varies considerably from year to year depending on whether

their progress review occurs with the ASH.

Beyond lead agency roles, staff participate in other work group meetings and in

cross-cutting work groups that are convened to do progress reviews on age, racial/ethnic,

or gender groups. Staff outside HHS also participate in Healthy People 2000 activities. 

For example, Department of Transportation and Consumer Product Safety Commission

staff play a large role in the unintentional injuries work group. Given the scope of effort,

counting the hours let alone the staff costs of Federal employees in the Healthy People

2000 process would present a formidable accounting challenge. Going beyond the Federal

level efforts in States, communities, or the private sector have not been quantified. 

Another considerable cost of this process centers on data collection. Many surveys and

information systems have been modified to track national objectives. Periodic

supplements to the National Health Interview have been developed to encompass a range

of health promotion and disease prevention issues. Special surveys have been created to

capture information on school health programs, worksite health promotion and health care

providers’ counseling practices. Because it is difficult to decipher whether the information
drives the objectives or when the framework affects the data collection, attributing what

percentage of the national information infrastructure is attributable to Healthy People is

not possible.

VI. Lessons Learned

The most significant limitation to fully utilizing the Healthy People 2000 agenda is

insufficient data. The Nation lacks the data and surveillance infrastructure to fully assess

morbidity, mortality, risk factors, and preventive services utilization. The political will to

invest in new data systems to provide national data, let alone State and community data,

undermines the foundation of any performance and accountability mechanism. Even

where reliable data systems are in place, issues such as changing survey samples,

questions, and definitions, comparability of data sources (where the baseline and update

source are different), and use of proxy measures for certain objectives produce ongoing

difficulties in fully determining the Nation’s improvements in health. The timeliness of

national information is yet another challenge. Most baseline information is from 1987,

lagging three years behind Healthy People 2000's 1990 publication date. Similarly, the

mid-decade report uses predominantly 1992 data. This three year time lag reflects the fact

that national mortality and natality data systems are only as current as the last State’s

submission.

Despite limitations in data infrastructure, Healthy People has effectively reinvented how

the public health community measures its successes. With its concentration on health

outcomes, Healthy People has empowered public agencies at the Federal, State, and local

levels to focus on, measure, and hold themselves accountable for results. The axiom,

“What gets measured gets done”, is proven time and again as public agencies utilize

Healthy People 2000 in strategic planning and resource allocation. The efforts of ODPHP,

which provides support and coordination for numerous public health initiatives in addition to

Healthy People 2000, proves that careful investment of small resources can change the terms

of debate around policy issues, in this case disease prevention and health promotion, in

fundamental ways. 
VII. Next Steps

Keeping in mind that targets have yet to be achieved for the year 2000, ODPHP staff are

currently planning the process for building a prevention agenda for 2010. Healthy People

2000 Steering Committee members, work group coordinators, and Consortium members

will be asked about their views on the structure of the framework for the 2010 plan. 

ODPHP staff are reviewing other country’s plans for ideas on the development of a new

structure. ODPHP also plans to survey States and localities to determine their ability to

measure Healthy People 2000 objectives.

One of the primary challenges will be to strike a balance between broad participation in the

development process and the creation of a manageable agenda. More active participation

of groups not traditionally involved in public health, such as health plans, businesses, and

the faith community, will be explored. And questions remain to be answered regarding

whether Healthy People 2010 should incorporate social and economic indicators, which

are also important determinants of health. In addition, the special population targets that

highlight disparities among groups will need to be reexamined. Currently, the targets are

set at what was agreed to be realistic objectives, yet in many cases the targets recognize

that the disparities between the subgroups and the total population persist. Subobjectives

for women may also be advocated, even in cases where a disparity does not exist, altering

the criteria for inclusion as a subobjective.

Although a number of benefits have accrued from Healthy People efforts, the process has

not been without its barriers, and improvements continue to be searched for and

implemented when possible. Lessons learned will certainly be applied as the Nation

embarks on Healthy People 2010.
References

 US Dept. of Health, Education and Welfare. Healthy People: Surgeon General's 1

Report on Health Promotion and Disease Prevention. Washington, D.C. US Dept. of

Health, Education and Welfare. 1979. US Dept. of Health, Education and Welfare

Publication No. PHS 79-55071.

 US Dept. of Health and Human Services. Healthy People 2000 National Health 2

Promotion and Disease Prevention Objectives. Washington, D.C. US Dept. of Health

and Human Services; 1990. Publication No. PHS 91-50212.

 U.S. Dept. of Health and Human Services. Promoting Health/Preventing Disease: 3

Objectives for the Nation. Washington, D.C. 1980.

 U.S. Dept. of Health and Human Services, Promoting Health/Preventing Disease: Year 4

2000 Objectives for the Nation. Washington, D.C. September 1989.

 US Dept. of Health and Human Services. Healthy People 2000 Midcourse Review and 5

1995 Revisions. Washington, D.C. US Dept. of Health and Human Services; October

1995. 

 US Dept. of Health and Human Services. The HHS Strategic Plan draft. Washington, 6

D.C. July 1996. 

 US Dept. of Health and Human Services. The Food and Drug Administration Strategic 7

Plan draft. Washington, D.C. July 1996. 

 US Dept. of Health and Human Services. The Centers for Disease Control and 8

Prevention Strategic Thinking Paper. Atlanta, GA. July 1996. 

 US Dept. of Health and Human Services. The President's Council on Physical Fitness 9

and Sports Strategic Plan. Washington, D.C. July 1996. 
 US Dept. of Health and Human Services. Report Physical Activity and Health A 10

Report of the Surgeon General. Atlanta, GA. US Dept. of Health and Human Services,

Centers for Disease Control and Prevention, National Center for Chronic Disease

Prevention and Health promotion. 1996. Publication No. S/N 017-023-00196-5.

 U.S. Dept of Health and Human Services, The 1990 Health Objectives for the Nation: 11

A Midcourse Review. Washington, D.C. 1986. 

 National Center for Health Statistics. Health, United States, 1991 and Prevention 12

Profile. Hyattsville, Md: 1992. US Dept. of Health and Human Services Publication No.

PHS 92-1232. 

 National Center for Health Statistics. Health United States, 1992 and Healthy People 13

Review. Hyattsville, Md: 1993. US Dept. of Health and Human Services Publication No.

PHS 93-1232. 

 National Center for Health Statistics. Healthy People Review, 1994. Hyattsville, Md: 13

1993. Public Health Service. 1995

 Personal communication from the Administration on Aging, Identification of State 14

Agencies on Aging Relationship to Healthy People 2000. June 26, 1996

 US Dept. of Health and Human Services, Office of Disease Prevention and Health 15

Promotion. Healthy People 2000 Consortium Exchange. Washington, D.C. 

 State of Kansas, Department of Health and Environment, Healthy Kansans 2000 Health 16

Promotion and Disease Prevention Objectives for Kansas. Topeka, Kansas. Winter

1996.

 Maine Department of Human Services, Bureau of Health, Healthy Maine 2000 A 17

Health Agenda for the Decade: Maine' Health Objective for the Year 2000. Augusta,
Maine. September 1993. 

 Arkansas Department of Health, Healthy Arkansas 2000: Arkansas Health Promotion 18

and Disease Prevention Objectives. Little Rock, AK., September 6, 1991.

 National Center for Health Statistics. Healthy People 2000 Statistical Notes. 

19

Hyattsville, Md: 1992. US Dept. of Health and Human Services Publication No. PHS

92-1237. 

 Thomas Peters and Robert Waterman. In Search of Excellence. New York, New 20

York: 1st Edition - 1982. Harpers & Row Publishers and Warner Books: Revised - 1984. 
Exhibit I
Exhibit II
Exhibit II - Preparation of the Case Study

The case study, “Objectives Setting for Improved Health: A Public Health Service Case

Study 

for the National Performance Review,” is based on records and publications that

document the Healthy People objectives setting process, dating back to 1979, as well as

interviews with ODPHP staff who participated in the process. Authors of the case study,

Ashley Coffield and Deborah Maiese, currently work on the Healthy People 2000 staff

and have experienced first hand the successes and barriers to engaging Federal agencies,

States, and the private sector in

the Healthy People 2000 process. Ms. Maiese is the Healthy People 2000 Coordinator

and 

Ms. Coffield was the Healthy People 2000 Consortium Coordinator.

Claude Earl Fox, MD, MPH, a reviewer of the case study, is Deputy Assistant Secretary

for Health (Disease Prevention and Health Promotion) and Director of ODPHP. Dr. Fox

participates in progress reviews with the Assistant Secretary for Health, chairs the Healthy

People 2000 initiatives.