Hopes and realities of public health accountability policies.

Holding local boards of health accountable presents challenges related to governance and funding arrangements. These challenges result in (a) multiple accountability pressures, (b) population health outcomes whose change is measureable only over long time periods and (c) board of health activity that is often not the key immediate direct contributor to achieving desired outcomes. We examined how well these challenges are addressed in Ontario, Canada at early stages of implementation of a new accountability policy. Findings reveal that senior and middle management are open to being held accountable to the Ministry of Health and Long-Term Care (MOHLTC), but are more oriented to local boards of health and local/regional councils. These managers perceive the MOHLTC system as compliance oriented, and find internal accountability systems most helpful for performance improvement. Like health-care system accountability metrics, performance indicators are largely focused on structures and processes owing to the challenges of attributing population health outcomes to public health unit (PHU) activities. MOHLTC is in the process of responding to these challenges.