Can a relatively small set of exemplary health indicators be identified which will reflect progress toward the health goals of the Nation--and do so in a manner which prompts public understanding and policy action related to the important determinants of that progress? This report presents the initial findings of a working group formed within the U.S. Department of Health and Human Services (HHS) to explore this question in the context of developing Healthy People 2010. The report will be provided as a background paper to an expert panel convened to carry forward and expand the assessment, engaging the outside community of health policy and science professionals.
Healthy People, the prevention agenda for the Nation, targets increasing the years of healthy life for Americans and reducing the health disparities. It is a statement of national opportunities--a tool that identifies the most significant and controllable health issues for Americans and focuses public and private sector efforts to address them. Healthy People offers a simple but powerful idea: provide the information and knowledge about how to improve health in a format that enables diverse groups to combine their efforts and work as a team. It is a roadmap to better health for all that can be utilized by many different people, by States and communities, professional organizations, groups concerned with a particular threat to health or a particular population group. Healthy People has become the Nation's road map to good health because it organizes the best scientific knowledge in a format that is useful for decisionmaking and for action.
The origin of Healthy People is the 1979 Surgeon General's report on health promotion and disease prevention--also titled Healthy People. The foreword to that report states boldly that its purpose is to "encourage a second public health revolution in the history of the United States . . . let us make no mistake about the significance of this document, it represents an emerging consensus among scientists and the health community that the nation's health strategy must be dramatically recast to emphasize the prevention of disease." The 1979 report was grounded in the notion that establishing national health goals and monitoring our progress could motivate action to facilitate their accomplishment. That first report focused solely on prevention and established targets for health improvements in the five life stages of infancy, childhood, adolescence, adulthood, and older age.
By 1990, the public health community had gained a great deal more experience with the concept of public health goals for the Nation. When Healthy People 2000 was released, the document had grown into a comprehensive agenda with 319 objectives organized into 22 priority areas. The over-arching goals were to increase years of healthy life, reduce disparities in health among different population groups, and achieve access to preventive health services. The process of developing Healthy People 2000 involved comments from more than 10,000 individuals and organizations, regional hearings to assure that the agenda reflected the diverse views of the Nation, and the assignment of lead responsibility for managing the 22 priority areas to component agencies of HHS. More important, the entire national public health community was a part of the process and collectively influential in determining the priority areas, objectives, and targets. Their collaboration has occurred chiefly through what we call the Healthy People Consortium--an alliance of national membership organizations that support and are involved in the Healthy People process. The consortium started in 1987 with 157 organizations and has now grown to more than 350. State health agencies and environmental agencies, numbering nearly 300, also participate in an annual meeting held in conjunction with the meeting of the American Public Health Association.
Following the publication of Healthy People 2000, 46 states, the District of Columbia, and Guam have developed their own Healthy People plans. Most states have emulated national objectives, but virtually all have tailored them to the specific needs of their own State. Within the Federal Government, Healthy People provides a framework for measuring performance by outcomes. Success is measured by positive changes in health status or reductions in risk factors, as well as improved provision of certain services, a concept that the Government Performance Review Act of 1993 establishes for programs Government-wide. Within HHS, Healthy People objectives have been specified by Congress as the metric for measuring the progress of the Indian Health Service, the Maternal and Child Health Block Grant, and the Preventive Health Services Block Grant. In the development of the strategic plan for the Department of Health and Human Services, Healthy People objectives were used to set the targets for many of our strategic objectives.
Although Healthy People is not a scorecard, it does provide a means of drawing attention to periodic benchmarks on the health of the nation. In addition, Healthy People 2000 holds potential as a strategic management tool--for the Federal Government, for States, for communities, and for the private and voluntary sector partners. Periodic progress reviews on each of the 22 priority areas represent a vital part of the Healthy People process. These reviews involve private sector partners, States, and communities and are intended to facilitate the emergence of a clearer sense of what needs to be done to accelerate progress.
Plans are now under way for Healthy People 2010--the prevention agenda for moving into the 21st century (Appendix B). October 1996 through December 1999 defines a critical window of opportunity for HHS and its partners to review the health status of the population, assess recent advances in our understanding of health, and incorporate those advances into the health objectives for 2010.
The notion of leading health indicators is not new to the Healthy People process. Indeed, the original 1979 Surgeon General's Report established targets for measurable improvement by 1990 for people at each of the five major life stages, for the very purpose of drawing attention to a limited number of measures that could be regularly tracked to provide a general indication of the health of the public. Those indicators, expressed as the goals of Healthy People, were to reduce the infant mortality rate by 35 percent by 1990; the death rate for children by 20 percent, for adolescents and young adults by 20 percent, and for adults by 25 percent; and to reduce the sick days (average annual days of confinement) for older adults by 20 percent. The 226 objectives set out the following year with the release of Promoting Health/Preventing Disease: Objectives for the Nation were identified as targets important to the accomplishment of the five life stage goals, as well as rallying points for the activities of organizations and institutions key to the effort.
Of the five goals, only the one for infant mortality emerged as a major focus of national attention before the end of the decade. Attention was drawn to infant mortality because it represented both an area in which the United States' performance was considerably below that of many other Western countries and because there was a substantial gap between whites and African Americans, generating both political and social interest in the progress. For the other four age groups, the combination of multiyear lags in the availability of the data, the absence of strong focused interest groups, and the lack of political interest in generating the attention detracted from their utility as leading indicators of the sort that might prompt both interest and action.
In the end, the 35 percent targeted reduction in death rate was reached for the Nation as a whole--although the socioeconomic gap did not narrow--as were the targets for children (about 25 percent, against the 20 percent target) and adults (25 percent). Reasonable progress was even made for adolescents and young adults (9 percent reduction in death rates) and for older people (17 percent reduction in age-adjusted bed disability days). Because the overall results were generally impressive and quite close to the targets set a decade previous, these five goals became compelling testimony to the notion of establishing health objectives and monitoring the resulting progress.
The objectives themselves, because they were so numerous, did not represent a practical set of leading indicators, although the framework in which they were cast proved a useful educational tool. Prior to the release of Healthy People and the 1990 objectives, the notion of prevention had rather loose structure and boundaries. The grouping of the objectives into the three categories of health promotion, health protection, and clinical preventive services, therefore, facilitated understanding of the content and a focus for prevention. In this respect, the 1990 initiative met part of the aim for a set of leading health objectives--that related to improving public understanding and interest--but fell short of the aim of giving specificity to that interest.
With respect to the prospects for, and focus of, leading health indicators, the development of Healthy People 2000 brought two important changes: 1) the shift away from the mortality target as the focus for the goals and 2) the identification of 47 objectives from among the full set as flagship objectives for the set (Appendix C). The first change was implemented because a criticism of the 1990 goals was that they focused too extensively on mortality, on quantity rather than quality, of life, and not enough on the disparities that existed in health status and prospects among population groups in the United States. Hence, the two lead goals for Healthy People 2000 became qualitative rather than quantitative and addressed an intent to increase the years of healthy life for all Americans and to reduce health disparities among Americans.
The preeminence of health disparities as a focus for Healthy People 2010 is noteworthy. HHS staff members who work on Healthy People view the achievement of significant reductions in health disparities among racial and ethnic groups, age groups, economic groups, disability groups, gender groups, and geographic locations as a primary challenge for the next decade. A Presidential Initiative is directed to the problem (Appendix D).
In theory, both goals of Healthy People are valuable and appropriate dimensions for national attention as leading health indices. However, both represent important analytic challenges with respect to the development of a reliable calculus, regularly available, that might be used to report progress, a considerable impediment to their practical utility as leading health indicators. Moreover, because they displaced the mortality-based life-stage targets with which some quarters of the health community were becoming familiar, those mortality targets were not available to complement and reinforce the new measures.
The utility of the 47 flagship objectives has also been limited. During the development of Healthy People 2000, with its 319 national objectives, it became apparent that a smaller set of sentinel or key objectives would increase the usefulness of the document by serving as a focus of national attention and as a tool for monitoring America's health. In the Healthy People 2000 publication, 47 sentinel objectives were identified as representative of the priority areas; these objectives were monitored to assess overall progress of the initiative and were viewed as priorities for the general public. It seems, however, that although only 15 percent of the larger set, 47 targets may still be too numerous to generate focused interest and attention. Neither the political leadership nor the general public, nor for that matter the public health community, has been inclined to raise these 47 as their rallying points or issues of special concern. The fact that, to some extent unlike the full set of more than 300 objectives, they have not served as the focus for special attention during the many State and local health objective-setting activities suggests deficiencies inherent in their scope (perhaps too many), their content (perhaps of marginal interest or measurability at the subnational level), or their political appeal--or all three.
The experience with Healthy People 2000 and its set of sentinel objectives suggests that communication about health to the general public is improved when the scope and focus facilitate understanding and when the issues are clearly drawn and are relevant, both personally and to localities. Monitoring our progress toward Healthy People 2000 objectives provides a national accounting, but to move toward implementation requires making the goals relevant and understandable to organizations, groups, and individuals with the expectation that they will make the changes in policy and behavior that will improve health. The leading health indicators should communicate important benchmarks and progress in the health of the United States.
In October 1997, the Acting Deputy Assistant Secretary for Health (Disease Prevention and Health Promotion) determined that in Healthy People 2010, more extensive work on the issue of leading health indicators could play a critical role in extending the reach of Healthy People beyond the health community to opinion leaders, the public, and nonhealth professionals and ultimately enhance the broader impact of the full Healthy People 2010 effort. The HHS working group convened for this report comprised 22 members representing the Office of Public Health and Science, the Public Health Service agencies, and other HHS agencies (Appendix A). It was charged with developing a background paper that describes the potential uses of leading health indicators, criteria that might be applied to leading health indicators, and examples of candidate leading health indicators. This report is submitted in response to that request.
Following this introductory section, Section Two provides an overview of the concept and experience to date with the various approaches to developing health indicators, including a brief description of the experience with leading economic indicators. Section Three summarizes the experience to date by grouping various approaches under the rubric of a series of overlapping models. Section Four begins with a discussion of the criteria used by the working group in assessing the various alternative models and then, based on those criteria, discusses three likely candidate sets for the shape of the leading health indicators. It concludes with a discussion of ways in which these sets might change if timing for communicating results were an issue. Section Five examines currently available data sources for monitoring health indicators. Section Six concludes with a discussion of the implementation considerations.
A special comment is warranted on the matter of terminology, which has implications for focus. Terminology has been the subject of much discussion among the working group members. The activity began with a working title of "sentinel objectives," the term that was used to characterize those objectives labeled as "representative" in Healthy People 2000. Because the traditional use of the word "sentinel" implies a measure of early warning of trouble, other terms--e.g., key, flagship, priority--have been considered by the working group. For the purpose of this report, the term "leading" is used as a general expression of the character of the measures and as a term with which the public is familiar. It is used in effect as a placeholder of sorts for the possibilities.
With respect to selecting the term "objective" or "indicator," the working group's discussion focused more on issues of content than terms. The Healthy People initiative is oriented around an objective metric. Each objective has a target that should be achieved by the end of a given decade. The working group believes that the inclusion of targets has been a driving force in the success of Healthy People, but, on the assumption that the general public more readily understands the terms "indicator" and "goal" (and Healthy People already has goals), "indicator" has been used in this report. The working group encourages further discussion on terminology. Of particular importance is the need for the leading health indicators to be an integral piece of the Healthy People document, linked clearly to the framework of goals and objectives that constitute Healthy People 2010.