Phase I Report
Recommendations for the Framework and Format of Healthy People 2020

Section III. Historical Context for Developing Healthy People 2020

The Healthy People initiative was launched with the publication of Healthy People: the Surgeon General's Report on Health Promotion and Disease Prevention, a document presenting quantitative goals to reduce preventable death and injury by 1990. The U.S. Public Health Service released a companion document the next year, setting out specific, quantifiable objectives to attain these broad goals. Since then, HHS has issued updated national health promotion and disease prevention goals and objectives each decade, i.e., Healthy People 2000 (issued in 1990) and Healthy People 2010 (issued in 2000).

How Previous Iterations of Healthy People were Developed

As it has moved through the decades, the Healthy People initiative has expanded in size (see Exhibit 1). The number of objectives increased with each update, as did the number of categories for organizing those objectives (termed "priority areas" in the 1990 Health Objectives for the Nation and Healthy People 2000, and "focus areas" in Healthy People 2010).^iv

This trend toward expansion was due, at least in part, to the increasingly participatory nature of the objective development process over the decades. As summarized in Appendix 6, the process for creating objectives evolved from one that was largely expert-driven with opportunities for feedback from the public (for the 1990 Health Objectives), to one that emphasized public engagement, feedback, and participation throughout the development process (for Healthy People 2010). Emphasis on public participation has continued in the two-phased process for developing Healthy People 2020 (as noted earlier, in the methodology section).

Exhibit 1. Expansion of the Healthy People Initiative Over Three Decades

Why Historical Context is Important

The Healthy People initiative has been a long-term effort, spanning three decades. It has evolved in response to the changing needs and circumstances of the Nation. As a result of the Healthy People initiative, a wealth of experience has been accumulated in developing, monitoring, maintaining, and assessing progress on national objectives. It is important to reflect on the lessons learned—both positive and negative—through this effort.

The strengths of past Healthy People efforts are numerous. They include cross-agency collaboration within the federal government and an extensive process of stakeholder and civic engagement. Healthy People has yielded a comprehensive database of measures and has prompted the creation of data sources for many objectives that previously lacked data (i.e., developmental objectives). Since the 1980's, states and some metropolitan areas have also used Healthy People to develop their own goals and objectives, patterned on the national model.^3,4,5 The recommendations in this report are intended to build on these strengths, and to make Healthy People 2020 more effective in some areas that have proved challenging in the past.

Examples of past challenges have included: an unwieldy printed format that detracted from the usability of Healthy People; a lengthy list of objectives that was difficult to manage; a disease-specific approach to organizing objectives that has not encouraged cross-cutting collaboration around risk factors; lack of transparency about target-setting methods for specific objectives; lack of progress or slow progress in achieving objective targets; lack of tracking data to assess progress; inadequate guidance on how to achieve the objectives; and lack of guidance to users in setting priorities. Appendix 7 offers a detailed discussion of these challenges and highlights opportunities for Healthy People 2020 to address them.

Progress in Achieving the National Objectives

Although no comprehensive evaluation of the Healthy People initiative has been conducted, the Office of the Assistant Secretary for Planning and Evaluation (ASPE) and the Office of Disease Prevention and Health Promotion (ODPHP) launched a study in 2002 to examine how Healthy People 2010 was being used. The study's overall conclusions were that Healthy People 2010 is a visible, practical tool that is being used by public health agencies at the state and regional levels. Barriers to usage were also identified, including a lack of implementation tools that could be used to achieve the objectives, and resource constraints. Results are summarized in Appendix 8.

HHS conducts midcourse reviews to assess progress in reaching Healthy People objectives midway through each decade. Final reviews are conducted at the end of the decade. In 1991, the National Center for Health Statistics (NCHS) published data on the final attainment status of each of the 1990 Health Objectives. The report indicated that 266 targets had been measured for the 226 objectives. Among the 266 measured targets, 32 percent (85) were attained and 34 percent (90) progressed in the right direction. Another 23 percent (61) could not be evaluated because data were unavailable. For the remaining 11 percent (29), the attained value moved away from the target.⁶

A final review of Healthy People 2000 that was conducted by NCHS showed that 21 percent of the objectives (68) met their year 2000 targets and another 41 percent (129) moved toward their targets. Fifteen percent of the objectives (47) moved away from the targets, and 2 percent showed no change from the baseline (labeled "unlikely to achieve"). The status of 32 objectives (10 percent) could not be assessed. Another 11 percent of objectives (35) showed mixed results (objectives with mixed results are not displayed in Exhibit 2).⁷

Exhibit 2. Most Recent Data on Achievement of Past Healthy People Objectives

^*All percentages for the 1990 Health objectives reflect attainment of the 266 measured targets.

^**Percentages for Healthy People 2000 objectives do not add up to 100% in this table because 11 percent of objectives (35) that showed mixed progress have been excluded.

^§Percentages for Healthy People 2010 objectives do not add up to 100% in this table because 12 percent of objectives (57 out of 467) showed mixed progress have been excluded.

^§§This percentage includes 28 objectives that were deleted, as well as 158 objectives that could not be assessed due to a lack of tracking data.

The midcourse review for Healthy People 2010 was published in 2006. Although there were 467 objectives in the initiative, "tracking data" were not available to assess trends over time for 34 percent of them (158) as of January 2005.^v Another 28 objectives were deleted from the remaining 309, either "because data were not available or because of a change in science."⁸ A review of individual chapters from the midcourse review shows 27 objectives lacking data, and one deleted due to a change in science. This left only 60 percent of Healthy People 2010 objectives (281) for which progress could be assessed at midcourse.

In the set of 281 Healthy People 2010 objectives with tracking data, 10 percent (29) met the target and 49 percent (138) moved toward the target. Twenty percent (57) moved away from the target, and another six percent (17) showed no change from the baseline. The remaining 14 percent of objectives (57) showed mixed progress.⁹ To facilitate comparison across decades, percentages in Exhibit 2 have been recalculated to show progress across all 467 of the original Healthy People 2010 objectives (including those lacking data or tracking data). Objectives with mixed progress are not included.

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