Co-creation could make public health research more inclusive, relevant and impactful. However, without explicit theory, aligned with clear guiding principles and transparent methods for integrating stakeholder knowledge, it risks becoming inconsistent, procedural and difficult to evaluate.
Co-creation can be understood as a research approach engaging diverse and relevant stakeholders across any or all stages of a study—from problem identification to the evaluation of changes. By drawing directly on stakeholder input, co-creation enables a more nuanced understanding of local priorities and challenges. This, in turn, helps deliver interventions that are closely aligned with the contexts in which they are implemented.
References to co-creation have surged across development research and practice in recent years. Funders, governments, policymakers, and NGOs now frequently expect co-creation to make research and innovation more inclusive and to accelerate real-world impact.
This expectation often rests on an assumption: that engaging stakeholders will naturally lead to better outcomes. However, research suggests that co-creation has a dark side, with serious implications that can undermine its intended benefits. This raises a critical question: how can researchers avoid this darker side?
Our recent work articulates the following key lessons:
- Prepare and share the co-creation methods in advance, such as explaining their purpose.
- Allow scope for flexibility
- Select a range of active and creative participatory methods.
- Make considered use of different meeting spaces and room arrangements
Co-creation in public health research
These practical concerns are particularly important in public health research, where co-creation is increasingly promoted as a means of enhancing inclusivity, relevance, and impact. Yet co-creation is seldom used as an explicitly articulated theoretical foundation, as highlighted in a recent systematic review.
To date, co-creation principles remain largely implicit, often assumed to be self-evident rather than systematically grounded in clearly defined theoretical frameworks. This means co-creation can mean very different things across projects, making it difficult to evaluate effectiveness, compare approaches, or replicate success.
Recent work has begun to address this fragmentation by identifying a more consistent language for co-creation. A recent comprehensive review identifies universal dimensions of the co-creation process across different types of co-creation, explicit theories, and research fields. These dimensions include multi-stakeholder collaborative action, co-learning toward innovation, and contextual knowledge production.
Identifying these dimensions is only a first step. Without transparent methods for integrating co-created knowledge, stakeholders may participate in the process while their insights remain peripheral to the scientific output.
This need for operational clarity is further supported by recent Health CASCADE work on evidence-based co-creation. This work identifies key principles across governance, scientific and methodological rigor and collective intelligence processes. These principles matter because co-creation cannot rely only on good intentions or broad claims of participation. To be credible, it must be planned, conducted, and evaluated through principles that can be upheld in practice.
Reviews of co-creation in health research show the consequences of this problem. There is a wide variation in how co-creation is defined and applied. Without a shared theoretical and methodological basis, co-creation risks becoming increasingly fragmented and difficult to assess.
What does this mean for policymakers?
The lack of clarity surrounding theory use in co-creation has direct implications for policy and practice. Another scoping review finds that the deficit of synthesised evidence on co-creation methods limits the rigor of the research approach and stagnates the development of best practices. When co-creation is reduced to a set of activities – such as consultations, workshops, or stakeholder meetings – it can become a procedural exercise rather than a mechanism for meaningful change.
In such cases, participation may be present, but underlying issues such as power imbalances, institutional constraints, or resource inequalities remain unaddressed. Evidence from implementation research shows that these factors play a role in determining whether co-creation leads to effective and equitable outcomes.
This underscores the need to engage with explicit theory as a way of addressing these limitations. Explicit theory can help define how and why co-creation is expected to work, identifying the mechanisms through which it may lead to impact.
Co-creation approaches informed by meta-theory, such as critical realism, may be best suited to public health co-creation. Through critical realism, co-creation can prioritize focus on the interaction between context, mechanisms, and outcomes, allowing stakeholders to understand not only whether an intervention works, but how it works, for whom, and in which settings. This is particularly important in public health, where emancipatory practice hinges on policy interventions that operate within complex social systems.
For policymakers, the implications are clear. First, funding and program design related to co-creation research should require explicit articulation of the theoretical underpinnings informing co-creation. This includes definitions of co-creation, the related theory, and the rationale (the how and why) for using the theory in co-creation. Without this, it can be difficult to determine whether co-creation is delivering value for money or contributing to policy goals.
Second, research implies that evaluation frameworks ought to be holistic—going beyond measuring participation alone. Indicators such as the number of stakeholders engaged or workshops conducted are easy to capture, but they provide limited insight into impact. Evaluations can, instead, examine how co-creation influences participation, context, experience of co-creators, impact, satisfaction, and fidelity (to name the most assessed process evaluation components for co-creation).
Third, a cumulative evidence base is needed. Future research and practice should operationalize the principles and attributes of evidence-based co-creation to refine and implement co-creation effectively. This requires greater consistency in how co-creation is conceptualized, operationalized, and studied. Best practices should be informed by explicit theories, dimensions, methodological principles, stakeholder engagement considerations (e.g., youth participation), and co-creation role frameworks. Without striving toward best practices, co-creation lessons not only remain limited but also isolated and difficult to scale.
Reframing co-creation as a theory-driven and principle-based approach does not diminish its value. On the contrary, it strengthens its potential to address complex public health challenges. Explicit theory enables co-creation to move from an appealing idea to a robust and reliable methodology.
If co-creation is to fulfil its promise, it must evolve from a broadly defined practice into a clearly articulated, evidence-based approach. Only then can it provide different stakeholders, such as researchers, policymakers, and practitioners, with the tools needed to design interventions that are participatory, effective, scalable, and grounded in a clear understanding of how change happens.
This is part of a special debate on Public Health Innovation by GlobalDev at the Global Development Network (GDN), done in collaboration with the Health AI for All Network (HAINet) and the Social Innovation Hub for Health in LAC (SIHILAC).
