Accountability Is a Public Health Intervention

By M.E. Avila

One of the greatest lessons I learned as a Culture of Health Leadership Institute (CoHLI) Fellow was that health equity is never just about healthcare.

It is about relationships.

It is about power.

It is about trust.

Most importantly, it is about whether our institutions are willing to hold themselves to the same standards they expect from the communities they serve.

That lesson has stayed with me throughout my career. Whether I have been working alongside community health workers, supporting survivors of violence, coordinating emergency preparedness efforts, or building cross-sector partnerships, I have always believed that people deserve systems they can trust.

Trust is fragile.

It is built over time through consistency, honesty, and accountability.

It can also be lost in a single decision.

Recently, I found myself on the other side of the systems I have spent my career strengthening.

When concerns arose regarding confidentiality, I requested what I believed was a reasonable step: an audit of record access. Not because I had already decided someone did something wrong. Not because I wanted someone disciplined.

I simply wanted answers.

As someone who has taught continuous quality improvement, I understand that audits are one of the most valuable tools organizations have. They are not about punishment.

They are about learning. They tell us whether policies are working as intended, whether safeguards are effective, and where opportunities exist to improve.

Instead, I was told an audit would not be conducted.

That response has caused me to reflect on something much bigger than my own experience.

What does accountability look like in public health?

We ask communities to trust us with their personal information.

We ask survivors to tell us stories they may have never shared with another person.

We ask employees to report concerns when something doesn't feel right.

But trust cannot flow in only one direction.

Institutions must also be willing to demonstrate that they deserve it.

As a CoHLI Fellow, we talked often about creating a Culture of Health. I have come to believe that culture is not built by strategic plans, vision statements, or carefully chosen words.

The opportunity to learn alongside leaders from across the country through the Culture of Health Leadership Institute fundamentally reshaped the way I think about systems change. The Institute, supported by the Robert Wood Johnson Foundation and facilitated by the National Collaborative for Health Equity, challenged participants to think beyond programs and policies. The work emphasized that lasting change occurs when institutions intentionally examine the systems, relationships, and structures that influence health and opportunity.

That perspective aligns closely with the principles of the Truth, Racial Healing & Transformation National Collaborative. Truth cannot exist without transparency. Healing cannot occur without trust. Transformation requires organizations to be willing to learn from their own practices rather than simply defend them.

One of the most powerful lessons from those experiences is that accountability is not an administrative exercise; it is an act of leadership. Organizations demonstrate integrity not by claiming to be equitable, but by consistently asking whether their policies, decisions, and systems reflect the values they promote.

Health equity is often discussed in terms of reducing disparities, expanding access, or addressing the social determinants of health. Those efforts are essential. Yet equity also depends on institutional credibility. Communities are more likely to trust public institutions when they believe concerns will be examined fairly, questions will be welcomed, and systems will be evaluated with the same commitment to continuous improvement that public health professionals encourage in every other aspect of their work.

Creating a Culture of Health requires more than collaboration across sectors. It requires organizations that are willing to be reflective, transparent, and accountable. Those are not separate goals from health equity; they are foundational to achieving it.

Culture is revealed by what organizations do when someone asks a difficult question.

Do we become curious?

Or do we become defensive?

Do we examine our systems?

Or do we simply assure people that everything is fine?

Those moments define culture far more than any mission statement ever will.

The Truth, Racial Healing & Transformation framework speaks about changing narratives. For me, one narrative I hope we begin to change is the belief that accountability signals weakness.

It doesn't.

Organizations that are willing to examine themselves are not weaker.

They are stronger.

They communicate confidence in their systems while recognizing that every process has room for improvement.

That is how trust grows.

This experience has reminded me that health equity is not only measured by access to

services or health outcomes.

It is also measured by whether people believe they will be heard when they raise concerns.

Whether they believe confidentiality will be protected.

Whether they believe institutions will seek truth, even when the answers may be uncomfortable.

As public health professionals, we often talk about upstream interventions, those actions that prevent harm before it occurs.

I would argue that accountability is one of those interventions.

Transparent systems prevent distrust.

Thoughtful reviews prevent repeated mistakes.

Independent audits protect both the people receiving services and the professionals providing them.

They strengthen organizations before problems become crises.

As both a public health leader and someone who has now experienced these systems from the inside in a different way, I remain hopeful.

Hopeful that we can create organizations where questions are welcomed rather than feared.

Where accountability is viewed as an investment rather than a threat.

Where transparency becomes part of organizational culture instead of a response to public pressure.

Because when institutions are willing to learn, communities are more willing to trust.

And trust may be one of the most powerful health interventions we have.