Co-production of knowledge through research involves collaborations between researchers and end-users of research, including patients and the public, health professionals, health system managers, and policy-makers. This approach is being advocated globally, and across sectors. But there remains uncertainty on what co-production of research entails, how to do it, when and when not to do it. More evidence on these issues is essential if the co-production of research is to deliver on its promise to produce knowledge and share power and responsibility from the start to the end of research and avoid wasting time, resources, and the good will of end-users.
The Alliance collaborated with the BMJ to release a special collection on Increasing the Impact of Health Research through Co-production of Knowledge. It provides an overview of the evolution, potential, influence, learning and challenges in co-producing evidence to inform decision-making in health policy and practice, and points to the core principles which should underpin it.
The collection was launched at a webinar co-hosted by the Alliance on 16 February 2020. The webinar featured authors from select articles and others from the BMJ and the Alliance. A recording and write-up are available below.
There are growing calls for research co-production to bridge the gap between knowledge and action, with researchers working alongside communities, policy-makers and others to identify a problem and produce the knowledge needed for solutions. It seems
clear that co-production matters, but there is less clarity on what this means in practice. How do we co-produce? What do we co-produce and when?
The new BMJ collection on Increasing the Impact of Health Research through Co-production of Knowledge sets out how co-production can inform decision-making
in health policy and practice. Its 13 articles reflect what is happening around the world, with a focus on voices from low-income and lower-middle-income countries. Together, the articles provide an overview of the evolution of co-production,
its potential, influence, lessons and challenges.
Curated by the BMJ in partnership with the Alliance for Health Policy and Systems Research at WHO, the collection was launched at an Alliance-hosted webinar on Co-producing knowledge for stronger health systems on
16 February.
The webinar, with a panel of authors and representatives from the Alliance and the BMJ, emphasised the importance of specific context, with no single model for co-production that would work everywhere. But it also stressed common principles –
power-sharing, collective sense-making and trust – that must shape all co-production from the earliest stages of research design. Panellists explored key concepts, such as the ‘triangle that moves a mountain’: the powerful leverage
that can be exerted when researchers, communities and policy-makers come together around a common cause. They also noted that the COVID-19 pandemic has highlighted the urgent need for collective and proactive efforts to strengthen health systems
through the use of robust evidence.
The challenges
Kamran Abbasi of the BMJ re-affirmed the journal’s commitment to co-production over the past two decades, but noted that “It’s hard. It requires commitments and resources and you don’t always succeed. But you need to have the collective will and the belief in the process as a better way of doing things.”
One challenge has been the dominance of wealthier countries in co-produced research: to date, only 2% of the co-produced literature has emerged from low- and middle-income countries. It is hoped that the new BMJ collection can help to redress the
balance by amplifying voices from these countries, providing a platform for more co-production in the future.
Robert Marten, Abdul Ghaffar and their colleagues have summarized the challenges in
their article for the collection: “Co-production exists in pockets of good practice and in piecemeal projects, but the vision of a research ecosystem with co-production at its centre remains aspirational. It is difficult to envisage what such a system might look like. While the challenge of unequal power dynamics between stakeholders may be resolved at a local level, what does this mean for national and international research communities and health systems?”
What do we need for effective co-production?
In their article, Irene Agyepong and her colleagues outline the pillars for the effective co-production of health research in low-and-middle income countries.
At the webinar, Irene listed these as, first: advocacy to emphasise and demonstrate the value of co-production. As one well-known cartoon demonstrates, “In trying to design something, if you just use one mind, you may not get exactly what you want. […] You need to bring together the different thinking to end up with what the users really need and that will work in their context.”
Second, funding: because this takes resources. Co-production has not been a funding priority in low- and lower-middle-income countries to date, and that needs to change. Third: incentives, particularly for academic researchers who may not be
able to take sole credit for their work. Fourth: building the capacity to do this kind of work, “and finally, be ready to be in there for the long-run, rather than the short-term.”
Core principles: power-sharing, collective sense-making and trust
Kumanan Rasanathan summarized the article on building a collaborative research culture in Cambodia.
This is a country that offers great opportunities for co-production across thematic sectors, given its rapid socio-economic development and its maturing research institutions, as well as the framework provided by the SDGs. Policy colleagues and
communities are deeply engaged in the process, and the country offers an example of ‘the triangle that moves a mountain’, with policy-makers, researchers and communities working together to foster change and solve complex challenges.
Not every country enjoys such opportunities, however.
“If we really want to see co-production across thematic sectors, across stakeholders, with communities, with patients”, said Kumanan “it comes down to issues of power, to really interrogating whose incentives and whose institutions are prioritised. It involves researchers and academics being willing to surrender power over the stewardship of research. It involves journals thinking differently and really engaging with the realities, time demands and incentives of people in low- and lower-middle-income countries. Are researchers and journals willing to take on those different perspectives? Hopefully, this collection will assist in that task.”
In their article, Lucy Gilson and her colleagues stress the importance of collective sense-making for action, drawing on findings from Kenya and South Africa. Research-based
initiatives in these countries have gone beyond research itself to embed researchers within government organisations, and create regular journal clubs that bring health managers and researchers together to share experience.
"This is not about just a passive sharing of knowledge. It’s about a testing of ideas, a critique of ideas, and a dialogue about those ideas. There’s a focus not just on knowledge sharing, but on the action that results from sharing knowledge."
Co-production, it is argued, rebalances skewed power dynamics in two ways. First, those involved are not just the researchers or senior decision makers. Second, there is a shift in terms of the knowledge that is valued, moving beyond the evidence produced by researchers to embrace, engage with and draw on the knowledge of those most directly affected by a particular problem. As well as rebalancing power, co-production has to be about building trust, which “supports the mutual learning and the collective sense-making that are essential to action.”
Also touching on issues of trust, K. Srinath Reddy and his colleagues explore ethical challenges in the co-production of knowledge in their article. At the webinar, Srinath pointed out that when health systems research tries to engage everyone, it must not only accommodate divergent perspectives, but also address prior prejudices.
"How do we deal with them, not merely to ensure robust research design that is free of bias, but ensure the ethical dimensions of the research in terms of its conduct and its equitable distribution of the benefits?"
Drawing on a study on how frontline health workers in the slums of Delhi deal with maternal and child health, Srinath stressed that “we have to be very sure that we are on firm ground. When dealing with power asymmetries, the whole definition of who is contributing to the research design and whose perspectives are dominating it becomes very important. We should not allow power asymmetries to unsettle the research question in a way that is unfair to community voices. Ethics must be considered by researchers, because we must not cause harm to the people who are co-producing the research.”
Looking ahead
Summarizing both the panel and the BMJ collection editorial, Sally Redman looked at the future of co-production, noting that the collection itself illustrates the importance of context. Effective co-production needs a more detailed understanding of what it means in practice in different contexts, the conditions that support it, its precursors and the issues where it can have the greatest traction.
Regardless of the context, however, effective co-production requires a fair balance of power, relationships of trust and strong partnerships, and all three of these take time.
”You can’t do a co-production project and then simply move on. That’s not the way it works, because the establishment of trust has to happen over a long period of time. This means changes to funding patterns, because in most countries funding supports short-term projects. Investment in long-term partnerships would be a better way to support co-production.”