The COHESION-I Project seeks to improve patient satisfaction and health system responsiveness at the Primary Health Care (PHC) level in India, Mozambique, Nepal, and Peru. This project continues the work initiated by the COHESION Project (2016-2020), where formative research and co-creation processes were conducted to inform intervention development in Mozambique, Nepal, and Peru.
The four-year COHESION-I Project (2022-2026) has two components. The first seeks to co-design, implement, and evaluate context-specific interventions in Mozambique, Nepal, and Peru. The second component encompasses formative research followed by co-creation and co-design processes to develop an intervention that will be pilot-tested in selected settings in India. Both components aim to improve patient satisfaction, health system responsiveness, and health system indicators. In this blog, we are focusing on the co-design approach we are following across countries.
Steps in the co-design process
Using participatory processes enables the COHESION-I Project to engage and involve stakeholders at the national, regional, and local levels in each country. This is also seen as an opportunity to foster ownership and long-term sustainability of the interventions. While the co-creation process currently in progress in India follows an optimized methodology from COHESION (read more here and here), the co-design process that will be followed in the four countries comprises six steps:
- Step 1: Selection of sites
- Step 2: Initial coordination and community mapping
- Step 3: Building the characteristics of intervention components with stakeholders
- Step 4: Design of preliminary intervention outputs
- Step 5: Validation of the intervention outputs
- Step 6: Final adjustments to the design of the intervention outputs
The first step consists of selecting six sites per country, in groups of two they will receive a different intervention composition. In the communities (A&B) where formative research and co-creation processes were conducted between 2017 and 2018, and co-design processes in 2023 and 2024, co-created/co-designed interventions will be implemented. Two new communities (C&D), where co-design processes were carried out in 2023/2024 will also receive the same (co-design only) intervention. Whereas the two remaining communities (E&F) will continue usual care and will not receive any intervention, this is to facilitate comparing the outcomes between the intervention arms and usual care. This selection process prioritizes common key variables (location, settlement classification, population density, presence of PHC health facility, distance to reference health facility, among others), and seeks community authority acceptance for project participation.
Step 2, involves engaging key stakeholders at national, regional, and local levels to secure authorization and support for the COHESION-I Project. This includes meetings with health sector representatives at national, regional and local levels, as well as with community leaders to discuss the project and their expected roles. One of the outputs of this second stage is developing a community mapping, helpful for subsequent project activities.
The following step consists of participatory workshops with community authorities, social leaders, patients, caregivers, and PHC health workers to discuss their local health needs and determine the specific characteristics of the interventions. This encompasses modes of delivery (e.g., frequency, channel) and outputs (e.g., content). The feedback obtained is then analyzed and used for the fourth step of the co-design process, to develop preliminary intervention outputs. This process is carried out by the research team and in some cases with the support of external experts on specific topics. Examples of activities conducted in this step include determining the content of training sessions for health workers, developing education and communication materials, and identifying the feasibility of implementing small local health facility improvements.
In the fifth step of the co-design process research team members validate with community members and PHC health workers the preliminary intervention outputs. This is done through interviews, workshops, and focus groups where participants provide in-depth recommendations to improve the content and quality of the outputs, as well as make them more clear, relevant, and accurate to the local population and contexts. In this step, research team members also assess the operational and logistical steps required for the successful implementation of the interventions. Lastly, the recommendations obtained are used to refine the intervention outputs before implementation, with considerations made to logistical and budgetary constraints.