Co-production of knowledge: the future

Abstract

A new collection highlights the role of co-production in strengthening health systems

Co-production is a collaborative model of research that includes stakeholders such as patients, the public, donors, clinicians, service providers, and policy makers. It is a sharing of power, with stakeholders and researchers working together to develop the agenda, design and implement the research, and interpret, disseminate, and implement the findings.

Co-production has been embraced because of its potential to improve the quality and relevance of research and its effect on policy and practice.^{1 2 3} This is nicely captured in the Thai concept of the “triangle that moves the mountain,” whereby researchers, citizens, and policy makers work together to achieve change.⁴

However, co-production is not straightforward; it requires additional resources and takes much longer than traditional research.³ It can be associated with additional conflict, although surfacing and working through stakeholder conflicts may be highly productive in the longer term.⁵ Despite the burgeoning literature, few studies have evaluated whether co-production achieves its promise and the conditions which optimise its value. Nonetheless, our experience and the articles in this BMJ collection (www.bmj.com/co-producing-knowledge) suggest the following considerations will be important.

Firstly, co-production is highly context dependent.⁶ What works well in one situation and at one time may be impossible in another. Whether and how co-production can occur will be determined by systemic issues, including the culture and development of the health and policy system, resourcing and leadership, the wider culture, and the evolution and drivers of the research sector.^{7 8 9} There is much to learn from examining how co-production works in diverse settings, including low and middle income countries, where local ownership of solutions is vital. However, most research has so far been in highly developed settings, with less than 2% of co-production literature examining low and middle income countries.¹⁰ This collection is beginning to address this imbalance.

Secondly, co-production requires trust, genuine power sharing, and respect for the different expertise brought by stakeholders. Trust also relies on effective communication and honest discussions about what can and cannot be done; it can be assisted by upfront agreement about basic principles such as mutual respect, openness, and reciprocity.¹¹ Knowledge brokers can help improve communication and develop shared expectations.¹² Critically, trust is built by working together over time—sharing views and tackling challenges as a team.

Trust is particularly important in working with less powerful stakeholders.^{4 7 13 14} In low and middle income countries funders and donors may need to reorient their views to place more trust in local knowledge^{15 16}; new kinds of funding from USAID and other donors have supported initiatives to build trust and facilitate co-production.¹⁵ In Australia, research involving Aboriginal people has often been perceived as exploitative. Despite this history, long term partnerships, leadership by Aboriginal communities, commitment to capacity building, and upfront agreement about who determines priorities and owns the information can enable trust and effective co-production.¹⁷

Thirdly, there is now substantial interest in the practical requirements for co-production, including skills, systems, and incentives. For example, it has proved possible to build skills and systems to increase the use of research by policy agencies¹⁸ and to strengthen researchers’ skills and confidence in their ability to build relationships and communicate their research findings.¹⁹ Universities could encourage co-production by placing greater value on impact. However, this will depend on the capacity to measure research impact in more sophisticated ways that capture the value to end users.^{17 20}

Finally, a different approach to research funding will be needed to support the complex partnerships necessary for co-production. Historically, research funding was mainly provided for short term projects and did not effectively support the development of long term partnerships or collaborative infrastructure; Beran and colleagues describe the need to fund “partnerships rather than projects.”¹³ More recently, many agencies have established funding opportunities that support long term relationships and co-production (such as the Doris Duke Charitable Foundation’s African Health Initiative,¹⁵ Australia’s National Health and Medical Research Council partnership centres, the UK’s collaborations for leadership in applied health research and care, and Canada’s knowledge to action grants). These are to be encouraged as critical to co-production.

As this collection shows, there is much interest and activity in co-production. No doubt our thinking will evolve over the next few years. Recently, for example, we have gained new insights about co-production from responses to covid-19, including the value of long term partnerships that can be mobilised rapidly.²¹ However, over the next few years, it will be critical to shift the focus from conceptual and descriptive work to more rigorous examinations of the effect of co-production and tests of when, where, and how it can be used most effectively.