Co‑production is about levelling hierarchies and… sharing risk and responsibility… Good co‑production will always contain elements of lived experience… It’s about sharing risk and responsibility and looking out for each other.”

Background and Overview

Across health systems, the starting point for quality has long been Quality Assurance (QA): setting standards, running audits, and checking compliance against protocols and accreditations. QA creates an essential baseline by defining minimum acceptable performance and protecting patients from harm, but it often operates as a top-down, inspection-driven system that can feel bureaucratic and policing to frontline staff. Meeting standards matters, yet doing so on inspection day does not guarantee consistent, everyday safety or meaningful improvement in how care is experienced.

Quality Improvement (QI) reframes the problem. Rather than only asking whether standards are met, QI asks how work actually happens, what processes create variation, and which small, testable changes can make performance more reliable. The classic operational logic for QI echoes the Juran trilogy: plan, measure and control, and improve. Practical QI requires an explicit method (for example, a model for improvement, Lean, or Six Sigma), routine measurement using run charts or SPC charts, and iterative testing so teams can learn what works in their context. QI also depends on systems thinking: understanding how teams, processes, information flows, and organizational beliefs produce outcomes. Variation is the signal that processes are not yet reliable, and people’s attitudes and local norms often drive that variation; addressing those human and cultural factors is as important as changing technical processes.

Co-Production, framed here as Quality 3.0, moves beyond internal improvement to invite patients, families, and communities as partners in designing, delivering, and owning health. Co-production shifts the focus from disease management to ownership of health: prevention, family- and community-centered services, and local solutions that make care usable and sustainable. Practical examples of this orientation include community-driven models of prevention and family-focused care bundles; historic public health programs such as GOBI-FFF (growth monitoring, oral rehydration, breastfeeding, immunization, female education, family planning) show how prevention and community engagement can deliver population health gains. Co-production asks systems to redesign so that services are planned with people, not only for them.

These three stages form a continuum rather than discrete silos. Standards and accreditation remain necessary as Quality 1.0 provides the scaffolding for safety and comparability. QI methods are required to make those standards reliable in everyday practice. Co-production is the next cultural and operational step: it embeds values and local knowledge into services so quality becomes shared, meaningful, and sustained. Importantly, standards and certification still matter within a co-produced system, but they must be adapted to local contexts and implemented in ways that enable, rather than block, frontline ownership. Local accreditation models and context-sensitive standards can be as rigorous as external ones while being more affordable and relevant.

Values and leadership underpin the whole journey. For QI and co-production to take root, systems require leaders who are just, informed, flexible, and committed to creating a reporting and learning culture. Core values such as kindness, respect, courage, honesty, transparency, and a commitment to equity shape whether co-production is possible in practice. Leadership must create protected time, mentor teams, and foster resilience so that frontline workers can apply QI skills and partner with communities without burning out.

Putting the journey into practice demands capacity, methods, measurement, and local adaptation. Teams need training in improvement methods, practical tools for measurement and data use, clear mechanisms for capturing and responding to lived experience, and pathways that integrate community voice into service design. When standards, methods, values, and leadership align, the result is safer, more reliable care that also restores meaning, compassion, and connection to everyday practice. This is the journey every healthcare worker is invited to take: from assurance to improvement to genuine co-creation of health.

Key Themes

A central theme is the question of power in healthcare relationships. When people enter the system as “patients,” they often lose agency. Care is too often done to them, with instructions given rather than choices shared. Co-production requires a shift from coercion and compliance to partnership, where power is redistributed. It means patients can stop the line, ask questions, and make decisions with providers rather than being passive recipients of care. Without this power shift, quality remains one-sided and incomplete.

The ladder of co-production illustrates this transition. At its lowest rungs, care is done to patients, characterized by coercion or one-way education. As systems climb the ladder, patients are consulted and informed, moving into engagement where care is done for them. Co-production lies at the top, where care is done with them. Yet many healthcare systems remain stuck in the middle, signaling the urgent need for cultural and structural shifts that enable meaningful collaboration.

Shared decision-making is a cornerstone of this transformation. Instead of rigidly prescribing care, providers co-assess, co-design, co-decide, and co-deliver with patients. Asking simple but powerful questions such as “What matters to you?” allows health workers to align clinical decisions with patient values, preferences, and lived realities. This approach improves trust, safety, and satisfaction, while reducing unnecessary conflicts and non-adherence.

Co-production is not limited to patients alone; it extends to families, communities, and healthcare teams. Recognizing kinship and community roles ensures that healthcare is not just person-centered but kin-centered, addressing broader social and cultural determinants of health.

Values such as kindness, respect, compassion, dignity, and openness are the foundation for co-production. Without these, efforts risk becoming tokenistic. Embedding values into daily practice creates a culture where healthcare workers and patients meet as equals, forging relationships rather than transactions. This relational approach generates “moments of truth” where quality is truly experienced, reinforcing trust and accountability.

Another theme is the need to replace old power with new power. Old power sits with professionals and institutions, operating like currency—held by few, controlled from the top, and transacted through rules and protocols. New power functions like current—shared, relational, and participatory. In healthcare, this means moving away from command-and-control models to ones where authority is distributed, relationships matter, and communities shape solutions. Transitioning from old to new power calls for flexible leadership, systems thinking, and willingness to relinquish control to foster genuine partnerships.

Another theme is the importance of reframing patient safety and improvement through positive deviance. Instead of focusing solely on adverse events and failures, systems should identify and learn from what goes well. Highlighting successful practices, often born of resourcefulness in constrained environments, empowers teams to replicate success and build confidence in improvement. This asset-based approach complements co-production by valuing contributions from all stakeholders.

Underlying all of this is the recognition that patients are people first. They are not conditions to be managed but individuals with families, hopes, and lived experiences. This human-centered view reframes care as a relationship rather than a transaction. It also demands values such as kindness, respect, dignity, compassion, and partnership. Embedding these values creates the “moment of truth” where quality is truly experienced by both providers and patients.

Healthcare workers have to appreciate the value of starting small and practicing adaptability. Co-production may feel daunting, but it begins with a single patient, a single question: “What matters to you?” Much like learning a new dance, it takes practice, flexibility, and willingness to move outside comfort zones. Providers may know many technical “dance steps,” but real improvement comes when they learn the patient’s dance too. Starting with one case and testing co-production creates momentum that over time reshapes practice, improvement projects, and community engagement.

Post-Presentation Discussion

A recurring theme is the tension between patient, family, and provider decision-making, especially in sensitive areas like end-of-life care. Families often request interventions that may not be clinically beneficial, creating conflict. These situations reveal how crucial early conversations and honest, transparent communication are in preventing misunderstandings. Co-production does not remove these tensions, but it provides a framework where respect, fairness, and openness guide shared decisions, even in the most difficult circumstances.

Patients also often assert autonomy in unexpected ways, such as discharging themselves against medical advice. Traditionally, such decisions are met with resistance and negativity from providers. A co-production mindset reframes these moments as opportunities for dialogue rather than conflict. By recognizing that patients hold power over their own lives and bodies, the conversation shifts from restriction to partnership, creating a more positive and respectful environment.

The rise of “Dr. Google” adds another layer of complexity. Patients increasingly arrive with self-diagnoses, expectations for specific drugs, or misconceptions shaped by online sources. Instead of dismissing these perspectives, co-production requires acknowledging them as part of the patient’s journey. Respecting that patients seek knowledge elsewhere, and guiding them toward reliable sources, helps transform potentially adversarial encounters into constructive exchanges. This openness extends to traditional and alternative healing practices, which remain important in many communities. By respecting these choices rather than discrediting them, providers strengthen trust and foster genuine collaboration.

Participants also reflected on the practical challenges of co-production in high-volume clinical settings. With long queues and limited time, clinicians worry that collaborative approaches may slow care delivery. Yet the insight that co-production is more about mindset than minutes reframes the issue. Simple shifts, such as asking patients upfront what matters most to them or using brief pre-consultation questionnaires, can align priorities quickly and save time later. Over time, as patients learn this “new dance” alongside providers, conversations become more efficient and outcomes more aligned with their needs.

The conversation also underscored the importance of building knowledge, sharing evidence, and amplifying African voices in this field. While literature on co-production is still limited, emerging repositories, professional societies, and communities of practice are beginning to fill the gap. Crucially, it was stressed that African contexts demand African solutions, and that these must be documented, published, and shared. Supporting mentorship for writing and research ensures that local innovations are not lost, but instead contribute to global learning. Publishing even small-scale experiences can create momentum, much like the first step in quality improvement cycles, opening the door for broader recognition and influence.

From Standards to Shared Solutions

The journey from assurance to improvement to co-production is a cultural shift that redefines how quality is created and sustained. Standards and audits remain important, but they are not enough without systems that learn, adapt, and share power with patients and communities. Co-production reframes quality as something lived and experienced through partnership, trust, and shared responsibility. In resource-limited but people-rich contexts, the most powerful progress comes when providers and patients learn each other’s dance steps; meeting as equals to co-create solutions rooted in kindness, respect, and local realities. By embracing this continuum, health systems can move beyond compliance to build care that is safer, more compassionate, and truly transformative

Join the Conversation

We invite you to share your reflections, experiences, and examples of how you are engaging patients, families, or communities in co-producing health. Your insights can inspire others, strengthen learning across contexts, and help shape more people-centered, resilient systems of care.

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“QA is a commitment made for excellence, while Quality improvement involves actions to maintain or achieve excellence”

“Quality assurance – setting the standards  Quality Improvement – monitoring the set standards, sealing gaps, exploring better standards”

“Mutie from Kenya I couldn’t stop thinking of how we understand well that kindness – making the patient feel seen and heard – is important in our care but somehow struggle to implement it.”

“I couldn’t stop thinking about incorporation of patient safety incident as a module for training health personnel. If this is voiced out it will make a huge difference in patient safety.”

Quality care goes beyond the individual. Kin-centered care recognizes that a person’s wellbeing is deeply connected to their family and community.

Key Takeaways

Understanding social and cultural contexts enhances the impact of healthcare interventions.

Kin-centered approaches strengthen community ownership and shared responsibility for care.

Integrating kin-centered principles fosters empathy, inclusion, and sustainable recovery.

The quality journey in healthcare has evolved; from meeting standards to improving systems, and now to co-producing health. True quality is about shared ownership, human-centered systems, and creating value through collaboration and integrity.

Key Takeaways

Meeting standards is only the foundation; continuous improvement must follow.

Quality 3.0 emphasizes shared ownership of health rather than mere disease management.

Sustainable healthcare quality thrives on collaboration, prevention, and community empowerment.

In healthcare, power dynamics often define the patient experience. Shared power means empowering patients to question, speak up, and take part in decisions that shape their own care.

Key Takeaways

Educating patients about their care builds trust and helps them make informed decisions.

Treating patients as partners, not passive recipients, fosters accountability and better outcomes.

Patients and healthcare providers must collaborate as equals to improve care experiences.

Balancing co-production with family decisions in healthcare is about respect, honesty, and shared understanding. When providers, patients, and families journey together, even the hardest conversations lead to compassionate, fair, and ethical care.

Key Takeaways

Families need to be part of the care journey, not just informed about it.

Open, honest communication builds trust during difficult care decisions.

Compassionate care acknowledges that some answers unfold along the journey.

From Quality Assurance to Quality Improvement to Co-Production:
A Journey Every Healthcare Worker Should Take