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Background: Since the 1990s, Tanzania has actively encouraged stakeholder participation in health services through Health Facility Governing Committees (HFGCs) to promote social accountability within its broader health system reforms. While previous studies have explored the functionality of the HFGCs, this study aimed to understand whether stakeholder participation in the HFGCs contributes to promoting social accountability in the health system.

Methods: Between July and October 2022, a qualitative study in two districts of Tanzania was carried out. Selected participants, knowledgeable about HFGCs, included facility managers, HFGC members representing diverse stakeholders in the committees, local government leaders, district health secretaries, and religious leaders. Twenty in-depth interviews were conducted and analysed thematically.

Results: Findings revealed low stakeholder participation in the committees´ activities, partly due to the committees´ inability to effectively sensitize and mobilize them. Inadequate support from local government leaders and the dominance of the facility managers in the committees´ activities, also affected the committees´ role as promoters of social accountability.

Conclusion: The HFGCs in Tanzania have faced challenges in promoting social accountability due to weak stakeholder participation. Key issues include limited awareness of HFGCs, inadequate mobilization, and insufficient training, supervision, and guidelines from district councils. Additionally, flawed election processes, leadership interference, lack of political support, and limited financial resources undermined the committees’ effectiveness. To improve engagement, district councils should enhance stakeholder sensitization, build HFGC capacity, ensure that facilities allocate 5% of their budgets for committee activities, monitor performance, and encourage local government support for HFGCs.