Policies are "those laws, regulations, formal and informal rules and understandings that are adopted on a collective basis to guide individual and collec tive behavior" (Schmid et al. 1995). In this chapter, a health polity is defined broadly to include policies that address prevention on a population basis as well as those influencing health care utilization and quality.
Policies tend to alter or control the legal, social, economic, and physical environment (Cheadle et al. 1992) and are supported by the notion that individuals are strongly influenced by the sociopolitical and cultural environment in which they act. Health policies can be divided into two general areas: legislation/regulation and organizational policy (Cheadle et al. 1992). Legislation or regulation involves formal policies written into law by the appropriate governing bodies (e.g., nutrition guidelines enacted by a government or regulatory policies to limit exposure to occupational chemicals). Organizational policies are those implemented by specific establishments such as schools, health departments, managed care organizations, and health insurance companies. For example, a business may be persuaded of the benefits of worksite health promotion programs, including their cost-effectiveness (Stokols et al. 1995; Pelletier 1996) and therefore may implement policies to encourage exercise, nonsmoking, and other healthy behaviors.
Various definitions of the core functions of public health (Institute of Medicine 1988; Roper et al. 1992; Oberle et al. 1994) recognize the importance of the health policy development process. A common rubric involves assessment, policy development, and assurance (Institute of Medicine 1988). Assessment refers to the concept of community diagnosis, including the tools of public health surveillance and epidemiologic research to determine health effects and health hazards. Using the results of assessment as a basis, policy development is the process by which society makes decisions about health problems through planning, goal setting, policy leadership and advocacy, and provision of public information. Stated differently, policy development is the "means by which problem identification, technical knowledge of possible solutions, and societal values set a course of action" (Institute of Medicine 1988). Assurance is the guarantor function of public health to ensure that health services and legislative mandates are met according to agreed upon goals.
Core functions of public health likely differ based on the location and size of health agency, and roles continue to evolve as the health care system changes. Traditional public health, particularly at the local level, has centered largely on delivery of individual services, such as provision of immunizations or prenatal care. The need for a greater focus on the overall community, focusing on policy initiatives, has been noted (Schmid et al. 1995) and may be a more effective means of utilizing limited public health resources. Policies are likely to have both direct and subtle effects on the health of the population (Brownson et al. 1997a). Direct effects tend to be more measurable and may include risk factor prevalence, disease incidence or prevalence, dis ability, and mortality. More subtle effects may occur prior to outcome changes. These include changes in social norms, attitudes toward health, or health-care-seeking behavior (Milio 1986). In addition, as health reform efforts progress at the state and local levels, managed health care is stimulating new partnerships between traditional public health and private health care providers (Baker et al. 1994), which may in turn provide a greater emphasis on improving health policies in the overall community.
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