Governments can be accountable for improving the fairness of their priority setting through enhanced transparency and stakeholder engagement. A case analysis is conducted of priority setting in a government health care context in Ontario, Canada, assessing how implementation of hospital accountability agreements meets the conditions of a leading international ethical framework for priority setting, "accountability for reasonableness" (A4R). Hospital accountability agreements provide a mechanism for government to ensure that public funding achieves desired performance in hospitals. A key goal of priority setting is fairness. A4R links priority setting, legitimacy, and fairness to theories of democratic deliberation, making a claim for fairness if the four conditions of relevance, publicity, revision/appeals, and enforcement are satisfied. Regarding the relevance condition, this analysis suggests that government only partially met the relevance condition providing limited stakeholder engagement but with evidence of policy learning and movement toward the establishment of inclusive stakeholder arrangements. Evidence suggests that government eventually progressed toward meeting the publicity condition. Government only partially met the revision/appeals condition and did not meet the enforcement condition, as the other conditions were only partially met. It is our view that regional governance structures in Ontario (i.e., Local Health Integration Networks or LHINs) provide an opportunity for the province to improve the fairness of their accountability agreement processes through enhancing transparency and stakeholder engagement. More broadly, this case study provides a guide for government to enhance accountability by focusing on A4R to improve the fairness of its priority setting