formance measures can then be developed as the basis for strategic actions.

The rationale for adopting a broad definition of health lies not only in its value to the population served by the health system and its usefulness in identifying measures of the origins of health. A broad definition of health also is appropriate for the changing nature of the "health care system," reflects the interconnectedness of health and social systems, and is consistent with current scientific evidence about how health is produced in communities (Aguirre-Molina, 1996; Warden, 1996).

Changing Nature of the "Health Care System"

Many Americans view health as a simple biomedical construct in which health is determined by the provision of health care (Lamarche, 1995). This perspective on health developed during this century, beginning in the 1930s with well-baby clinics and services for "crippled children" and expanding in the 1950s with national investments in biomedical research facilities such as the National Institutes of Health and construction and funding of hospitals through the Hill-Burton program (Guyer, 1990). With advances in medical science and increases in the number of hospitals, policymakers and health care providers became concerned about differential access to health care resources, especially for underserved and hard-to-reach populations. Poverty and geography were viewed as barriers to health care and thus to good health.

Beginning in the 1960s, programs designed to improve access to health services were created, including Medicare and Medicaid. These programs markedly reduced financial barriers for the poor and elderly, and they also ensured a supply of well-trained physicians by providing funds for medical school and residency training programs.

The biomedical model of health has fostered the development of a personal health care system centered around technologically advanced hospitals and highly trained medical specialists. However, the high cost of maintaining these resources is the subject of current public debate. In addition, questions have been raised about the overall contribution of the biomedical model to improvements in health status. Although important, health care has probably been overemphasized as a determinant of health. Of the 30-year increase in the life expectancy achieved this century, only 5 years can be attributed to health care services (Bunker et al., 1995).

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