Although accountability drives in the Indian health sector sporadically highlight egregious behaviour of individual health providers, accountability needs to be understood more broadly. From a managerial perspective, while accountability functions as a control mechanism that involves reviews and sanctions, it also has a constructive side that encourages learning from errors and discretion to support innovation. This points to social relationships: how formal rules and hierarchies combine with informal norms and processes and more fundamentally how power relations are negotiated. Drawing from this conceptual background and based on qualitative research, this article analyses the views of government primary health care administrators and workers from Koppal district, northern Karnataka, India. In particular, the article details how these actors view two management functions concerned with internal accountability: supervision and disciplinary action. A number of disjunctures are revealed. Although extensive information systems exist, they do not guide responsiveness or planning. While supportive supervision efforts are acknowledged and practiced, implicit quid-pro-quo bargains that justify poor service delivery performance are more prevalent. Despite the enactment of numerous disciplinary measures, little discipline is observed. These disjunctures reflect nuanced and layered relationships between health administrators and workers, as well as how power is negotiated through corruption and elected representatives within the broader political economy context of health systems in northern Karnataka, India. These various dimensions of accountability need to be addressed if it is to be used more equitably and effectively.