Over the past decade, Guinea’s government has shifted from a centrally managed health system to a decentralized one, transferring power, decision-making, and funding to various administrative levels. These changes have been implemented through national policies and strategies designed to improve health services and outcomes.

This study examines how well actors at decentralized levels understand and fulfill their new roles in delivering community health services. It also explores how their responsibilities align with available resources and capacities, and how these factors influence the institutionalization of community health under decentralization. Additionally, the study evaluates early evidence of improvements in maternal and child health (MCH) indicators.

We analyzed the “decision space” of community health actors across communes with varying levels of PNSC implementation and tracked MCH service delivery indicators over time. We expected decision space, knowledge, capacity, and accountability to be highest in fully implemented communes, moderate in partially implemented ones, and lowest in control communes.