# Implementation of the national community health policy in Guinea: a decision space analysis of the roles and responsibilities of community health workers

## TL;DR

This study examines how community health workers in Guinea understood and carried out their roles from 2017 to 2021, finding that their decision-making space was influenced by factors like vaccination coverage and presence.

## Contribution

The study introduces a decision space analysis to evaluate how community health workers interpret and implement national health policies in a decentralized system.

## Key findings

- CHW and RECO showed high knowledge and implementation of their roles across all commune types.
- Higher BCG and pentavalent vaccination coverage was significantly linked to expanded de jure decision-making space.
- Commune type was not the main determinant of decision-making space for CHW and RECO.

## Abstract

Community health workers (CHW) are crucial for universal health coverage (UHC) in low- and middle-income countries. Decentralization supports this goal but can cause issues if local actors misunderstand their roles. This study explores how Guinea’s local health system actors understood and executed their responsibilities in delivering community health services from 2017 to 2021.

This is a subanalysis of 168 CHW from a larger study of 522 respondents on the implementation of community health policy in Guinea. We used a sequential explanatory mixed-methods design to assess the knowledge, involvement, and decision space of national community health policy actors, focusing on CHW and community volunteers (Relais communautaires [RECO]). This analysis was guided by decision space theory and explored both de jure (formal) and de facto (actual) decision-making. De jure decision space refers to the choices authorized by official strategies, policies, or laws, while de facto decision space reflects the choices reported by local actors in practice.

Across all commune types, CHW and RECO demonstrated high knowledge and implementation levels of their roles in community health. Contrary to the initial hypothesis that fully implemented communes would have the highest decision-making space, commune type was not the primary determinant of decision-making space for CHW and RECO. The presence of CHW was positively associated with greater de jure and de facto decision-making space and enhanced capacity (p = 0.050). Univariate analysis showed that increased BCG vaccination coverage (vaccine to protect against tuberculosis) was significantly associated with expanded de jure decision-making space (p = 0.041). Bivariate (p = 0.014) and multivariate (p = 0.011) analyses revealed that higher pentavalent vaccination coverage (vaccine to protect against diphtheria, tetanus, pertussis, hepatitis B, and Haemophilus influenzae type b) was also significantly associated with a larger de jure decision-making space.

In countries with decentralized responsibilities, it is crucial for community health actors to understand their decision-making range to improve health outcomes. Also, ensuring sufficient and consistent capacity and funding is essential to enhance health services.

The online version of this article (10.1007/s00103-025-04076-8) contains supplementary material, which is available to authorized users.