Comparing the adoption of co-production in health and welfare contexts

The healthcare sector is facing new challenges related to changes in demographic, epidemiology and lifestyle of the worldwide population. To optimize current healthcare services, it is important to identify solutions that support providers in understanding patients’ needs and expectations (OECD Publishing, 2018). Co-production has been identified as a possible solution as it involves ‘service users in any of the design, management, delivery and/or evaluation of public services’ (Osborne, et al., 2016). Despite this approach has been adopted in several field, healthcare is one of the most used (Dhirathiti, 2018) and challenging one (Bovaird, et al., 2016). Healthcare professionals have highly professionalized skills and competences that distinguish them from patients or caregivers. This disequilibrium of knowledge makes the equal discussion between patients and professionals more complex to put in place (Parrado, et al., 2013). On the one hand, professionals with specific clinical knowledge feel at higher level than patients, on the other hand, patients feel unable to contribute due to their lack of competences and experience in the field (Crompton, 2019). This discrepancy in term of power is a barrier for the adoption of co-production, which requires an equal partnership between actors (Weaver, 2018). This article investigates this issue by comparing the power dynamics that arise from co-production (in particular, co-design) process in the healthcare and welfare sectors. The aim is to study how the power dynamics affect the co-production process in the healthcare sector compared to the welfare one. To achieve this objective, we adopt a multiple case study methodology, comparing two examples of co-design processes with service users in the healthcare and welfare sectors. In the first case, we analyze the co-design of the patient surgical journey in an orthopedic department of an Italian hospital. In the second care, we investigate the co-design of a new service for family caregiver of fragile and non-self-sufficient elders in a remote and rural area of Italy. Comparing the same process in different sectors allows us to deepen the influence of the context on the power dynamics (Farr, 2018). In the healthcare case, we carry out 4 co-design workshops, involving 1 researcher, 6 clinicians and 6 patients overall. In the welfare case, we organize 4 co-design workshops with 24 family caregiver, 4 researchers and 2 providers overall. Workshops last from 80 to 120 minutes and are verbatim transcribed to increase the effectiveness in the analysis of non-numeric data (Halcomb and Davidson, 2006). The transcripts are analyzed through a well-defined process with the support of NVivo software. The process uses an inductive approach that starts labelling the text with ‘in-vivo-codes’ and grouping codes in categories (Glaser, 1967). Once we have compared results with the existing literature, we organize categories in themes, identify patterns and generalize results (Saldaña, 2015). We expect to find few examples of equal relationships among stakeholders in the healthcare sector, proving the major role of power dynamics in this sector. By comparing the interactions among actors in these two sectors, we will try to assess the drivers that influence both in positive and negative way the equal collaboration. Disequilibrium in competences, knowledge (Crompton, 2019) and expectations, the presence of hierarchical structure (Weaver, 2018) with fixed practices and processes (Brown and Head, 2019), the inability to set the roles and duties during co-production processes are only some of the drivers recognized by the literature that influence power dynamics among actors (Agranoff, 2016). This raises the question of how (and if) co-production can be implemented in the healthcare sector. In line with this consideration, this paper suggests possible guidelines that may facilitate the adoption of co-production in this field in the next future.