Over the past two decades, community participation has emerged as an important dimension within decentralised district healthcare systems. In Tanzania, initiatives to strengthen community participation have focused on the formation of the health committees. Studies have reported variations in the performance of the committees. An exploratory case study design focusing on two districts was adopted to explore the differences in practice of the health facility committees in a well‐functioning district and one that is not. In both study districts, the committees were in place. The most common activities of the health committees were assisting the clinic in day‐to‐day running. The health committees' influence on policy, planning and budgeting was limited. Managerial and leadership practices of the district health managers, including effective supervision and personal initiatives of the top‐district health officials coupled with