This chapter explores the critical role of governance and leadership in embedding Social Accountability (SA) within medical education institutions. It underscores the necessity of visionary leadership to foster a culture of SA and examines various leadership models—transformative, participative, ethical, and collaborative—that can drive systemic change. The discussion extends to the governance structures, policies, and evaluation mechanisms essential for operationalizing SA principles. Through case studies of institutions like the Université de Montréal, the University of Gezira, and NOSM, the chapter highlights real-world examples of leadership and governance strategies that align medical education with community health needs, emphasizing the importance of ethical commitment, strategic partnerships, and inclusive practices.