Formal healthcare systems in West Africa, particularly in Chad, frequently encounter challenges of reach and resource limitations. This has resulted in a significant dependence on community-based health initiatives. A clearer understanding of local agency within these initiatives is needed to inform sustainable health development. This study aimed to compare the structure, operational models, and perceived outcomes of different community-based medicine initiatives in Chad. Its primary objective was to analyse the role of local agency in the design and implementation of these programmes. A qualitative comparative case study design was employed. Data were collected through semi-structured interviews and focus group discussions with initiative leaders, community health workers, and beneficiaries from four distinct community-based programmes in different regions of Chad. Documentary analysis of programme records supplemented this data. Resource mobilisation was identified as a critical determinant of sustainability. Initiatives with strong embedded local leadership were reported to be more resilient. Programmes that formally integrated local knowledge and leadership structures demonstrated greater community engagement and perceived effectiveness. One initiative, for example, reported a substantial increase in antenatal clinic attendance following the integration of traditional birth attendants into its referral system. Local communities in Chad exercise significant agency in developing and sustaining health initiatives. Comparative analysis indicates that models which formally integrate local knowledge and leadership structures show more positive outcomes in terms of community engagement and perceived effectiveness. National health policy should seek to formally recognise and support community-led initiatives through training and resource-sharing partnerships. Further research is needed to develop frameworks for scaling successful local models while preserving their community-owned character. Community health, local agency, Chad, comparative study, maternal health, health systems, West Africa This study provides a comparative analysis of community-based medicine in Chad, offering evidence for the central role of local agency and presenting models for sustainable integration into broader health systems.