Strategies for enacting health policy codesign: a scoping review and direction for research

In implementation science, health policies are often conceptualized as outer setting factors that enable improved population health by directing funding towards the implementation of evidence-based interventions (EBIs) [1‐3]. The emerging research focused on policy development strategies [4, 5], however, suggests “evidence-based” is a less helpful construct than “evidence-informed” [6]. In this policy development subfocus area of implementation science, scholars increasingly recognize the need for pull rather than push strategies to ethically and effectively integrate research evidence from health science into the complex realities of real-world policymaking [7, 8].

This evidence-informed perspective also aligns with political science models that explain policy and public administration failures. In one such model, New Public Governance [9, 10], failures are attributed to misalignment among the sectors needed for successful policy implementation (e.g., policymaker, service delivery sector, consumer, community member). The relationship between poor sector alignment and poor EBI implementation is routinely documented in implementation science as well [11]. Updated implementation science frameworks [12, 13] identify the need for collaborative planning rather than top-down strategies when innovations or contexts present high complexity.

Policymaking is one such highly complex decision-making environment. Policymakers and those facilitating policy development have to navigate conflicting constituent values, short time frames, and difficulties accessing timely, relevant knowledge. Many of the questions addressed by policy have multiple causal factors and competing courses of possible action [14]. When surveyed, policymakers note the difficulty of accessing and appropriately applying research evidence given these constraints [15, 16]. As a result, research evidence tends to either be unused or applied in non-optimal ways, posing barriers to implementation successes and health equity.

Codesign is a framework for collaboration potentially well suited to addressing the complexity of multi-sector policymaking. The purpose of codesign is to develop a space for sense-making among individuals with different cultures, beliefs, and forms of knowledge [17]. As articulated by thought-leaders in this field, effective bridging among sectors requires a mindset shift among policy developers from expert to facilitator. Operationally [18], this moves the developer from being the one to gather knowledge and produce recommendations and policies, to one who convenes and creates opportunities for individuals from diverse professional and lived experience backgrounds to create shared understanding and agreement on policy direction. As noted by Evans and Terry [19], common features of design-based models include iterative stages of divergence and convergence, with a series of phases starting with discovery or inspiration, leading to design or ideation, and followed by implementation.

The integrative approach fundamental to codesign provides a model for bringing research evidence together with system knowledge and service user knowledge in an “additive” approach to policymaking [20]. The use of research evidence in this collaborative framework reflects conceptual use as articulated by Carol Weiss [21]. Sometimes referred to as enlightenment use, conceptual use describes how research influences the way policymakers and those in the policy arena think about a topic. This may result in a shift of mindset or mental model or may confirm the participants’ view of the problem in a way that enhances motivation to act [22, 23]. This also aligns with the predictions of New Public Governance (NPG) which posits that focusing on the process of policy formation rather than a specific policy structure (e.g., funding an EBP) is expected to produce better downstream outcomes [24, 25]. In NPG, successful policy formation can be evaluated by assessing the extent to which considered policies are scrutinized by multiple perspectives, encompass clearly defined goals and strategies, are descriptively innovative, articulate how the policy could navigate the trade-offs of complex policy problems (wicked problems), are supported by diverse policy stakeholders, and are sufficiently flexible to be adjusted over time [9].

Codesign and similar cocreation approaches are rapidly growing methodologies in health services [26], but the literature on the application of codesign within health policy is limited. Consequently, the claimed benefits of this approach to health-related policymaking are largely theoretical. The complex nature of policymaking suggests the application of any methodology in this area, especially one with the ambitious claims of codesign, requires thoughtful theoretical and empirical scrutiny. The dramatic rise in visibility and popularity of codesign has led to widespread adoption of the term. In a survey of public service workers (n = 466), 90% self-reported the use of codesign [27] but proponents of formally described codesign approaches argue that it is rare to find the skills and mindsets for codesign within the public sector [28]. Politically, some are concerned that the use of term codesign in policy spaces is being coopted to provide participants with a false sense of ownership while policy decisions continue to be dictated by more powerful actors [29, 30].

To advance our understanding of codesign as a policymaking strategy in health policy research, we undertook a scoping review of the health policy codesign literature. Our aim was to characterize the existing state of research in this area, analyze available approaches against the claims of guiding theory, and propose recommendations for developing and evaluating codesign as a strategy for policy formation within policy dissemination and implementation science. In doing so, we adopted a broad definition of policy, including Big p, little p, and policy-enabled service development [31]. Big p policies are laws that regulate resources. Little p policies are institutional norms and regulations. Policy-enabled service development includes policymakers or policy levers in service innovation.

We conducted this review to examine how policy codesign is being defined and operationalized in health policy scholarship. We identified a small, growing literature that is expansive in geographical reach and topic area. Health policy codesign is being implemented across continents with somewhat higher representation in the literature among Anglophone countries. The approach is being used to address diverse health topics, including social determinants (housing, economic development), public health, and health services. The maturity of the science across disciplines is at an early stage. Reported outcomes were qualitative and not consistently defined but pointed towards common areas of interest for measuring outcomes.

Efforts to enact little p policy (organizational adoption of practices) was slightly more common than big p policy or program development efforts. Studies were twice as likely to engage policy users as representatives in decision-making than as full owners or as informants. Full ownership approaches tended to be complex, requiring significant resources devoted to community mobilization [41, 50], dialogue, and voting [56]. Representative approaches tended to be more time-limited, using discrete engagement events such as workshops, to engage participants from multiple sectors [19, 43, 63]. Informant approaches were focused on improving the robustness of information available to policymakers in their decision-making.

Relying on the author-reported benefits of codesign, we identified a trend association between the use of full ownership approaches and the reported level of community mobilization and knowledge of community needs. We also identified higher reported benefits in novel ideas within representative ownership approaches. Because the reported outcomes were purely descriptive, we identify this as a productive area for future research. Potential trade-offs between community mobilization and novel ideas suggest different policy codesign structures may yield different benefits and should be used to solve different types of policy problems. This aligns with the general guidance of research and policy participation frameworks [66]. In Gupta’s split ladder of participation framework, for example, the model suggests only using complex, policy user intensive efforts when the health topic is controversial, with little agreement among sectors in values or beliefs about the relevant research evidence.

We did not attempt to examine associations between the linearity or phases of policy codesign efforts and outcomes because of the variation in approaches. We observed general trends; however, all approaches identified a phase in the process in which information had to be “put together” in some way to propose a policy solution, with these solutions coming middle to late in the policy formation process. Accordingly, a common feature noted across the articles reviewed and that spanned disciplinary approaches, was the greater amount of time required to facilitate a policy codesign effort when compared to traditional timelines. Studying the trade-offs between timeframe and the development of trusting relationships is an important area of future research. It is likely that long timeframes could hurt the acceptability or scalability of policy codesign and researchers will be motivated to find ways to shorten timeframes to improve efficiencies. Findings from the articles reviewed here suggests facilitation expertise might be a factor in reducing timeframes; on the other hand, studies cautioned that imposing urgency when forming partnerships with individuals marginalized by race, poverty, and/or disability will further harm those individuals. The intended benefits of a proposed policy should not outweigh the potential for harm among individual participants in the codesign process [67, 68]. Distilling insights from experienced community/multi-sector facilitators and examining time-limited activities and methods from participatory design could yield a set of guiding principles for making these tradeoff decisions. Researchers studying policy codesign can assist by clearly documenting activities within phases, time devoted to phases, and participant perceptions of the codesign process using participatory process measures [69‐71].

Knowledge gathering and integration, possibly the area of greatest interest for implementation science, was infrequently described in meaningful detail among the reviewed studies. Traditionally, the field of participatory design and codesign has not considered the use of research evidence as a core element of knowledge synthesis. Although as formally trained designers are moving more into health services research, the use of research evidence within design engagements is becoming more prevalent [72]. In our review, research evidence was formally presented in the policy codesign efforts of facilitator teams that came from health services research organizations [45, 59, 65], whereas research use was less formally introduced or not introduced by facilitator teams with participatory design or public policy backgrounds. The use of research evidence within anti-racist and decolonizing movements within health services research is currently contentious; a key question for the field is how to make appropriate use of research evidence without imposing this use on communities [73, 74]. Policy codesign, and codesign broadly, provides a promising framework and set of methods for resolving this tension.

In codesign, participants can request information to round out their view of a topic, including the research evidence, without this needing to be pre-selected or imposed by a facilitator team. In Owens [59], for example, the facilitator team used an established systems-design model, Theory U, which does not require a formal “research evidence” component. In the project, the codesign participants requested a review of best practices in jail-based reentry for opioids and a research team conducted a rapid evidence review (RER) on the topic. The RER was translated into a 10-min video and research brief and sent back to the team to review and discuss. Interestingly, the paper notes that when asked if they “learned something new,” no one on the team noted the RER findings. However, the cross-service model developed strongly resembled existing evidence-informed recommendations while also including innovative components (e.g., peer navigation support). This and other literature suggest research evidence can be a valuable information source but should not dominate and sometimes may not be necessary (or could be harmful) when designing policies and systems to solve intractable health problems [75, 76]. The promise of policy codesign, albeit in an infant stage, is having a framework for selecting and synthesizing information and engaging partners to create the most transformative or effective policy solution possible for that moment.

Policy codesign is an emerging and converging area of study that shows promise for reconciling some of the competing demands on governments to engage citizens, be responsive to community needs, and steward the effective use of public funds to improve health. Studies of policy codesign show little consistency in specific methods but are coalescing around phases in which actual policy development comes after a meaningful number of activities devoted to coalition building, information gathering, and synthesis. Outcomes reported by study authors suggest key areas of measurement for continuing to study and advance policy codesign including community mobilization and the development of novel ideas.