“Part of the overall framework of doing ‘the work’ is really honoring co-production and moving from tokenized youth voice into more of a true co-creation process.”

– Santa Cruz County Behavioral Health Professional and TCP Participant

Introduction

The intention of this blog is to share learning and insights from the Transformational Change Partnership, which develops the capacity of public-serving agencies to advance system-level changes that improve outcomes and reduce disparities. Backed by interdisciplinary research, the blog is based on learnings from the TCP and presents practical actions that practitioners and policymakers can use to diagnose, reimagine and improve public systems. 

As we increasingly recognize the complexity of diversity — not only in ethnicity but also in the entirety of identities that shape our communities and their needs — there is a growing urgency to create truly inclusive approaches.  This vision lies at the heart of “co-production,” a transformative approach redefining the creation, implementation, and evaluation of services and policies. More than just consultation, co-production invites community members to the table as equal stakeholders, leveraging their lived experiences to drive meaningful change.1,2 While healthcare often takes center stage in these conversations, the principles of co-production extend far beyond, influencing sectors such as education, research, housing regeneration, and public policy.3 4 5

Co-production is not an abstract ideal; it is becoming a cornerstone of modern governance and public service. Across the United States, federal and state agencies are embedding co-production into their frameworks, recognizing that true progress occurs when community members are active partners rather than passive recipients. The Transformational Change Partnership (TCP) provides an actionable model for achieving this shift, supporting counties as they build sustainable and inclusive systems of care.

One powerful example is California’s Sacramento County Children’s Coalition exemplifies this shift. Appointed by the Board of Supervisors, this advisory body evaluates community needs, assesses services, and provides policy recommendations to promote the health and well-being of children, youth, and families.6  Around the Coalition’s table sit voices from every corner of the community: a retired nurse who cared for generations of children, a former pediatrician with deep knowledge of health equity, a retired educator who understands academic barriers, a youth advocate passionate about behavioral health, and more. Together, they form a tapestry of lived experiences, ensuring county decisions regarding youth and families are shaped by diverse community perspectives. One large project that emerged from the Coalition was the creation of the 2022 Children’s Report Card, a 122-page comprehensive review of the challenges that Sacramento County youth and families face to inform policymakers, the majority of which was written by community members. Co-production in action provides a direct pathway to reduce disparities that have excluded far too many individuals from accessing services originally designed to serve them. 

At its core, co-production goes beyond improvement of services — it’s about creating trust, fostering mutual respect, and ensuring that systems are not only sustainable but responsive to real community needs.7 8 9 When community members are treated as equal partners, the results are transformative: policies become more effective, services more equitable, and outcomes more lasting.10 This is a fundamental shift in how we approach collaboration and progress. TCP enables and amplifies such efforts by providing county agencies with the training, frameworks, and partnerships necessary to implement systemic change in collaboration with the very communities they serve.

Key Learning: “When community members are treated as equal partners, the results are transformative: policies become more effective, services more equitable, and outcomes more lasting.” 

Co-Production: The Peak of the Ladder of Co-Production 

The Ladder of Co-Production, conceptualized by Sherry Arnstein and later modified by the National Co-Production Advisory Group, illustrates the progression of citizen involvement in decision-making processes (Figure 1).11 At its apex lies co-production, representing the highest form of partnership where power and responsibility are equitably shared between professionals and community members.12 13 True co-production integrates lived experiences, perspectives, and realities of marginalized groups — voices often overlooked by decision-makers shaping programs, services, and strategies. This approach is not simply about inclusion; it’s about equitable partnership, ensuring those most affected by the inequities and those with the closest touch points to community realities are actively involved and trusted leaders.  

In contrast, the lower rungs — such as informing and consultation — often involve superficial one-way communication or tokenistic involvement, lacking genuine influence over outcomes.14 By striving for co-production, organizations can ensure that services are not only designed for the community but led by the community. TCP helps organizations move beyond surface-level engagement toward deep, structural inclusion, successfully seen in Placer and Yolo Counties.

Figure 1. Ladder of Co-Production.

Figure 1. Source: Ladder of co-production – TLAP. January 13, 2021. Accessed January 2, 2025. https://thinklocalactpersonal.org.uk/resources/ladder-of-co-production/.

Why it Matters – From the Perspective of a Co-Production Consultant 

“I came to understand a critical factor contributing to these barriers: the lack of representation among those designing the very programs, services, and systems meant to support us.” 

As a Black man, I have often felt the weight of massive, invisible barriers to accessing resources and opportunities that should inherently be available to me and others who look like me. From school support services, such as counselors who could guide me toward achieving my educational goals, to safe spaces for discussing challenges with therapists or counselors, my experience has been one of limited access. While these services might seem readily available to many, my reality — and that of many others in my community — was starkly different. 

As I transitioned into community organizing in my adult life, I came to understand a critical factor contributing to these barriers: the lack of representation among those designing the very programs, services, and systems meant to support us. When decision-makers lack lived experience or an understanding of the socio-economic realities faced by Black and Brown communities, the resulting solutions often miss the mark. Moreover, the absence of diversity extends beyond race and ethnicity to include gender, sexual orientation, class, disability, and other intersecting identities. 

These missing perspectives in social services, health care, mental health, education, and other county systems exacerbate disparities. Even well-intentioned efforts to address these issues often fail to go beyond surface-level solutions. Entrenched employees, skilled in maintaining system functionality, can struggle to envision alternative approaches due to the rigid, bureaucratic processes they operate within. Furthermore, the voices of those most impacted by barriers are either excluded or tokenized, preventing the fundamental rethinking required to address systemic inequities effectively. 

Co-production offers a powerful solution that must go beyond superficial gestures like surveys or one-off consultations. The lived experiences and expertise of those directly impacted must drive the development of solutions. It must encompass not only values but skills that promote inclusive participation, shared power and responsibility, transparency, capacity building and building on assets, health and reconciliation, compensation of lived experience, and evaluation and accountability. By collaborating with individuals who intimately understand the barriers they face, county systems can create more efficient and effective processes that meet the real needs of diverse communities.  

Having trained co-production to counties and organizations for many years, including with the Transformational Change Partnership (TCP), the most common challenges I see are: 

Challenges in County Systems 

  • Lack of Representation: Insufficient diversity in staff and leadership roles. 
  • Exclusion of Marginalized Voices: Processes often fail to meaningfully include the perspectives of marginalized communities. 
  • Procedural Focus: A tendency to address problems as procedural rather than people-centered, such as focusing on fee schedules or assessments rather than geographic access to services. 
  • Cultural Competence Deficits: Staff may lack cultural competence, relevance, and humility when serving diverse clients. 
  • Client Partnership Overlooked: Failure to recognize clients as essential partners in program and service design. 
  • Siloed Operations: Departmental silos create service bottlenecks that disproportionately affect clients. 
  • Inadequate Data Collection: Limited focus on collecting data about the experiences of underrepresented clients with the greatest needs. 
  • Absence of Advisory Bodies: A lack of diverse client stakeholder advisory groups to guide and evaluate services and processes. 

TCP works directly with county leaders to address these barriers, providing tailored support to dismantle outdated structures and replace them with participatory models.

Implications for Practice: Turning Principles into Action  

Co-production requires ongoing commitment, reflection, and adaptation. Below are practical steps organizations can take to embed co-production into their systems: 

  • Build Relationships, Not Transactions: Invest time in building genuine, trust-based relationships. 
  • Start with Intentional Conversations: Establish a dedicated community advisory group to review and guide strategies, programs, and service; create a space where community members feel safe sharing their perspectives. 
  • Deep Engagement: Develop processes that deeply engage client stakeholders to identify barriers and co-create solutions. 
  • Cross-Departmental Training: Conduct cross-departmental trainings with community stakeholders on cultural competence, humility, relevance, and sensitivity, fostering shared understanding and equitable practices. 
  • Commit to Transparency: Enhance transparency and communication about program development, implementation, and evaluation to improve accessibility and understanding for clients and families. Be clear about the purpose of community involvement and how contributions will influence outcomes. 
  • Empower Frontline Staff: Address internal power dynamics by empowering frontline staff to influence changes in processes and services, supported by management and leadership. 
  • Capacity Building: Partner with third-party trainers to build the capacity of community stakeholders, equipping them to collaborate effectively with county staff and leadership. 
  • Measure What Matters: Implement robust data tracking systems to capture and regularly evaluate the experiences of underrepresented clients, using this information to drive continuous quality improvement in services and co-production. 

A Collective Responsibility 

Co-production is a cultural shift in how we approach collaboration and governance. It calls for humility, patience, and a willingness to share power. And the rewards are undeniable: stronger policies, healthier communities, and systems that are truly reflective of the people they serve. Through initiatives like the Transformational Change Partnership, we are witnessing the tangible benefits of integrating community voices into system-level decision-making. The journey isn’t easy, but it’s one worth taking — together. 

Additional Resources

Slay, J. & Robinson, B. (2011) In this together: building knowledge of co-production, New Economics Foundation, London.  

Slay, J. & Stephens, L. (2013) Co-production in mental health: A Literature Review, New Economics Foundation, London. 

McClinton et al. (2024) Co-Production Competencies, California Institute of Behavioral Health Solutions & Sacramento County. 

Authors

Sidra Ahmad
Ryan McClinton 

Sidra Ahmad, MS 

Behavioral Health Associate in Strategic and Equity Initiatives

California Institute of Behavioral Health Solutions 

Ryan McClinton 

Diversity and Equity Consultant

Clayborn Consulting  

References 

  1. Slay J, Lucie Stephens. Co-production in mental health: A Literature Review 4 (2013): 1-36. New Economics Foundation. 2013;4:1-36. ↩︎
  2. Redman S, Greenhalgh T, Adedokun L, et al. Co-production of knowledge: the future. BMJ. 2021;372:n434. doi:10.1136/bmj.n434 ↩︎
  3. Gordon S, O’Brien AJ. Co-production: Power, problems and possibilities. International Journal of Mental Health Nursing. 2018;27(4):1201-1203. doi:10.1111/inm.12504 ↩︎
  4. Laura Michelle Makey CLW. Co-production: what it is and how it can ensure inclusive practice for service users and staff. Accessed January 2, 2025. https://journals.rcni.com/nursing-management/evidence-and-practice/coproduction-what-it-is-and-how-it-can-ensure-inclusive-practice-for-service-users-and-staff-nm.2022.e2046/abs ↩︎
  5. Julia Slay, Ben Robinson. In this together: building knowledge of co-production. New Economics Foundation. Published online July 2011. ↩︎
  6. SACRAMENTO COUNTY CHILDREN’S COALITION. Accessed January 2, 2025. https://dcfas.saccounty.net:443/Admin/childrenscoalition/pages/childrenscoalition_home.aspx ↩︎
  7. Ladder of co-production – TLAP. January 13, 2021. Accessed January 2, 2025. https://thinklocalactpersonal.org.uk/resources/ladder-of-co-production/ ↩︎
  8. The Ladder of Co-Production. Business Lab. January 31, 2020. Accessed January 2, 2025. https://www.businesslab.co.nz/tools/the-ladder-of-co-production ↩︎
  9. The Importance of Co-Production in Health and Social Care. February 15, 2024. Accessed January 2, 2025. https://catalystgrp.co.uk/blog/the-importance-of-co-production-in-health-and-social-care/ ↩︎
  10. Co-Production In Health & Social Care – Why Is It Important. Accessed January 2, 2025. https://www.theaccessgroup.com/en-gb/blog/hsc-co-production-in-health-and-social-care-why-it-is-important/ ↩︎
  11. Susan Conquer, Luke Bacon, Will Thomas, Sophie Walters, Helen Langton, Naomi Harflett. The value of co-production within health and social care: a literature review. Healthwatch Suffolk. Published online September 2021. ↩︎
  12. Beth Nightingale, Catherine Leyshon, Michael Leyshon, Timothy Walker. Co-Production in Service Delivery: Opportunities and Barriers, A literature review. Published online 2016. ↩︎
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  14. Tangcharoensathien V, Sirilak S, Sritara P, et al. Co-production of evidence for policies in Thailand: from concept to action. BMJ. 2021;372:m4669. doi:10.1136/bmj.m4669 ↩︎