tributions of other health-system stakeholders. (As defined in Chapter 1, the health system comprises public health, clinical care, and other stakeholders that acknowledge their current and potential contributions to a community’s health.)

Governmental public health is not the only actor in the system that is accountable for or involved in creating the conditions for health. Clinical care providers are de facto stewards of a community’s health and are mandated or otherwise charged with health-related duties. Others, such as employers and businesses, may not currently see themselves as contributing to or detracting from a community’s health and well-being (see Chapter 1), but their recognition of their roles and their ability to contribute to health could be facilitated. They often face regulatory pressures, such as rules regarding environmental waste and pollution and zoning limitations. Others, such as community-based organizations, may be seasoned contributors to health, but there are no measurement frameworks for accountability for their work. Those roles are discussed in greater detail later in this chapter.

The measurement of performance and the demonstration of accountability and quality in clinical care have a long history, with a major national movement punctuated by milestone Institute of Medicine (IOM) reports on the subject of quality, federal quality initiatives (such as those undertaken by the Centers for Medicaid and Medicare Services), and the creation of such bodies as the National Committee for Quality Assurance (and its Healthcare Effectiveness Data and Information Set quality measures) and the National Quality Forum and its efforts to set national priorities and endorse standards for and conduct outreach and education on performance improvement in clinical care.

Accountability (in the broad sense of demonstrating results and effectiveness to the public) is a somewhat more recent focus in the public health community, and this is in part due to the complex array of factors that contribute to population health and the challenging nature of communicating about them. As described in Chapter 1, one challenge is that health outcomes (such as disease and death) have multiple interconnected causal pathways, and the science required to elucidate them is far from advanced in many cases. In addition, public health agencies, although broadly charged with ensuring the public’s health, have direct or clearly traceable responsibility for only a small proportion of those pathways.

The simple logic model introduced in Chapter 2 and reprised in Figure 4-1 suggests that a straightforward measurement framework for accountability would link all inputs (resources, capacities, processes, interventions, and policies) with outputs (intermediate and more distal health outcomes). However, there are many obstacles to such a framework, and these are discussed below. It is important to note that accountability is closely linked with needs assessment, planning, and priority-setting—activities identified at the beginning of the process.

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