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Introduction: Social accountability initiatives are considered a way to address inefficiencies and improve overall health system performance. Tanzania has introduced Health Facility Governing Committees (HFGCs) to improve social accountability of the health system. However, information on how communities perceive these committees is lacking.  This study aimed to assess the prevalence and social determinants of the HFGCs accountability from the community perspective in Tanzania.

Methods: The research employed a cross-sectional survey design in two Tanzanian districts (Handeni and Mbarali) selected for their contrasting health performance. Data collection took place from July to October 2022, involving 1184 households in 31 villages/mitaa. The study measured social accountability through a set of six questions, focusing on community support, sensitization, feedback, trust, engagement, and overall accountability of HFGCs. Socio-demographic data such as sex, age, education, occupation, type of health facility and district were also collected and analyzed using linear regression to identify factors influencing perceptions of accountability.

Results: The findings revealed a low prevalence of social accountability as measured by the variables of community awareness and engagement with the HFGCs. Only a small percentage of respondents felt adequately informed or involved in the activities of these committees. Social determinants such as higher education levels and certain occupations, such as business and retirement and those living in Handeni district, correlated positively with a better perception of social accountability.

Conclusion: The study highlights significant challenges in the operational effectiveness of HFGCs in Tanzania, with a notable disconnect between these bodies and the communities they serve. Despite the theoretical framework for social accountability, actual community engagement remains low, impacting the overall efficacy of health governance at the local level. Future research should focus on improving community awareness and participation in these committees to improve their functionality and accountability, thereby aligning with national health objectives and local needs.