The Public Health Workforce: An Agenda for the 21st Century A Report of the Public Health Functions Project U.S DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service TABLE OF CONTENTS Executive Summary v Acknowledgments vii Introduction Context Composition of the Public Health Workforce Competency-Based Curriculum Distance Learning System Development Future Directions 11 National Leadership 11 State and Local Leadership 12 Workforce Composition 12 Curriculum Development 13 Distance Learning 16 Implementation 17 Appendix A: Appendix B: Appendix C: Appendix D: Appendix E: Appendix F: Appendix G: Appendix H: Appendix I: The Public Health Functions Project 19 Public Health in America 21 Revision of the Federal Standard Occupational Classification (SOC) System: New Occupational Categories Recommended for the Field of Public Health 23 Descriptions of Selected Public Health Workforce Assessment Studies 27 Competencies for Providing Essential Public Health Services 29 Healthy People 2000 Consortium 43 The Faculty/Agency Forum Competencies by Discipline 47 Competencies Reviewed by the Competency-Based Curriculum Work Group 49 Public Health Functions Steering Committee and Working Group; Subcommittee on Public Health Workforce, Training, and Education and Work Group Member Lists 51 References 57 Bibliography 61 EXECUTIVE SUMMARY must play a vital role in realizing the vision of “Healthy People in Healthy Communities.” The Subcommittee divided its efforts into: Today our Nation faces a widening gap between challenges to improve the health of Americans and the capacity of the public health workforce to meet those challenges Deeply concerned with this trend, the Public Health Functions Steering Committee in September 1994 commissioned the Subcommittee on Public Health Workforce, Training, and Education, charged to: • Enumerating the current workforce in public health function positions and assessing future changes in workforce roles and the impact of these changes on the workforce composition; • Identifying training and education needs for core practices/essential public health services; and • Developing a strategic plan for using distance learning approaches to provide high-priority public health education and training provide a profile of the current public health workforce and make projections regarding the workforce of the 21st century The Subcommittee should also address training and education issues including curriculum development to ensure a competent workforce to perform the essential functions of public health now and in the future Minority representation should be analyzed and the programs to increase representation should be evaluated Distance learning should be explored The Subcommittee should examine the financing mechanisms for curriculum development and for strengthening the training and education infrastructure The specified action items listed below, and elaborated upon in the full report, represent essential first efforts and will require the concerted attention of all partners on the Public Health Functions Steering Committee and many others if they are to have the desired impact These steps are not sequential, and work on all of them should proceed concurrently The necessary actions include: National Leadership The Public Health Functions Steering Committee should continue to serve as the locus for oversight and planning for development of a public health workforce capable of delivering the essential public health services across the Nation, including support for any legislative authorization or financing mechanisms needed to fully implement this report and a commitment to ensure that current workforce development resources are wisely invested in achieving identified goals Each partner organization is encouraged to develop specific plans and policies that complement this collaborative effort The plan presented here builds on work already in place with a call to practical action of Federal, State, and local public health agencies; academic public health departments; community health coalitions and organizations; philanthropies; and all others concerned with the health of Americans This report uses as an analytic framework the statement Public Health in America, with its enumeration of 10 essential services of public health, incorporating and building upon previous discussions of public health functions The public health workforce includes all those providing essential public health services, regardless of the nature of the employing agency The report endorses individual and organizational excellence as the only standard acceptable to the public and decisionmakers who State and Local Leadership In order to ensure that programs are appropriately tailored to the unique configuration of needs and resources in each State and in each local jurisdiction, a mechanism to develop State public health *By “Federal, State, and local public health agencies” this report means any health, substance abuse, environmental health and protection, or public health agency charged with some portion of the roles encompassed in the statement Public Health in America v The Public Health Workforce: An Agenda For The 21st Century competencies associated with each of the various professions that make up the workforce workforce planning and training should be developed and implemented This mechanism should include not only development of identified leaders, but also cultivation of leadership qualities throughout the workforce The State, or where appropriate, regional, efforts should emphasize possible partnerships among practice and academic entities involved in public health These efforts should be responsive to and provide input into those at the national level In addition, these efforts must involve local public health entities and be responsive to their needs Basic, advanced, and continuing education curricula to train current and future public health workers in the identified competencies should be supported (where existing) and developed (where not yet in place) Implementation should be coordinated with the State planning efforts (above) and make maximum use of new technologies (below) Improved methods (such as certification) of identifying practitioners who have achieved competency Workforce Composition A standard taxonomy should be used to identify the should be identified and implemented if demonsize and distribution of the public health workforce in strated effective official agencies (health, environmental health and protection, mental health and substance abuse; local, Distance Learning All partners in the effort to strengthen the public State, and national) and private and voluntary health workforce should make maximum use of organizations This effort should be coordinated evolving technologies such as distance learning with the Bureau of Labor Statistics to enhance A structure should be established to develop an uniformity in occupational classification reporting integrated distance learning system building on To the extent possible, the taxonomy should be existing public and private networks and making consistent with Public Health in America, information on best practices readily available recognizing that specific occupational titles will vary across organizations The agenda presented in these recommendations only partially fulfills the original charge to the SubUsing the same taxonomy, the Steering Committee committee In its continuing leadership role, the should recommend and support a mechanism to Steering Committee should identify other tasks that quantify the future demand for public health workneed continuing attention and make plans for their ers, paying particular attention to issues of diversity completion With the continued attention of the and changing demographics in the workforce Public Health Functions partners, the public health workforce will be strengthened to contribute Curriculum Development The statement of competencies for the public health even more to the health of communities in the 21st century workforce developed by the Subcommittee should be refined and validated, identifying the subset(s) of vi ACKNOWLEDGMENTS It is difficult to acknowledge all the individuals who have contributed to the development of this complex and detailed report The major contributors were the members of the Subcommittee on Public Health Workforce, Training, and Education and they are listed in Appendix I In addition, members of the Public Health Functions Working Group and Steering Committee provided important comments on earlier drafts of this report and their input has been greatly appreciated and valued Prevention and Health Promotion; Kristine Gebbie, Office of Disease Prevention and Health Promotion; the workgroup chairs, Doug Lloyd, Health Resources and Services Administration; Neil Sampson, Health Resources and Services Administration; Dick Lincoln, Centers for Disease Control and Prevention; Dennis McDowell, Centers for Disease Control and Prevention; and specific contributors and reviewers, Jerre Jensen, Public Health Training Network; Susanne Caviness, Indian Health Service; Valerie Welsh, Office of Minority Health; Faye Malitz, University of Maryland; Anthony Moulton, Centers for Disease Control and Prevention; Herbert Traxler, Health Resources and Services Administration; and Michael Weisberg, National Library of Medicine The Subcommittee would like to recognize the specific efforts of the staff, Alex Ross, Health Resources and Services Administration; D.W Chen, Health Resources and Services Administration; Nona Gibbs, Centers for Disease Control and Prevention; Nicole Cumberland, Office of Disease vii INTRODUCTION The Public Health Functions Steering Committee also developed a consensus statement, entitled Public Health in America, in 1994 (see Appendix B) Building further upon the core functions of public health (assessment, policy development, and assurance) identified by the Institute of Medicine (IOM) in its 1988 study The Future of Public Health, the consensus statement describes what public health does and what services are essential to achieving healthy people in healthy communities Successful provision of these essential services requires collaboration among public and private partners * within a given community and across various levels of government The Subcommittee used these essential services as a framework for their respective activities Today our Nation faces a widening gap between challenges to improve the health of Americans and the capacity of the public health workforce to meet those challenges The public health community is actively engaged in a wide range of activities to keep the current workforce up to date and to anticipate future needs As a leadership forum for action on public health infrastructure issues, the Steering Committee of the Public Health Functions Project (see Appendix A) in September 1994 commissioned the Subcommittee on Public Health Workforce, Training, and Education to review factors related to workforce challenges and to make recommendations for an action plan Their charge was as follows: To further an understanding of the public health workforce, a Subcommittee is charged with providing a profile of the current public health workforce and making projections regarding the workforce of the 21st century As a part of this effort, the Subcommittee should examine the current and future shortfalls in the public health workforce, looking broadly at Federal, State and local levels, in public health departments as well as mental health, substance abuse, and environmental health agencies and at the emerging need for public health competencies in managed care systems, health plans, and in other governmental agencies such as departments of agriculture, education, and justice The Subcommittee should also address training and education issues including curriculum development for graduate training in public health and ongoing training and development activities to ensure a competent workforce to perform the essential functions of public health now and in the future Minority representation in public health disciplines should be analyzed and the programs to increase representation should be reviewed and evaluated Distance learning and other advanced technology training methods should be explored to ensure that training and education activities are carried out in the most efficient and cost-effective manner Therefore, the Subcommittee shall examine the financing mechanisms for curriculum development and for strengthening the training and education infrastructure, as well as explore the feasibility of establishing a Council on Graduate Public Health Education *The partnership must include all agencies and private or voluntary organizations in the areas of health, mental health, substance abuse, environmental health and protection, and public health responsible for fulfilling Public Health in America The Public Health Workforce: An Agenda For The 21st Century Appendix G: The Faculty/Agency Forum Competencies by Discipline In addition to the Universal Competencies, competencies were developed for the following specific disciplines by the Public Health Faculty/Agency Forum: Public Health Administration Epidemiology and Biostatistics Behavioral Sciences Environmental Public Health For details refer to: Sorensen, Andrew A., and Ronald G Bialek, eds 1993 The public health faculty/agency forum: Linking graduate education and practice Gainesville, FL: Florida University Press 47 The Public Health Workforce: An Agenda For The 21st Century 48 Appendix H: Competencies Reviewed by the Competency-Based Curriculum Work Group Competency Set Lead Organization Universal Competencies The Public Health Faculty/Agency Forum 1989 Competencies for Education in Maternal and Child Health Association of Teachers of Maternal & Child Health Association of Schools of Public Health MCH Council 1993 Public Health Leadership Competencies for State Regional Programs The National Public Health Leadership Development Network Draft version 1996 Community-Based Public Health Competencies Johns Hopkins University School of Health 1996 A Competency-Based Framework for Professional Development of Certified Health Education Specialists The National Commission for Health Education Credentialing, Inc 1996 Addiction Counselor Competencies Curriculum Review Committee of the Addiction Training Center Program 1995 Educating Environmental Health Science and Protection Professionals: Problems, Challenges, and Recommendations Association of Schools of Public Health Larry J Gordon 1991 Competency Objectives for Dental Public Health American Public Health Association: Dental Section 1990 49 Date The Public Health Workforce: An Agenda For The 21st Century 50 Appendix I: Public Health Functions Steering Committee and Working Group Subcommittee on Public Health Workforce, Training, and Education: Competency-Based Curriculum Work Group Distance Learning Systems Work Group Workforce Composition Work Group PUBLIC HEALTH FUNCTIONS STEERING COMMITTEE MEMBERS (MARCH 1997) CO-CHAIRS Jo Ivey Boufford, M.D Acting Assistant Secretary for Health U.S Department of Health and Human Services David A Kessler, M.D Commissioner of Food and Drugs Food and Drug Administration Ciro Sumaya, M.D., M.P.H.T.M Administrator Health Resources and Services Administration Audrey F Manley, M.D., M.P.H Acting Surgeon General U.S Department of Health and Human Services Michael H Trujillo, M.D., M.P.H Director Indian Health Service MEMBERS Lisa Simpson, M.B., B.Ch Acting Administrator Agency for Health Care Policy and Research Mary des Vignes-Kendrick, M.D., M.P.H President National Association of County and City Health Officials E Richard Brown, Ph.D President American Public Health Association Luceille Fleming President National Association of State Alcohol and Drug Abuse Directors Allan Rosenfield, M.D President Association of Schools of Public Health Jack Dillenberg, D.D.S., M.P.H President Association of State and Territorial Health Officials Stuart B Silver, M.D President National Association of State Mental Health Program Directors David Satcher, M.D., Ph.D Director Centers for Disease Control and Prevention Edwin Pratt, Jr Past President National Association of the Local Boards of Health Harold Reheis, P.E President The Environmental Council of the States 51 The Public Health Workforce: An Agenda For The 21st Century Harold E Varmus, M.D Director National Institutes of Health Edward Baker, M.D., M.P.H Director Public Health Program Practice Office Centers for Disease Control and Prevention Maurice Mullet, M.D Chairman of the Board Public Health Foundation Charles Gollmar Acting Director, Office of Program Planning and Evaluation Centers for Disease Control and Prevention Honorable Richard S Schweiker Chair Partnership for Prevention Jeffery R Harris, M.D., M.P.H Associate Director for Policy, Planning, and Evaluation Centers for Disease Control and Prevention Nelba R Chavez, Ph.D Administrator Substance Abuse and Mental Health Services Administration Gary Hogelin, M.A Assistant Director for Policy and Planning Office of Surveillance and Analysis Centers for Disease Control and Prevention PUBLIC HEALTH FUNCTIONS WORKING GROUP MEMBERS (MARCH 1997) Ray M Nicola, M.D Associate Director, Division of Public Health Public Health Program Practice Office Centers for Disease Control and Prevention CO-CHAIRS David Satcher, M.D., Ph.D Director Centers for Disease Control and Prevention Reverend Samuel Nixon Director, Affiliate Relations Department Congress of National Black Churches Claude Earl Fox, M.D., M.P.H Deputy Assistant Secretary for Health (Disease Prevention and Health Promotion) Robbie Roberts Executive Director The Environmental Council of the States MEMBERS Raymond Seltser, M.D Center for Primary Care Research Agency for Health Care Policy and Research Peter Rheinstein, M.D Director, Medicine Staff, Office of Health Affairs Food and Drug Administration Katherine S McCarter, M.H.S Acting Executive Director American Public Health Association Ronald Carlson Associate Administrator for Planning Evaluation and Legislation Health Resources and Services Administration Michael K Gemmell, C.A.E Executive Director Association of Schools of Public Health Douglas S Lloyd, M.D., M.P.H Associate Administrator for Public Health Practice Health Resources and Services Administration Cheryl Beversdorf, R.N., M.H.S., C.A.E Executive Vice President Association of State and Territorial Health Officials 52 Appendix I Audrey H Nora, M.D Director, Maternal and Child Health Health Resources and Services Administration Roscoe M Moore, Jr., D.V.M., Ph.D., D.Sc Associate Director Office of International and Refugee Health Stephen B Permison, M.D Deputy Director, Quality Assurance Division Bureau of Health Professions Health Resources and Services Administration Valerie Welsh Office of Minority Health Thomas Kring Acting Deputy Assistant Secretary for Health Office of Population Affairs Neil H Sampson Acting Director, Division of Associated Dental and Public Health Professions Bureau of Health Professions Health Resources and Services Administration RADM Stephen B Corbin Chief of Staff Office of the Surgeon General CDR Susanne Caviness, Ph.D Chief, Patient Registration, Quality Management Indian Health Service Susan Blumenthal, M.D Deputy Assistant Secretary on Women’s Health Office on Women’s Health Nancy Rawding Executive Director National Association of County and City Health Officials Jud Richland Executive Director Partnership for Prevention Christine G Spain, M.A Director, Research, Planning and Special Projects President’s Council on Physical Fitness and Sports Edwin Pratt, Jr Past President National Association of Local Boards of Health Ronald Bialek, M.P.P Executive Director Public Health Foundation John Gustafson Executive Director National Association of State Alcohol and Drug Abuse Directors Duiona Baker, M.P.H Senior Policy Analyst Office of Policy and Program Coordination Substance Abuse and Mental Health Services Administration Robert Glover, Ph.D Executive Director National Association of State Mental Health Program Directors William Harlan, M.D Associate Director for Disease Prevention National Institutes of Health STAFF Kristine Gebbie, Dr.P.H., R.N Senior Advisor, Public Health Functions Office of Disease Prevention and Health Promotion Eric Goosby, M.D Director Office of HIV/AIDS Policy Nicole Cumberland Operations Coordinator, Public Health Functions Office of Disease Prevention and Health Promotion 53 The Public Health Workforce: An Agenda For The 21st Century SUBCOMMITTEE ON PUBLIC HEALTH WORKFORCE, TRAINING, AND EDUCATION COMPETENCY-BASED CURRICULUM WORK GROUP Rick Bothwell Division of Clinical and Preventive Services Indian Health Service Lee Bone Department of Health and Policy Management Johns Hopkins School of Public Health/Kellogg Community-Based Public Health CO-CHAIRS Dick Lincoln Public Health Program Practice Office Centers for Disease Control and Prevention (until October 1996) Association of Schools of Public Health Jeanne Wehage Department of Health Policy and Management Johns Hopkins School of Public Health Neil H Sampson Bureau of Health Professions Health Resources and Services Administration Jerre Jensen Public Health Training Network MEMBERS Raymond Seltser Center for Primary Care Research Agency for Health Care Policy and Research Elaine Auld Society for Public Health Education Janice Taylor State of Washington Department of Health Catherine Kordek American Public Health Association Susanne Rohrer Center for Substance Abuse Treatment Substance Abuse and Mental Health Services Administration Wendy Katz Association of Schools of Public Health Major Bruno Petrucelli Walter Reed Army Institute of Research Division of Preventive Medicine U.S Department of Defense Alison Wojciak Association of Schools of Public Health Jane C Nelson Center for Public Health Practice Emory University School of Public Health Susan Conrath Internal Environments Division U.S Environmental Protection Agency Mary Haack George Washington Center for Health Policy Michelle Solloway George Washington Center for Health Policy STAFF D.W Chen Bureau of Health Professions Health Resources and Services Administration Rosemary Duffy Bureau of Health Professions Health Resources and Services Administration Nicole Cumberland Office of Disease Prevention and Health Promotion Alexander F Ross Health Resources and Services Administration 54 Appendix I DISTANCE-BASED LEARNING SYSTEMS WORK GROUP D.W Chen Bureau of Health Professions Health Resources and Services Administration CHAIR Dennis McDowell Division of Media and Training Services Public Health Program Practice Office Centers for Disease Control and Prevention Ronald Merrill Health Resources and Services Administration Alexander Ross Health Resources and Services Administration MEMBERS Lynn Kazemekas Center for Information Dissemination Agency for Health Care Policy and Research Neil H Sampson Bureau of Health Professions Health Resources and Services Administration James G Hill Director, Office of Rural Health American Psychological Association Alan Lee Myers Training Officer Indian Health Service Tom Kubisyn Assistant Executive Director Policy and Advocacy in the Schools American Psychological Association Michael Weisberg National Library of Medicine Rita Kelliher Public Health Foundation Scott Becker Association of Schools of Public Health Steve Seitz Public Health Advisor Center for Substance Abuse Prevention Substance Abuse and Mental Health Services Administration Nona Gibbs Public Health Program Practice Office Centers for Disease Control and Prevention Lisa Nelson U.S Environmental Protection Agency Robert Fatula Television Design and Development Branch Food and Drug Administration Ruth Salinger Office of the Secretary U.S Department of Health and Human Services Gary German Division of Human Resource Service Food and Drug Administration Michelle Solloway George Washington Center for Health Policy STAFF Jerre Jensen Senior Advisor Public Health Training Network Pam Vocke Surveyor Training Improvement Team Health Care Financing Administration Nicole Cumberland (Part-time) Office of Disease Prevention and Health Promotion 55 The Public Health Workforce: An Agenda For The 21st Century WORKFORCE WORK GROUP Jim Baxendale National Association of State Alcohol and Drug Abuse Directors CHAIR Douglas S Lloyd Health Resources and Services Administration Bruce Emery National Association of State Mental Health Program Directors MEMBERS Carolyn Clancy Agency for Health Care Policy and Research Valerie Welsh Office of Minority Health Karen VanLandeghem Association of Maternal and Child Health Programs Kay Eilbert Public Health Foundation Wendy Katz Association of Schools of Public Health Duiona Baker Substance Abuse and Mental Health Services Administration David Manning Association of State and Territorial Health Officials Richard House School of Public Health University of North Carolina at Chapel Hill Mary Haack George Washington Center for Health Policy STAFF Alexander F Ross Health Resources and Services Administration Michelle Solloway George Washington Center for Health Policy D.W Chen Bureau of Health Professions Health Resources and Services Administration Nicole Cumberland Office of Disease Prevention and Health Promotion Madeleine Golde National Association of Social Workers 56 REFERENCES Addiction Training Center Program Curriculum Review Committee 1995 Addiction counselor competencies American Association of Public Health Dentistry, Health Policy and Program Management and Administration Group 1990 Competency objectives for dental public health Journal of Public Health Dentistry 50 (5):338-344 American Council for Education 1996 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Mental health, Untied States, 1996 SMA96-3098 Washington, DC: Government Printing Office Pew Health Professions Commission 1995 Critical challenges: Revitalizing the health professions for the twenty-first century San Francisco, CA: UCSF Center for the Health Professions Prevention Report December 1994/January 1995 A time for partnership: A report of state consultations on the role of public health Public Health Foundation 1992 State health agency staff, 1989 HRA 240-89-0032 Washington, DC: PHF Public Health Foundation 1994 Core public health functions expenditures Washington, DC: PHF Public Health Workforce Consortium 1989 Source materials HRA 240-88-0026 Washington, DC: Government Printing Office Schade, C 1995 A preliminary comparison between local public health units in the Canadian province of Ontario and in the United States Public Health Reports 110(1): 35-41 Solloway, M., M Haack, and L Evan 1996 Assessing the training and education needs of the public health workforce in five states HRA 282-92-0030 Draft Washington, DC: Government Printing Office, 1997 Sorensen, Andrew A., and Ronald G Bialek, eds 1993 The public health faculty/agency forum: Linking graduate education and practice Gainesville, FL: Florida University Press The National Commission for Health Education Credentialing, Inc 1996 A competency-based frame work for professional development of certified health education specialists Allentown, PA: NCHEC U.S Department of Health and Human Services Public Health Service 1995 Healthy people 2000: Midcourse review and 1995 revisions Washington, DC: Government Printing Office U.S Department of Health and Human Services Public Health Service Health Resources and Services Administration 1993 Final report: Improving training of preventive medicine residents through the development and evaluation of competencies HRSA92-468(P).Washington, DC: Government Printing Office U.S Department of Health and Human Services Public Health Service Substance Abuse and Mental Health Services Administration Center for Mental Health Services 1995 Mental health managed care and workforce/training project: A 3-year plan (FY 1995-1997) and status report Mimeo Winslow, C.D., and W.L Bramer 1994 Future work: Putting knowledge to work in the knowledge economy NewYork, NY: The Free Press 59 The Public Health Workforce: An Agenda For The 21st Century 60 Bibliography These sources were not cited directly in the report or appendices but were found to be helpful and can be used by readers as further sources of information on public health workforce issues Gebbie, K.M 1996 What currently employed public health nurses need to know New York: Columbia School of Nursing Harmon, R.G 1996 Training and education for public health: The role of the U.S Public Health Service American Journal of Preventive Medicine 12(3):151-155 Hinman, A.R 1996 Distance learning and distance education: A personal perspective American Journal of Preventive Medicine 12(1):5-8 Ibrahim, M.A., R.M House, and R.H Levine 1995 Educating the public health work force for the 21st century Family & Community Health 18(3):17-25 Institute of Medicine 1995 Nursing, health and the environment Washington, DC: National Academy Press Josten, L 1996 Educating nurses for public health leadership University of Minnesota Lane, D.S., V Ross, M.D Parkinson, and D.W Chen 1995 Performance indicators for assessing competencies of preventive medicine residents American Journal of Preventive Medicine 11(1) Melville, S.K., and J Coghlin 1995 Population-based medical education: Linkages between schools of medicine and public health agencies HSA93-1072(P) Washington, DC: Government Printing Office Pickett, G., and J.J Hanlon 1990 Public health: Administration and practice St Louis: Times Mirror/Mosby College Publishing Stein, D.H., and M.E Salive 1996 Adequacy of training in preventive medicine and public health: A National survey of residency graduates Academic Medicine 71(4):375-380 Studnicki, J, et al 1994 Analyzing organizational practices in local health departments Public Health Reports 109(4):485-490 U S Department of Health and Human Services Public Health Service Substance Abuse and Mental Health Services Administration Center for Mental Health Services 1993 Workforce training and development for mental health systems Mimeo Wohlford, Paul, Hector F Myers, and Joanne E Callan, eds 1993 Serving the seriously mentally ill: Public-academic linkages in services, research, and training Washington, DC: American Psychological Association 61 ... partners, the public health workforce will contribute even more to the health of communities in the 21st century 17 The Public Health Workforce: An Agenda For The 21st Century 18 Appendix A: The Public. .. Pew Charitable Trust 15 The Public Health Workforce: An Agenda For The 21st Century DISTANCE LEARNING • All partners in the effort to strengthen the public health workforce should make maximum... Institutes of Health • Office of the Assistant Secretary for Health • Substance Abuse and Mental Health Services Administration 21 The Public Health Workforce: An Agenda For The 21st Century 22