HEALTH GOALS

Health goals can provide direction to health policy, guide efforts to improve health, and help to evaluate progress. A goals process almost always leads to greater emphasis on health promotion and disease prevention. The idea of specifying health goals grew out of the management-byobjectives movement that developed after World War II and became part of the strategic planning movement in the 1960s and 1970s. Several related concepts are involved, although terminology varies from one setting to another. A "goal" is a statement of a desirable state of affairs, generally stated in fairly broad terms. An "objective" is a narrower, quantitative statement that sets out a target population, the intervention to be used, and the indicator to be measured. A "target" is a specific statement of the amount of improvement to be achieved and the date by which it is to be achieved.

THE UNITED STATES EXPERIENCE

In the United States, the initiative for setting goals has been led by the Office of Disease Prevention and Health Promotion. It grew directly out of the management-by-objectives movement, and has, accordingly, emphasized measurement. In 1979, Healthy People: The Surgeon-General's Report on Health Promotion and Disease Prevention set out five goals for the nation, organized by life stage. One goal, for example, was "to improve the health of adults, and, by 1990, to reduce deaths among people between the ages of twenty-five and sixty-four by at least 25 percent." Ten subgoals and fifteen priority areas were also specified. This was followed in 1980 by Promoting Health, Preventing Disease: Objectives for the Nation, which elaborated these goals into 226 objectives, including that "by 1990, the proportion of adults who smoke should be reduced to below 25 percent." (In 1979, the proportion was 33%.) A public health service agency was designated to lead the efforts to achieve each objective, and Model Standards for Public Health Agencies was published to guide public health practice.

The 1990 Health Objectives for the Nation: A Midcourse Review presented progress to that date and predicted whether the objectives would be achieved. Progress for each measurable objective was presented graphically. At the end of the cycle, the results were summarized in Prevention Profile Health, United States, 1991 (the prevalence of smoking in 1990 was reported to be 25.5%). Overall, the goals for mortality reduction had been achieved for infants, children, and adults, but not for young people; 32 percent of the objectives had been attained, 34 percent showed progress, 11 percent were moving in the opposite direction, and 23 percent could not be evaluated because of lack of data.

A new cycle began in 1991 with Healthy People 2000: National Health Promotion and Disease Prevention Objectives. While the first cycle emphasized mortality (except for elders) and was rather disease oriented, with little or no mention of inequalities in health, the goals in this cycle were broadened to include morbidity and quality of life, and a concern for reducing inequalities. The objectives for 2010 were released in January 2000.

Throughout, the objectives have not been intended solely for use by government agencies, but throughout the U.S. health care system, and there has been considerable consultation with health care organizations. Government activities have been strongly influenced in terms of programming, methodological work, and publication of newsletters.

THE EUROPEAN EXPERIENCE

The European initiative grew out of the Health for All initiative of the World Health Organization (WHO). The European Office of WHO decided that health promotion was the approach most likely to achieve the goal of health for all people, and an Office of Health Promotion was established. In addition to stimulating a worldwide health-promotion movement, the office coordinated the 1985 publication of Targets for Health for All, which listed thirty-eight targets for the European region. From the beginning the movement was much influenced by social scientists, and emphasized social development. (The first target stated, "By the year 2000, the actual differences in health status between countries and between groups within countries should be reduced by at least 25 percent, by improving the health of disadvantaged nations and groups.") Countries were encouraged to develop their own strategic plans and goals, and most countries in the region have done so. The targets were revised in 1991, and a new set of twenty-one targets, Health 21—Health for All in the 21st Century, was released in 1998. There has been less emphasis on measurement and evaluation than in the United States, and more emphasis on motivation and leadership in health policy.

LESSONS LEARNED

It is difficult to evaluate whether improvements in health in many countries are related to the health goals process, especially since those jurisdictions with a major commitment to health improvement are also those most likely to specify health goals. There has been little formal evaluation of the health goals movement.

In setting these goals, quantitative objects and targets are very desirable, but there is a risk that topics that are more difficult to quantify (e.g., the social environment) may receive less attention than they deserve. While it is reasonable to specify objectives and targets at all levels of health causation, it is important to ensure that the targets set at the various levels are compatible. Computerized disease models, like those used for the U.S. cancer objectives, can help to ensure this consistency. A life stage approach, in which goals are set separately for each age group, has been useful in both the United States and Europe. Different age groupings, however, may be appropriate for different goals. A more qualitative alternative to strategic planning is a scenario process (used in the Netherlands), in which hypothetical scenarios are developed for several plausible health changes, and policies developed that can deal with any of them.

Governments may be reluctant to commit themselves to health goals, especially to quantifiable targets, lest they be held to these commitments. But the U.S. experience suggests that the process can work. It is important for governments to involve the political opposition. Otherwise, when that faction comes to power it may regard the goals as "their" goals, and reject or ignore them. Although responsibility for the process is usually assigned to some government agency, consultation with nongovernmental organizations is essential. Marketing and communication are also extremely important. Development of the goals presents an opportunity to involve the entire nation or community in talking about health, and to assure cooperation. Implementation is particularly difficult, however, and may require special intersectoral structures like interdepartmental committees.

Robert A. Spasoff

(see also: Disease Prevention; Economics of Health; Essential Public Health Services; Evaluation of Public Health Programs; Health Goals; Health Promotion and Education; Healthy Communities; Healthy People 2010; Planning for Public Health; Policy for Public Health; Politics of Public Health )

Bibliography

National Center for Health Statistics (1999). Healthy People 2000 Review, 1998–1999. Hyattsville, MD: U.S. Public Health Service.

National Center for Health Statistics (1992). Prevention Profile. Health, United States, 1991. Hyattsville, MD:U.S. Public Health Service.

Office of Disease Prevention and Health Promotion (1986). The 1990 Health Objectives for the Nation: A Midcourse Review. Hyattsville, MD: U.S. Public Health Service.

U.S. Department of Health and Human Services (1979). Model Standards for Public Health Agencies. Atlanta, GA: Centers for Disease Control and Prevention.

—— (1980). Promoting Health/Preventing Disease. Objectives for the Nation. Hyattsville, MD: U.S. Public Health Service.

—— (1991). Healthy People 2000. National Health Promotion and Disease Prevention Objectives. Hyattsville, MD: U.S. Public Health Service.

U.S. Department of Health, Education, and Welfare (1979). Healthy People. The Surgeon General's Report on Health Promotion and Disease Prevention. Hyattsville, MD: U.S. Public Health Service.

World Health Organization (1985). Targets for Health for All. Targets in Support of the European Regional Strategy for Health for All. Copenhagen: WHO Regional Office for Europe.

—— (1998). Health 21: The Health for All Policy Framework for the WHO European Region (1998). Copenhagen: WHO Regional Office for Europe.