STREET-LEVEL BUREAUCRATS IN COMMUNITY-BASED HEALTH INITIATIVES: A CASE STUDY OF AGONA WEST

This study examines how street-level bureaucrats (SLBs) implement community-based health initiatives (CBHIs) in Ghana's Agona West Municipality through the Community-based Health Planning and Services (CHPS) program. The researcher employed a mixed-methods approach to investigate SLBs' discretionary practices to manage resource constraints and conflicting demands, implementation challenges, and coping strategies. Data were collected from 60 SLBs through surveys, 20 SLBs through in-depth interviews, and 32 community members through focus group discussions. Findings reveal that SLBs perform diverse roles, including service provision, health education, and surveillance, frequently expanding these roles based on community needs. They exercise significant discretion through service prioritization, protocol adaptation, and resource mobilization, particularly in resource-constrained rural settings. Implementation challenges include resource limitations, administrative burden, and policy-practice gaps. SLBs employ coping strategies such as task prioritization, creative resource mobilization, and community engagement. This study contributes to street-level bureaucracy theory by demonstrating recursive relationships between challenges, discretion, and coping strategies in African healthcare contexts. The researcher recommends realistic policy design, reduced administrative burden, supportive supervision, and systematic learning from SLBs' innovations to strengthen community-based health systems.