Rural clinics across Alabama are closing, leaving empty rooms that signal lost access. Families face long drives for basic care. A grandmother manages heart failure alone, a farmer delays cancer screenings, and a mother travels an hour for prenatal visits while caring for other children. These are real lives burdened by a fragile system.

The proposed Alabama Rural Health Transformation Program (ARHTP) offers a promising but still unproven way to address these challenges.

Last week, I explored transparency: the commitment to show clearly what is happening so communities, providers, and policymakers share the same understanding of the challenges ahead.

This week, I focus on accountability: the commitment to act on what transparency reveals and deliver on agreed-upon goals through clear roles, meaningful metrics, and open feedback.

Transparency tells us where we stand; accountability ensures someone is responsible for moving us forward. It is not about blame but about creating a disciplined path to meaningful, lasting change.

A strong reform plan requires clear responsibility, specific progress measures, and plans to handle setbacks. Many ARHTP details are still developing, making this a key moment to set expectations, build partnerships, and ensure progress delivers real improvements. Without consistent accountability, confusion, policy fatigue, and loss of trust are real risks.

Accountability protects communities, providers, state agencies, and taxpayers. Using data-driven decisions shows Alabama is strengthening its systems, not handing control to outsiders. We must use resources wisely to produce meaningful results.

Key ARHTP initiatives include regional telehealth hubs, expanded virtual consultations, improved behavioral and maternal health services, and a workforce pipeline from high school to residency. These proven models succeed when local partners work together with clear roles and aligned responsibilities. Effective programs create feedback loops so local insights guide state decisions, and state support strengthens local efforts. Alabama should adapt these strategies to fit its communities.

Good ideas alone are not enough. Local leadership must play a central role. Measurable milestones and public reporting help communities track progress and build trust.

Reform faces challenges. Implementation involves many agencies, varied reporting rules, and funding changes, which can pull efforts in different directions. Effective accountability also requires alignment: shared expectations, consistent measures, and clear roles across organizations so that each part of the system is working toward the same goals. Data infrastructure and interoperability barriers further complicate tracking and reporting. Success requires adaptive coordination to ensure system parts adjust without disrupting care.

In rural Alabama, the greater risk is inaction. Clinic closures, fewer services, and long travel times threaten both health and community vitality. Past efforts sometimes fell short due to fragmented services and limited coordination.

Workforce burnout remains an ongoing challenge and must be addressed within accountable reform.

To succeed, we must carefully prioritize services, responsibly use federal support, and acknowledge that funding stability and political commitment are crucial. We must be willing to end pilots that don’t work. Accountability should link funding to performance in a supportive, not punitive, way.

Current payment systems overvalue in-person visits while undervaluing coordination, prevention, and telehealth’s flexibility. Sustainable reform requires incentives aligned with today’s care delivery.

ARHTP’s goals are ambitious but achievable: five regional hubs, 100 virtual access points, 10,000 consultations, and a 15 percent reduction in avoidable hospital transfers over five years. Success depends on strong tracking from the start. Independent reviews, county dashboards, and neutral oversight will build trust and maintain transparency.

These measures reflect realities rural clinicians and leaders face. Their knowledge of staffing, technology, and workflows must guide change; not one-size-fits-all mandates. Broadband access is critical for telehealth and data reporting.

Workforce development is essential. Recruiting more doctors, nurses, and behavioral health professionals matters, but retention is the real challenge. Scholarships and rural residencies help, but communities must offer a quality of life that encourages people to stay.

Consider Dr. Samuel Reynolds, a composite rural physician. Returning home, he saw how coordinated care teams and telehealth could save patients long trips and connect them to specialists. Yet shifting metrics, fragmented reporting, and tight timelines made implementation difficult. Careful, consistent accountability across programs and agencies is vital to learning from past efforts and ensuring system coherence.

Local voices, including county and municipal officials, hospital CEOs, clinic directors, and community leaders, must guide these reforms. Federal support should set clear rules while empowering rather than controlling. Meaningful public-private collaboration and patient and family engagement are critical for success.

Lasting change requires more than good plans. It involves balancing priorities, navigating entrenched interests, and building consensus. This work is hard and slow. We must expect setbacks and be ready to adjust. Only then can accountability become practice, creating reforms rooted in the community.

Before a large rollout, leaders should clearly answer:

• How will success be measured and shared?
• Who will be responsible and held accountable at each step?
• Do we have the right people, tools, and resources?
• What happens if progress slows?
• How will feedback be gathered and acted upon?
• What oversight will ensure long-term accountability?

Answering these questions protects taxpayers, builds trust, and demonstrates responsible governance rooted in community.

Rural healthcare is more than keeping doors open. It supports schools, jobs, and families. If Alabama gets this right, ARHTP can be a turning point. With careful execution and honest accountability, we can preserve care and build a system that thrives.

The choice is not ambition versus realism; it is structured follow-through versus the status quo.

Next week, I will address sustainability, the final piece to turn promise into lasting strength.

David L. Albright, PhD, is a University Distinguished Professor at The University of Alabama, a board member of the DCH Healthcare Authority, and immediate past president of the Alabama Rural Health Association. The views expressed here are his own and do not necessarily reflect those of his institution or affiliated organizations.