Co-creation, co-design or co-production? Reflections on the development of urban health systems implementation strategies to improve access and quality of primary healthcare services in Bangladesh, Ghana, Nepal and Nigeria

Increasing populations and health-care demand are leading to a burgeoning of private, non-governmental and informal health providers addressing gaps left by overstretched public primary care and under-resourced local government in urban areas in low and middle-income countries (LMICs). While evidence-based interventions exist to address common conditions in primary care, how to implement these interventions within complex urban health system is less clear. Meaningful engagement of all relevant actors is seen as a key step; however, the complexity of urban contexts makes planning and instigating such processes challenging. To better understand processes of co-design of system-wide approaches to implement existing evidence-based interventions, we present reflective case studies from four cities in Bangladesh (Dhaka), Ghana (Accra), Nepal (Pokhara) and Nigeria (Enugu). Methods: We used the definitions and domains of co-creation, co-design and co-production from Vargas et al 2022 to analyse reports of design meetings from each city and conducted four workshops where research teams involved in the design processes developed timelines of design activities and decisions and reflected on their interactions with stakeholders including: city authorities; communities; informal providers; ministry officials; public and private primary care providers. We coded reports and workshop outputs according to domains identified by Vargas et al: focus, stakeholders involved; their role and level of participation; communication; value creation; resultant initiative; and potential outcomes. Results: Key characteristics of co-production, co-design and co-creation were observed, often simultaneously, within each of the health system intervention development process. These categorisations varied by stakeholder (e.g. city officials or communities) and at different points in the design process (e.g. analysis or material development). The inclusion of locally generated research results was key is shaping and focusing the interventions and implementation strategies to ensure they addressed the realities of local health systems. Intense engagement with local government and health provider stakeholders facilitated their willingness to challenges and find appropriate solutions. Conclusion: Careful consideration of context, hierarchies among professionals, relationships between providers, underlying values and targeted use of locally generated qualitative and quantitative information to highlight gaps and strengths is key to developing implementation strategies to strengthen urban health systems.