Ontario was used to explore the meaning, approaches, and measures of accountability, and examine the connection between primary health care (PHC) key attributes, performance measurement and accountability. This research study used qualitative research methods design and a theoretical framework to guide the inquiry, collection, analysis and interpretation of data (i.e., documents and 28 semi-structured interviews). This study offers empirical knowledge about the scope of accountability in PHC—who is accountable to whom, for what and how is accountability implemented and measured. These insights are valuable lessons for other jurisdictions, and suggest future research topics for scholars. This study found that in a public contract model, the key aspects of the PHC system performance measurement are: access to and utilization of insured services; and cost of reimbursing private providers. These are components of financial and political accountability of the funder. PHC providers and clinics have multiple lines of accountability. Clinical performance accountability is implicit and not routinely monitored. PHC providers are self- regulated and trust is placed on them to deliver evidence based care to achieve desirable patient outcomes. In this governance structure, metrics used in PHC are those that are easy to measure and within the control of clinicians. Metrics involving co-production of services and tacit use of clinical knowledge are left out because it is complex to get access to this data from disparate standalone systems, which results in low measurability of many services. If data sources could be linked, it may be feasible to align PHC performance and accountability with the four key PHC attributes: access, person-focused care, coordination and comprehensiveness. With this, relevant metrics can be fed back to PHC providers and publicly reported to enable patients to exercise their right as consumers to select care from high performing PHC teams. The latter could advance accountability in PHC.