geography, who organize around an issue, with collective discussion, decision making, and action. Geography, however, emerged as a critical point of reference in the committee's discussions. Although geographic (or civic) boundaries cannot adequately capture all of the potentially meaningful community configurations, they are a practical starting point.

This chapter begins with a discussion of the social and political realities of engaging communities in performance monitoring activities to improve community health. It proposes an approach in which responsibility for health goals is shared among community stakeholders and accountability for specific accomplishments is ascribed to individual entities. Strategies for managing the process of community-wide change are presented in the final section.

SOCIAL AND POLITICAL CONTEXT FOR IMPROVING COMMUNITY HEALTH

As communities undertake health improvement efforts, they need to be informed about the social and political environments in which a health system operates at the local, state, and national levels; ways in which those environments influence the health system; and ways in which the health system influences those environments.

At the national level, health care emerged as a high-priority issue in 1992. This reflected several factors related to underlying conflicts in the needs, resources, and values of various sectors of American society. First, questions have been raised about the limit to which the country can invest in health care. No nation spends a greater share of its national income on health care than the United States (Levit et al., 1994), and concerns about the unbridled growth of health care spending are so widespread that they have become the subject of presidential political debates. Proposals to constrain spending in the public sector for services to vulnerable populations (e.g., Medicaid and Medicare) raise questions about economic disparity in the nation. In the private sector, employers are concerned about their ability to meet current and future financial obligations to provide health benefits for employees. Similar concerns extend to health care institutions, which continue to absorb losses for charity care.

A second factor in the emergence of health as a high priority national issue has been politics. Health care was viewed as an important issue in the senatorial and presidential elections of



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