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Purpose: In Canada, community engagement and accountability are a political imperative, resulting in an omnipresent program with varied opportunities for public participation. The purpose of this paper is to promote leadership and commitment for health system transformation that truly benefits communities. Design/methodology/approach: This paper is based on the author's experience with many engagement and accountability activities, applied in varied settings, for purposes such as evaluation, planning, policy making and system transformation. The specific context is generalized with international experiences and references. Findings: The "lessons learned" are based on practical considerations with relevance for both novice and experienced practitioners: clarifying principles, processes and purposes at the outset; using effective leadership to achieve the desired impact; using a variety of methods to engage communities; clarifying engagement and accountability roles precisely; measuring things that are meaningful; and consulting with internal as well as external communities. Also, community leaders should recognize effort as well as results. Research limitations/implications: Commitment to engagement and accountability is commendable – but is it enough? The paper concludes by looking beyond health system impacts to propose a broader systems perspective. If clinical governors want to use engagement and accountability to achieve "total value" for their communities, they will need to demonstrate as leaders that they are committed to long-term thinking and broad social goals. Originality/value: Too much focus on the process of care may mask accountability for reporting outcomes or systemic impact. The sustainable development goals highlight the need for systems thinking and public expectations include corporate social responsibility. As shown in the examples cited, a deeper commitment to engagement and accountability requires looking beyond care delivery to social determinants and to systemic impacts of the health care industry itself. [ABSTRACT FROM AUTHOR]