In Mozambique, Nepal, and Peru, researchers are rolling out community-designed health interventions for chronic conditions like diabetes, hypertension, and neglected tropical diseases, and testing whether involving local people in the design improves care. This matters because health systems in low- and middle-income countries often fail people with long-term illnesses. Standard top-down programmes may not fit local realities, leaving patients underserved and health workers frustrated. The COHESION project first spent years studying communities and health systems, then worked with residents, clinic staff, and regional authorities to co-create tailored interventions. Now, in this four-year implementation phase, the team will compare co-designed interventions, non-co-designed versions, and usual care across six communities per country, measuring patient satisfaction, health worker responsiveness, and other system outcomes. If the approach works, it could offer a replicable model for strengthening primary care for chronic diseases—conditions that quietly strain health systems worldwide. A second component tests whether the same co-creation method can be adapted in India, potentially producing a generalisable protocol for other settings. The research does not promise a cure, but a practical, evidence-based way to make health systems more responsive to the people they serve.
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The COmmunity HEalth System InnovatiON (COHESION) project was a 3-year project that started in 2016 as a collaboration between research teams from Mozambique, Nepal, Peru and Switzerland. It enabled formative research to be conducted at the policy, health system and community levels using tracer chronic conditions that included non-communicable diseases (NCDs), such as diabetes and hypertension, and specific neglected tropical disease (NTDs): Schistosomiasis in Mozambique, Leprosy in Nepal and Epilepsy resulting from neurocysticercosis in Peru. The results from this formative research were utilised as part of a process for identifying adequate interventions through a participatory approach with communities, primary healthcare (PHC) workers, and regional health authorities. Upon completing all meetings, each country identified the main components to be included in their interventions that were focused on communities, health workers and facilities. Taking the work forward, this proposed project (COHESION-I) has two main objectives: first, the implementation and evaluation of the context-specific, co-created interventions in the three countries – Mozambique, Nepal and Peru (Component 1 –C1), and secondly, explore the possibilities to translate the experience and the lessons learnt to other countries (India) for adaptation of the COHESION approach in a different context (Component 2 – C2). Methods: C-1: We propose to work in six communities in each country. Two communities (A&B) where we have worked since 2017 as part of the formative research will receive the co-created/co-designed intervention encompassing activities with the community’s health service users and health providers. Two other communities (C&D) will receive the interventions that were co-created in communities A&B but will be co-designed in communities C&D and the intervention will last the same period. Finally, two different communities (E&F) will receive no intervention (“usual care arm”) to enable meaningful comparisons between intervention arms and usual care. The current project will enable us to evaluate the impact of a co-designed strategy in terms of (a) improved responsiveness of PHC workers and patient satisfaction, and (b) improved health care provision for chronic conditions. We will compare the impacts of the co-designed intervention to those of the non-co-designed intervention and usual care in terms of two major outcomes, responsiveness and patient satisfaction, as well as other health system-related outcomes. C-2: In India, we will follow the approach taken in the COHESION study and conduct a policy analysis, health system assessment, and community perception study. A co-creation process will follow this to develop context-relevant interventions to improve the provision of care for people affected by NCDs and NTDs. The co-created interventions will be piloted in the field for feasibility, acceptability, and preliminary effectiveness. If the COHESION approach proves to be locally adaptable in India, a protocol for the COHESION methodology will be developed that can be adapted to different settings. Timeline: 4 years. Anticipated impact: We expected to achieve an improvement in patient satisfaction, health system responsiveness, and in health system indicators through the empowerment of the communities to reach a sustainable change.
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