There are many good reasons to monitor the health (or status or condition or integrity or…) of marine ecosystems and determining how to do this effectively has been the subject of much research. Obviously, there isn’t a one size fits all approach, but for someone trying to run a program the different aspects that could be considered are ever increasing and overwhelming. Improving technology and new methodologies (e.g. eDNA) as well as better understanding of systems (e.g. microbiomes) jostle for consideration – should these supplement or replace older techniques and what might come along to supplant these in the near future? At the same time there is increased focus on engaging with stakeholders to ensure that what is monitored is both something considered important by experts reporting on ecosystem health and something that everyone else cares about. In this talk I precis the (100+) published reviews that have covered issues associated with designing and interpreting marine and coastal ecosystem health monitoring programs over the last 20 years, highlighting promising approaches like report cards but also remaining challenges. In particular, coherence and long-term sustainability remain key issues, especially with yet more new reasons/need for monitoring like ocean accountancy on the horizon.