performance measurement to improve the quality of health and other services in public and private settings.

A Broader Understanding of Health

There is a wider recognition in many settings that health is a dynamic state that embraces well-being as well as the absence of illness. The committee defined health as ''a state of well-being and the capability to function in the face of changing circumstances." Health is, therefore, a positive concept emphasizing social and personal resources as well as physical capabilities. This definition also underscores the important contributions to health that are made outside the formal medical care and public health systems.

For both individuals and populations, health depends not only on medical care but also on other factors including individual behavior and genetic makeup and social and economic conditions for individuals and communities. The health field model, as described by Evans and Stoddart (1994) and discussed further in Chapter 2, presents these multiple determinants of health in a dynamic relationship (see Figure 1). The model's feedback loops link social environment, physical environment, genetic endowment, an individual's behavioral and biologic responses, disease, health care, health and function, well-being, and prosperity. This multidimensional perspective reinforces the value of public health's traditional emphasis on a population-based approach to community health issues.

A Community Perspective

The array of influences on health identified by the field model also suggests that there are many public and private entities that have a stake in or can affect the community's health. These stakeholders can include health care providers (e.g., clinicians, health plans, hospitals), public health agencies, and community organizations explicitly concerned with health. They can also include various other government agencies, community organizations, private industry, and other entities that may not see themselves as having any explicit health-related role such as schools, employers, social service and housing agencies, transportation and justice agencies, and faith communities. Many of these entities have a local base and focus. Others that may play an essential role in shaping health at the local level such as state health de-

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