Community-Based Medicine in Ethiopia: An Analysis of Local Agency in West African Health Initiatives

Community-based medicine is a component of healthcare delivery in low-resource settings. In Ethiopia, various initiatives exist, but the specific role and agency of local communities within programmes influenced by West African models require further examination. This study aimed to analyse the role of local community agency in the design, implementation, and sustainability of community-based medicine initiatives in Ethiopia that utilise West African approaches. A qualitative, multi-sited ethnographic study was conducted. Data were collected through in-depth interviews with community health workers, traditional birth attendants, programme managers, and local beneficiaries. Focus group discussions and non-participant observation of initiative activities were also used. Data were interpreted using thematic analysis. Genuine local agency was strongest during implementation but was limited in the design and planning phases. A key finding was the strategic adaptation of West African models to local socio-cultural contexts, particularly in maternal health. Many community health workers reported feeling empowered to make minor operational decisions, while major budgetary and strategic control remained external. Local communities in Ethiopia demonstrate adaptive agency in implementing community-based medicine, ensuring cultural relevance. This potential is constrained by insufficient involvement in the foundational stages of initiative development. Future initiatives should institutionalise participatory co-design processes with communities from the outset. Donors and policymakers should devolve greater budgetary and strategic authority to local structures to improve ownership and sustainability. Community health workers, primary health care, community participation, health systems, Ethiopia, maternal health, qualitative research This original research provides empirical evidence on the dynamics of local agency within cross-regional health initiatives, highlighting the disparity between community adaptation in implementation and their exclusion from strategic design.