an intervention whereas program evaluation should examine the overall outcome.

Role of Performance Indicators in Stakeholder Accountability

Workshop participants agreed that defining accountability—which "actors" are responsible for what functions—is extremely important. Accountability for both process and outcome goals needs to be determined. The programs described at the workshop vary in how they hold groups accountable. For example, TAPII has led to ties between capitation and immunization rates, which fosters competition among health plans. Competition as a mechanism to gain accountability may be especially useful in the private sector. The Escondido program addresses accountability through formal written agreements detailing participation in the project, contract arrangements with providers, target rates for screening and performance, and management information systems for the integrated services. In other programs represented at the workshop, accountability is less explicitly defined. According to one panelist, it is hoped that "providers (will) come forward and increase their provision of services or education as it relates to the objectives."

Community Responses to Performance Indicators

The workshop participants reported that positive outcomes engender positive community response and that achievement of short-term objectives serves to cement community cooperation. They also commented on the importance of communicating realistic expectations to prevent discouragement with slower progress toward long-term objectives. Balancing short-term and long-term objectives helps maintain motivation.

Strong leadership is necessary to prevent coalitions from splintering into groups with self-serving agendas. On the other hand, outside leadership cannot substitute for communities' developing their own momentum to maintain programs. It was suggested that community groups need to be involved from the start in order for a community to be empowered and to continue projects regardless of changes in political personnel.

Tension between health problems articulated by the community and health problems identified by data analysis can potentially undermine community support for performance monitoring and health improvement activities. Participants suggested that the specific approach to selecting health issues should involve a larger community collaborative. However, the conceptual bases for selecting health issues should be founded on research that suggests that effective interventions will be possible.



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