Peter M. Hansen, Christina Synowiec and Nathan J. Blanchet share strategies for using co-production approaches to accelerate systems change
Technical institutions, such as universities and other governmental or non-governmental research agencies, often play a lead role in generating scientific evidence critical for improved health. However, they can be poorly connected to health policy and systems change processes. This results in generation of data and evidence that are less relevant to local context and less likely to be used to inform policy and systems change for improved health. [1, 2]
In our experience, co-production of knowledge between technical institutions and policymakers can play a key role in overcoming this disconnect.  The focus of much co-production work lies in ensuring that policymakers engage in the early stages of knowledge generation, together with researchers.  This is important, but insufficient. Ensuring technical institutions are involved at later stages of systems change processes together with policymakers, health providers and civil society representatives is critical for achieving real change.
The USAID-funded Health Systems Strengthening Accelerator (Accelerator) embraces co-production between technical institutions and policymakers to enhance country capacity to achieve health systems change.  In Guinea, the Accelerator is supporting a co-production process with researchers, policymakers, practitioners and end users to strengthen implementation of a new community health strategy. The strategy aims to ensure community access to services through recruitment and training of community health workers and mobilizers. It represents a complex system change that requires new revenue sources and funding as well as the incorporation of different mechanisms for governance, coordination and communication. The strategy includes new roles and responsibilities for local government and requires capacity development and essential supplies for a new cadre of salaried community health workers. Through the co-creation process, the Accelerator helps researchers, policymakers and end users analyze these issues and draw on global and local experience to create innovative solutions relevant to local context.
Originally planned as an in-person process, covid-19 has necessitated a shift in Guinea to a virtual approach using remotely-facilitated participatory workshops, informational webinars, and remote data collection.  In this context, establishing a robust system for adaptive learning becomes even more critical. With Guinean technical experts, stakeholders are jointly developing a set of monitoring, evaluation and implementation research activities to inform improvements in the design and execution of the community health strategy.  These activities will generate evidence to inform improvements and give stakeholders the opportunity to share their own knowledge and experiences. Establishing ongoing feedback loops and intentional moments to pause and reflect on what does and does not work is critical for enabling iterative adaptation in response to learning. 
In Liberia, close partnership between an Accelerator coach, regional technical institution and the Ministry of Health fostered policymakers’ capacity and motivation to use local and global evidence to address local health systems challenges.  Preliminary findings indicate this partnership led to changes in the way evidence was used by policymakers in Liberia. To inform their strategy for a Revolving Drug Fund proposal for financing medicines, technical experts and policymakers generated and used evidence from Liberia alongside evidence from Nigeria, Ghana, and elsewhere to identify the critical foundations needed for Revolving Drug Funds to work well. They examined the policy requirements, operational capacity and strategic communication plans as well as significant risks even when the foundations are strong. This resulted in strategic shifts in how policymakers are approaching the role of Revolving Drug Funds in the context of their broader national health financing strategy. 
We have seen through ongoing learning in Guinea, Liberia, and elsewhere that for many health systems strengthening efforts, co-production is likely to be more effective than alternatives where evidence generation and analysis are disconnected from systems change processes. Active partnerships between researchers and policymakers to diagnose problems and formulate potential solutions helps ensure data and evidence are relevant to local priorities, stakeholder timeframes align, and outputs are useful for decision-making. Another benefit we have seen is stronger policymaker leadership and motivation to apply the evidence in policies and practice.
However, a more expansive approach to evaluation is needed to strengthen evidence on how co-production can most effectively enable health systems strengthening efforts.  Much like the health system challenges that co-production aims to address, co-production can be complex, multi-pathway, and non-linear. The process constantly evolves through dynamic interactions of many diverse stakeholders. Therefore, it is not surprising that cause and effect relationships between co-production and outcomes are neither direct nor simple.  Evaluation approaches must account for this complexity and proactively identify unanticipated outcomes and non-linear effects. The involvement of intended beneficiaries of health systems change efforts and other key stakeholders as co-evaluators of co-production activities must also be considered.
The co-production of knowledge can play an important role in supporting country efforts to strengthen health systems and advancing the field globally. More experimentation and learning are needed to better understand how partnerships between technical institutions and policymakers not only co-produce knowledge, but also effectively co-produce health systems change.
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Peter M. Hansen is the results lead at the Global Financing Facility and former Project Director of the Health Systems Strengthening Accelerator.
Christina Synowiec is the lead and co-founder of Results for Development’s (R4D) Evaluation and Adaptive Learning practice, and a Senior Director at R4D.
Nathan J. Blanchet is a senior program director at Results for Development and acting Project Director for the Health Systems Strengthening Accelerator.
Competing interests: The Health Systems Strengthening Accelerator is a Results for Development (R4D)-led project. All authors have worked on the Accelerator in different capacities.
This article is part of a series produced in conjunction with the WHO and the Alliance for Health Policy Systems and Research with funding from the Doris Duke Charitable Foundation. The BMJ peer reviewed, edited, and made the decision to publish.
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