Ensuring that publicly funded health systems are democratically accountable is an enduring challenge in policy and practice. One strategy for enhancing public officials' accountability is to elect members of the public to oversee their performance. Several countries have experimented with direct elections to healthcare organizations. The most directly comparable examples involve some Canadian regional health authorities, New Zealand district health boards, foundation trusts in England and health boards in Scotland. We propose three aspects of the process by which the democratizing effects of elections should be judged: authorization, accountability and influence. Evidence from these countries suggests that the democratization of health systems is a complex task, which cannot be completed simply by introducing elections. Copyright © 2015 John Wiley & Sons, Ltd.