The development and vetting of national health objectives for disease prevention and health promotion is coming to a close as the final recommendations for what is in and what is out are being made to DHHS. Being a participant in the Healthy People process for 3 iterations now, I am well aware of the promises, frustrations, disappointments and exasperation it entails. After this last round, however, two possibly fatal flaws seem to loom even larger than usual for me. These flaws not only impact the deliberative process of what becomes an objective for the year 2020 and beyond, but also undermine our efforts to achieving a healthier nation through public health programs.
The first flaw has to do with our data, or lack of it, to monitor and evaluate progress towards goals. Fundamental management and social marketing premises are: ‘what gets measured gets done’ and what we monitor we can adapt and change. Yet, despite the intentions to manage by objectives, the latest comprehensive reviews of progress towards the Healthy People 2010 objectives found that only 51% of the health objectives for four major racial/ethnic groups had at least two data points during the decade from which to make judgments of our progress in meeting them [see the accompanying table I have compiled].
And where we can make judgments on our collective progress over the past decade to improve the health of Americans, the results are modest at best. For example, between 7.8%-17% of the targets set for Hispanic/Latino, non-Hispanic Black, non-Hispanic white or Asian population groups have been met or exceeded (keep in mind only 51% of the targets have such data). Depending on the racial/ethnic group, positive progress in moving towards the 2010 targets have been documented for another 37.4% (Asian) to 55.3% (Black) of those for which baseline and follow-up data are available. And for another 29.3% - 30.4% of the objectives with two or more data points, health indicators are moving in the opposite direction from the targets.
Let’s put that in a nutshell: for the half of Healthy People 2010 objectives we have data for, about 30% are moving in the wrong direction. Can we draw the conclusion that over the past decade we have been successful at even making a dent in fewer than 20% of all of the objectives we set for ourselves in 2000?
These figures are based on the data available as of August 2007. While we can expect some changes to the figures when the final report is compiled, it seems clear that less than half of the objectives for which we have data will be met. More importantly, for at least a quarter of these objectives we will have lost ground.
The discussions about how and why these improvements and setbacks have occurred will focus on any number of issues ranging from how the targets themselves were set; how data were (or were not) collected and reported; secular trends; improvements and impediments in the health care and public health systems; and lack of adequate resources or diversions of them into other priorities (e.g., public health preparedness).
However, these elaborations of the problem will not lead to the solutions to the second flaw I see: that we are not measuring, in most instances, the right things – we measure what we can measure. We use national surveys and datasets of morbidity and mortality, risk behaviors and the like to set outcomes for many Healthy People objectives. But in my mind, this is like a business setting a 10-year, or even 5-year, revenue goal – and stopping there. Healthy People 2020 is NOT a strategic document that lays out objectives and how we will reach them – and it should be if we want to deliberately (i.e., not haphazardly) improve health.
Another plausible response to the lack of progress on many Healthy People objectives is to call for more research into causes and treatments (or even prevention), greater use of evidence- and theory-based practices and greater involvement by more sectors of society to address these and other issues. There are clearly such needs that I support. However, I also view our current situation as one in which to focus on how to stimulate and support more innovation among public health staff, agencies and partners to improve the effectiveness (the behavioral outcomes, not awareness and information surrogates) and efficiency of our policies, partnerships, programs and interventions. And any and all of these recommendations must be backed up by metrics; how do we measure whether health departments are implementing more evidence-based programs for, say, obesity prevention, reducing infant mortality or increasing levels of physical activity among specific age groups? How do we know if community coalitions are adopting best practices and measuring behavioral outcomes in, for example, illicit drug use or injury prevention programs? Or how do we know that best practice guidelines are being taught in our schools of public health and are consistently applied throughout the public health infrastructure? Is innovation in addressing pubic health priorities driving research and development funding in the public sector (as opposed to investigator interests and review panel ideologies)? And these are just the ‘tops of the trees’ for questions we should be asking, and measuring, if we are in the business of improving health, and not just the rhetoric of it.Over the past year, and certainly the past few months, we have seen and heard a lot about health insurance and health care reform in the US. As we look forward to launching Healthy People 2020, I suggest we start looking at public health system reform that builds accountability, innovation and direction (what to do and what to avoid) into not just what we measure, but how, when and to what purpose we do it. Why not have the American Public Health Association and other groups start working now on these issues of measuring what is meaningful rather than what is easy so that by the time we start developing Healthy People 2030 we will have a national set of data collection tools that can tell us whether we are doing the right things to improve health?