implement a strategy. Issues to consider include whether an intervention can or will be implemented; whether it will reach all who need it; and whether intended beneficiaries can or will take advantage of health improvement efforts. Early consideration of these questions may make it possible to recast the strategy to overcome anticipated problems.

Work done on the evaluation of "comprehensive community initiatives" points to the value of a thoughtful articulation of the "theory of change" embodied in an intervention strategy—how and why an intervention is expected to work (Weiss, 1995; Connell and Kubisch, 1996). Specifying intended long-term and intermediate outcomes and how they would be achieved can help clarify assumptions about the purpose and operation of an intervention and guide the selection of performance indicators. Connell and Kubisch (1996) suggest that this process can promote collaboration and commitment to the intervention and help clarify pathways of accountability.

Establish Accountability for Health Improvement Activities

Establishing accountability is a key to using performance monitoring in the health improvement process proposed by the committee. Specific entities must be willing to be held accountable for undertaking activities, within an overall strategy for dealing with a health issue, that are expected to contribute to achieving desired outcomes. The committee sees a collective responsibility among all segments of a community to contribute to health improvements, but each entity must accept individual responsibility for performing those tasks that are consistent with its roles, resources, and capabilities. (See Chapter 3 for additional discussion of these issues.)

Depending on the health issue and the community stakeholders involved, different approaches may be necessary to reach agreement on who will be accountable for what. In some cases, community cooperation may be a sufficient basis for negotiating assignments of accountability. In other instances, incentives such as compliance with funding requirements or response to market pressures may make entities in the community willing to be held accountable. In some situations, however, accountability may result from regulatory or other legal requirements. Any combination of these factors may operate as a community resolves issues of accountability. For health departments, in particular, accountability under the "assurance" function (IOM, 1988) might be



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