Abstract

When Jean brought her ten-year-old daughter to the Blended Funding family support program in Seattle, her child had a long history of troubles: attempts at suicide, placements in heavy security residential settings, violent attacks on other students at school, and frequent emotional breakdowns. This was the legacy of her first three years of life in a Romanian orphanage. The orphanage was an inferior alternative to foster care. It was notorious for extreme neglect of babies, toddlers, and children who “failed to thrive” and ultimately died from lack of appropriate care.

Jean, a single mother, adopted her daughter as an orphan to give her a better life. However, after seven years of an outpouring of love and attention, her daughter was apparently no better off than when she arrived. Neurological damage continued to ravage, causing shaking and tremors. Violently, self-destructive episodes were frequent. During her most recent placement prior to being referred to Blended Funding, the psychiatrist told Jean to accept that the level of damage her child had suffered could not be repaired; her child could never lead a normal life.

Remarkably, six years later, that same child celebrated her birthday as a poised adolescent. Since then, her life journey has included graduating from school and college, caring for her mother through terminal illness, and taking on a career as a youth counselor.

On the other side of the American continent, members of a public housing complex in Baltimore turned expectations on their head in an entirely different context when they embraced an eight-hour per month work requirement that, two years earlier, residents angrily repudiated the policy. Over the course of three years, residents used the requirement to generate a whole new sense of community.

These two stories, different as they are, share a common thread: the use of co-production, a framework and set of operating principles for social and welfare services. Co-production is rooted in the idea that people and communities have the knowledge and capacity they need for self-empowerment if they have opportunities to exercise self-determination in an environment of mutual trust, respect, and shared commitment. Needham and Carr [1] found that co-production frameworks promote empowerment by positioning service users as equal partners in the design and delivery. In such cases, service providers and case workers bring their training, skills, and knowledge to act as skilled, culturally competent listeners, and collaborators with clients and communities. They become catalysts in achieving outcomes determined largely by the service users whose lives are being changed.

This article introduces a co-production framework, describes how it was applied by the two programs illustrated above, and briefly considers the challenges faced in implementing the approach in social work agencies and by case workers. Reducing social isolation is an urgent concern in social work and other disciplines. Providing workers an ecological and community-based frameworks are essential tools required by an increasing number of organizations including social work, health, housing, etc. Authorities such as Thomas and Milligan [2] amplify the urgency of social isolation as a public health issue. There is also an urgency to train new workers entering the profession through internships in diverse settings. As the curriculum for practicum education is recalibrated, there could be no better time than now to integrate co-production frameworks in the curriculum of helping professions [3].

Review of the Literature

There is a large volume of research studies on co-production. Bovaird [4], Van Ryzin [4], Goodwin [5], Needham [1], Toffler [6] and Ungar [7] have made significant contributions to the literature. 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. 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. Research demonstrates the impact of co-production; when community members are treated as equal partners, the results are transformative: policies become more effective, services more equitable, and outcomes more lasting [8]. This is a fundamental shift in how we approach collaboration and progress.

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.

Co-production was introduced in the 1970s by Elinor Ostrom, a Nobel laureate in economics sciences. It is a framework for gaining insight regarding the benefits that arise when citizens are engaged in contributing to the essential public services that public systems are mandated and paid to provide [9]. Examples she studied included citizen alert patrols to reduce crime, parent engagement in their children’s education, and resident engagement in the favelas of Rio de Janeiro to map and construct a sewer system. Such contributions by citizens – and the impacts of those contributions – had previously been overlooked and unseen. Ostrom’s early work on the concept opened the door to a flurry of research. But, to her great disappointment, the idea never found its way to the forefront of economic theory and public policy as she had initially hoped. However, co-production research has focused on areas of social work practice [4], Their research offers empirical evidence on engaging citizens as co-producers. Research focused on time banking and reciprocal exchange [10]. Their studies were policy-oriented and linked co-production and time banking. Social isolation and community empowerment were studied by Holt- Lunstad, [11]. She discusses recent evidence on why addressing isolation matters. Research on ecological and systems frameworks [7] promotes the use of ecological systems and resilience language. Research and practical applications continued, but over the following decades, they remained on the margins.

Application of Co-Production Principles

In the 1990s, Edgar Cahn developed a co-production approach to take what Alvin Toffler called the “prosumer” role. It is a combination of producer and consumer into the world of social action, social enterprise, and social justice in order to address critical public problems [6]. Since 2000, co-production has been increasingly adopted by government agencies in Great Britain as an approach for achieving the self-empowerment of individuals and communities. As this occurred, the co-production approach has been adapted for local needs. In this article, we focus on Cahn’s framing of the co-production approach, and especially the core principles which have served a double purpose: as guides to best practices, but also as pointers to the ideals that animated Cahn’s thinking and work as a lawyer dedicated to achieving social justice. His approach is elaborated extensively in his tome, No More Throw-Away People: The Co-Production Imperative [12].

Over the past decades, Cahn has elaborated on these five core operational principles and has created, among other things, a co production “fidelity index” for organizations to rate the degree to which those principles are actively applied. The five principles – assets, redefining work, reciprocity, community, and respect – are used to shape professional responses to social needs and are briefly described below.

Principle 1: An Asset Perspective

The first operational principle is an asset perspective that calls on social workers, case workers, and providers of services to appreciate that people are more than their problems. It says that individuals or groups at the receiving end of services will have the capacity to learn, listen empathically to other clients, contribute, and be a force for defining and achieving the improvements that are being sought. Clients have capacities they may not realize as assets until they get a chance to use them. One of the most valuable “capacities” that clients have is to share their experience and function as lay advocates. It is common for individuals and communities who have been marginalized or disempowered to underrate their competencies and to discount their own agency. Correspondingly, one of the most valuable skills that social workers bring to their role as a catalyst for empowerment is to actively engage in listening to learn where the strengths and sense of purpose of service users are strongest.

Principle 2: Redefining What We Value as Work

Co-production sees the effort made to sustain the resilience of family and community as real and important work, so essential that it deserves the term “the core economy” [5]. The market economy in which we live, however, regularly either ignores that work or discounts it. By understanding that caring for others is critical to our well-being and resilience in the face of life’s challenges, co-production puts that labor back in the center. Recognizing, chronicling, and celebrating the work that sustains the core economies of communities that have been marginalized by poverty or structural racism are essential to lifting up that work to build individual and community resilience [13].

Principle 3: Reciprocity

For social work agencies and non-profit organizations, the act of accepting clients brings with it the opportunity to explore the possibility of that client becoming a contributor as well as a recipient of help. Contributions may be voluntary or mandatory, but in either case, they invariably involve some level of choice. That element of choice opens the door to service users claiming their dignity by stepping forward as contributors as well as receivers of services. Contributions can involve some form of community engagement, outreach to others, acts of caring as simple as making a phone call to say hello or participating in processes that seek to bring about change. However, it is common for service providers to insist that inasmuch as responding to needs, their services must be free of reciprocal contribution as a matter of principle. Unintentionally, this also engenders possibilities of choice, a sense of meaningful action, and opportunities to build supportive connections.

Principle 4: Interdependence and Community Building

Social and welfare services generally treat each client as an individual whose right to confidentiality is paramount. Indeed, the Health Insurance Portability and Accountability Act (HIPAA) rules of privacy demand that. But clients and members of the communities in which they live are the very sources of connection and mutual reliance that people need in their daily lives. Co-production as a framework recognizes that mutual support provided by informal or formal networks provides resilience and staying power for newly adopted habits, relationships, and life paths. Thus, it calls for creating roles and procedures designed to recognize, nurture, and expand relationships of mutual support and interdependence.

Principle 5: Mutual Accountability and Respect

This fifth and final principle is perhaps the most idealistic one. For those working in the field, it can also be the most important for enabling professionals to establish boundaries that support, rather than cripple, effective self-empowerment. Authentic respect requires listening to voices that are otherwise unheard, especially when objective and system-based measures are used and may also involve listening to critiques of services that are unwanted and uncomfortable to hear. Conversely, it may require boundary-setting and potentially uncomfortably “straight talk” by providers needing to preserve the integrity of mutually agreed-to relationships and their rules. In the field, setting out and enforcing clear and unambiguous rules and boundaries grounded in mutual respect is a critical component of building the trust and capacity on which self-empowerment rests.

Together, these five principles form the core elements of co production. How co-production was implemented in two widely disparate contexts will now be described.

Blended Funding and Wraparound Services

Since its inception in the 1980s and through its adoption of wraparound services in the 1990s, the system of care approach to children in the mental health field has undergone a transformation: from the time when professionals were “in charge” to the current “family-driven and youth-guided care” that now exists. Located on the outskirts of Seattle, WA, the Blended Funding program [14] is an example of that evolution and illuminates not only how wraparound services have evolved, but also how the principles of co-production are applied in practice.

The program worked with youths with severe emotional disorders and their families. These children were identified by the child welfare and mental health systems as the “deep-end kids.” They are the ones whose emotional dysfunction made them the most difficult to serve and most often placed in residential homes. Hey also were children with the least beneficial outcomes from regular wraparound services. Given the depth of their challenges, these children and their families were also isolated in their own communities, with few resources to help meet their needs for stability or a sense of belonging.

The aim of Blended Funding was to use wraparound services to build on existing and often severely limited family and community relationships, thereby to generate the sense of belonging that children and their families need [15]. The aim was for the children to experience a rich range of experiences in the community that would help them feel nurtured and connected, to help them acquire social that support pro-social relationships, and to build on capacities and skills that would contribute to their well-being as they grow.

Introducing co-production added an explicitly contribution-centered frame to this wrap-around approach. This in turn altered the design and approach of day-to-day actions and routines for case workers and families. Among the outcomes of this transformation was a marked reduction in need for residential treatment for the youth in the program.

Bob Jones kept the authors of this article regularly informed of the differences that co-production led to as he integrated it more fully into wrap-around services. Two years after our initial meetings with him, we had a chance to visit the program. Our aim was to learn from him and the families what had changed and with what results. After a meeting with the families, we met with other stakeholders including the president of the program. We spent the day exploring the differences that introducing the five core values had made to the model of wrap-around that he had been dedicated to for years, especially in relation to the building of “natural,” organic communities for the children and families that would be sustained when services came to an end. It was an illuminating inquiry and is the basis of the description below.

Adding Co-Production to Wraparound Services

Wraparound in the systems of care approach to children’s mental health marked a giant leap forward in social services practice. In the 1990s, it transformed the provision of services for children with emotional disorders by calling on professional social workers to step back so that clients and their families can step forward to build a rich ecosystem of health-supportive experiences while remaining at home with their family and going to the local school. Using a team and strengths-based approach, wraparound encourages the youth and family to take a lead role in determining the youth’s needs, how to meet those needs, and how well things are going for the youth.

The case worker’s role in guiding the family and youth is critical, as they create a team that will consist of family members, important friends, and key service providers. The case worker convenes the team and the child to review the child’s strengths and needs and to determine what services will best build on strengths to address the needs.

Wraparound, therefore, fundamentally changed the social worker’s roles with three key requirements: The first is to respond in a culturally competent way to the needs of each child and his or her family, gaining their trust and being responsive to their expressed needs. The second is to ensure that community-based and professional services build on strengths instead of homing in on deficits and weaknesses. The third incorporates community-based “natural” supports as a critical element of care.

Bob Jones was a strong proponent of wrap-around services. He was also troubled by a trend that he observed: that “needs” were too quickly translated into “services” provided by systems of care. When this happens, a subtle distinction is lost; a service, however helpful, is not the same thing as a need, and the responses of case workers and team members can be unconsciously shaped by how well or poorly they understand this distinction. The need to learn to read, for example, is different from needing reading lessons. Not seeing the distinction leads to prescriptions for services that fail to meet real needs. This same kind of automatic translation of “need” into “service” can also apply to success criteria. For example, reducing the number of days in treatment by 50 percent would appear to be a good objective measure of success. But it is a mistake to only consider what the system counts as success while overlooking the child and family members’ perspective of what counts as success. Bob Jones observed that these habits of thought, combined with system characteristics such as accounting and the requirement to use funding efficiently and in accordance with specific rules, meant that even though wraparound aimed to provide natural support, an ethos of professionalism all to easily and quickly stepped in to shape the practice of wraparound.

Beds in residential placements provide another example of fiscal and other pressures on the systems of care trumping the needs of a child and family. System needs made it necessary to move young people along; but this leads to instability when youth need structure and stability. This is complicated by the fact that youth who stay in residential placement long term develop an inability to cope outside of “the system.” Frequent movement from one professional system to another – another feature of systems under pressure – increases instability in the child’s life. On the other side of the coin, however, the very attempt to provide residential services, which are outside of a youth’s regular community leads to the “connectivity trap:” Reduced connectivity in community leads to heightened need for professional services, which leads to further reduction of connectivity in the community. Therefore, it takes good judgment to balance legitimate system requirements, such as professionalism, prudent use of resources, and objective measures of impact, with the underlying needs of the child and family and their subjective experience of need, improvement, and success.

From a co-production perspective, these tensions result from an overwhelming treatment centered approach. Social work training provides social workers with skills and levels of professionalism that automatically confer authority. That authority, along with the needs of the system of care itself to operate with professional integrity, can easily lead to a weighting on the sides of professional assessments of what will be most appropriate. Moreover, the natural supports that were intended to overcome the deficiencies of professional care can easily become transformed into imitations of it. For example, reading lessons supplanting a more organic explanation and response for why a child is not reading.

Bob Jones saw that co-production as shaped around the five core values could turn the wraparound approach from a treatment centered modality to a contribution centered one. Co-production looks to the contributions that clients and the members of their natural support systems can offer, both to one another and to the community they need to build for themselves, on grounds that through their contributions the clients:

• Experience themselves as assets with skills, capacities and talents that others value.

• Are provided with both psychological and other rewards for doing the real work needed to build the family and community of which they are a part.

• Become the creators as well as the beneficiaries of natural support systems that help assure new levels of resiliency.

• Come to define themselves as meaningful providers as well as receivers of services.

Thus, the co-production approach added a new, extended role for the youth and families and for their natural communities. This role stands as a critical countervailing force to the tendency of professionals, case workers, and the system of care to shape or even dominate the more organic, homegrown capacities, skills, and thinking of client populations.

This reframing would give Blended Funding the chance to truly fulfill its original intent of building organic, supportive, committed relationships towards self-empowerment. Taking action to respond to each other’s needs, fears, and challenges with mutual contributions of support, the children and families could connect with one another as a first step. That first step in turn would engender possibilities for change, the ongoing opportunity to experience the outcomes for choices made and action taken, and the message of self-validation that gaining such knowledge brings. Nourishing and nurturing the natural, peer-based support would help build a sustained stable environment for the families and their children that would outlast the period of treatment.

A comparison between the roles that case workers and the families played in the treatment-centered approach and the contribution centered-approach to self-empowerment will be helpful for identifying the differences in roles that social workers and the children and families came to play. That comparison will start with the wraparound approach.

Wraparound

The wraparound approach directs case workers to seek the “least restrictive placement,” which means that residential placement is to be avoided unless necessary. Following this directive, case workers help family team members identify the youth’s strengths and needs. Taking guidance from the team, they then propose services that will be folded into the youth’s daily life and experience, such as mentoring, music lessons, literacy lessons, riding lessons for building trust, and so forth.

Case workers are trained to be alert to the youth and families expressed needs and goals. But they also stand in two separate and quite different worlds at the same time: the realities of the family and its informal relationships are one world; the other is the formal, professionalized system that employs them and rewards and sanctions them through lines of authority, fiscal requirements, professional networks that must be maintained, and so forth. As the bridge between these two worlds, the case worker has responsibility for helping the family team make good choices in defining which services will be most appropriate but must also bear professional responsibility for recommending and vetting the service providers that the youth and family can call on for services. Finally, it is the system that authoritatively defines success using, as much as possible, evidence-based “objective” measures rather than the subjective experiences of the youth and family.

But that is not the whole story. While the caseworker’s role is both prominent and powerful, the families have their own source of authority. Over time, the wraparound approach has increasingly sought to achieve self-determination as a goal for children with mental health issues and their families [16]. They have the role of consumers, purchasers, and advocates for their own cause and others. They can lodge complaints against the caseworker. They have the power to hire fire providers, though those actions must be passed through the case worker. The family can request an advocate if they need it. An essential part of wrap-around programs is a support group for the families in the program which is generally headed by a family or community member paid by the program. It holds social meetings, as well as trainings and social events where families meet, get to know one another, share information and experiences, and may form friendships and provide mutual support that will continue when they leave the program.

Regular wraparound services are ended when the professionals determine that the youth and family together will have gained skills needed for the youth to live a stable life in community. These include forming supportive intimate relationships, choosing and achieving goals in life, dealing with interpersonal conflict, expressing and managing anger appropriately, maintaining boundaries, and building trust by fulfilling commitments. With these new skills on hand, the youth will be able to live a more stable, happier life in the community. Yet wraparound’s emphasis on services could all too easily leave the youth and their families almost as isolated as at the beginning – this was particularly true of the really “deep end” young people and their families. Such social isolation in turn has harmful physical and mental health impacts and leads to the risk of falling back into the patterns that led to treatment.

Co-Production

As the director of Blended Funding, Bob Jones confronted these tensions inherent in the treatment-centered approach of wraparound that then existed by turning to a contribution-centered approach. He conferred extensively with the Family Support Group and applied the five core values as an underlying framework to reshape the allocation of roles and responsibilities in the program. Thus, when a new youth and family was referred to the program, it was not a case worker who first greeted them into the program, but a family member from the Family Support Group. That family member would have been trained in providing an initial program orientation – an orientation that the families themselves had played a major role in shaping.

In that orientation, the family trainers informed new families of the wrap-around process, modeled the roles played by other families as natural supports, answered questions about their experience as clients, conveyed their own trust in the wraparound process, and explained the roles of the case worker and service providers who would shortly step in to help form the team for the new youth and family.

The Family Support Group played strong roles in other ways. Members were invited to train as peer “partners” for new families. Bringing to bear their experience of the program and services, they offered a peer-based perspective of inside information. Moreover, since the case workers worked regular weekday hours (unless a crisis required their attention) the partner also provided support that was both paid and unpaid. For example, they may be asked to bring their additional knowledge and experience to the family’s team meetings, or to act as an advocate when a family found itself having difficulty with a service provider.

This was co-production occurring at the level of the individual family. Beyond the individual family, the Parent Support Group also acted at the collective and systems levels. It held social events that brought the families together, collected the members’ assessments of service providers, acted as a family-based early warning system of systemic failures and possible abuse, and created a list of “preferred” providers where family expressed high levels of satisfaction. By identifying and supporting client preferred providers, the group created an ever-strengthening pool of providers.

The group was also called on by management for advice and consent to shape and operationalize the program’s overall policies and administration in ways that assured the families a voice with real authority. All these things together meant that the Family Support Group also played a significant role in building an action-based connectivity that the regular wraparound model at that time did not. Family members became spokespersons and a constituency for the program and viewed themselves as healers for each other and as front-line co-producers of the program’s outcomes. Their strong engagement through the Family Support Group provided them with roles that validated them, and built powerful connections built on shared purpose and fulfilled commitments. Their roles as constituents, consumers, trainers, partners, advocates; their voice in the running of the program; and their organizing role for their social gatherings all helped the families form a strong sense of community that, at its base, grew from shared experience of the wraparound program.

With co-production principles brought more fully into the Blended Funding project, peer connections and the chance to learn through action became key aims of the program. What Bob Jones saw as the main difference arising from incorporating this new dimension to wraparound was that when services ended, families who had leaned on each other and joined with each other to exercise their voice did not dissolve the bonds they had formed; rather, strong family connections continued, forming an ongoing extended family and community that continued to provide the mutual support that was lacking when entering the program. Results showed that these once deep-end youth – youth who in the past had repeatedly returned to residential treatment – were now significantly more likely to continue living with their families in the community, thereby saving money to the state, and leading to better outcomes for the youth and the families.

It is in this context that the story of Jean and her adoptive daughter unfolded in this chapter’s introduction. Not all families had such remarkable outcomes. Bob Jones recalls that Jean had a formidable strength of will and as a professional in business was able to hold her ground. Determined that her daughter would one day be well, she exercised the authority that the Blended Funding program gave her to the fullest, for example using the budget that had been earmarked for her daughter to get her into a private school with small class sizes and insisting on that choice even when public officials questioned whether that was a legitimate use of the funds. But that was the purpose of the program – to give the families their voice and strength.

State budget cuts, however, led to a disbanding of the program. The parents joined in lobbying for the continuation of the program, asking the State to find funding from somewhere else, but their efforts failed to bear fruit. During the time that it ran, the Blended Funding program sharply reduced the rate of residential treatment, and for that reason routinely came in under budget. Fiscal issues shut it down in any case. No study was ever done to see what the long term impacts had been, so the evidence that the program greatly improved outcomes remains anecdotal. However, there has been evolution of wraparound services towards an ever- greater focus on self-empowerment with ever more central roles for the children and their families. They have come to stand at the process of defining needs, shaping services, and determining how systems should best respond. As part of that transition, the Blended Funding program highlights how the core values of co-production establish strong, functional overarching guidelines for creating a responsive interface between a formal system of care and the informal, organic systems arising from peer to-peer mutual support.

The next example, public housing in Baltimore, is less detailed, but demonstrates that the same principles can be applied in any social services situation to establish a culture an ecosystem, in effect in which self-empowerment can flourish with the support of a formal system of services.

Pleasant View Gardens

Located in East Baltimore, Pleasant View Gardens is a Hope VI development of two-story housing units that are home to both public housing residents and homeowners. In 2000, the development replaced two former tower blocks of public housing which residents described as being plagued by gang violence. The new development was designed as a complete neighborhood within the city, with rental and owned housing indistinguishable. It includes a large and well- appointed community center which also houses Baltimore Housing Authority personnel who manage the public housing units.

Mobilizing the residents as co-producers of a new sense of community had not been part of the original rebuilding plan, but when a court order required that the development must provide housing for all, and not just some, of the displaced tenants of the razed public housing project, it was suddenly imperative to find a way to prevent the new development from repeating the history of its high-rise predecessors. Faced with this challenge, the Housing Authority did something new: it sought to enlist the tenants as agents of change by setting up a residents’ timebank as a complement to a new federal regulatory requirement for public housing residents to contribute eight hours of community service each month as part of their rent. A timebank uses a medium of exchange, based on time, to encourage the give and take of mutual support between members. Members’ helping actions earn one-time credit for every hour given, regardless of the service performed. The aim of the timebank was to redefine the role of the public housing tenants as active co-producers and partners in community building [5].

The first big test was to find out how this would be received by the residents. Two years earlier, the Housing Authority’s attempt to impose a community service requirement on all public housing residents led to an outcry. Protests from residents and advocates forced the Housing Authority to back off from the policy; it did not want a repeat. Timebanking, therefore, was introduced as a way to turn that new requirement into an opportunity rather than a burden. When timebanking was explained to them, residents understood that this could work for them. What they did for each other not only helped build community; it gave them purchasing power to get discounts, services, merchandise, and help they could not otherwise have obtained.

The timebank became operational when funding was secured to appoint a resident coordinator. The coordinator’s role included helping residents learn of opportunities to give and receive, organizing events through the timebank, putting together a regular newsletter, and reaching out to local organizations and businesses to make agreements to accept time credits earned in the program for their goods or services. One of the organizations that became involved was the local Mass Transit Administration, which (for one day only) allowed tenants to buy a monthly bus pass worth $50 using time credits. Other examples were:

• Entry for children to the Boys and Girls Club on proof of having earned time credits.

• Discounts at Baltimore's Old Town Mall, for items that include clothing, shoes, books, coats, and hair accessories.

• The SHARE food program – on condition that the Timebank program would send volunteers to help pack food in boxes and distribute it.

Many of the residents earned more than the eight-time credits stipulated in their leases. They volunteered at the local elementary school, took part in security patrols, and shopped for seniors among other ongoing neighbor-to-neighbor services for each other. It became a new way for residents to become agents of change in their living space, their village, their habitat.

With the Blended Funding, this self-empowerment approach, powered by the core values of co-production, became victim to funding cuts. When funding from the Annie E. Casey Foundation came to an end, the Housing Authority decided not to fund the timebank coordinator position. Community members were distressed enough by this decision to mobilize a confrontation with the Baltimore Housing Authority offices to protest the loss, but this, their last act of contribution to the timebank and the community, failed to secure the funding needed. The timebank, and all the community action that it had directly fostered, ended. In both cases, however, the co- production approach with its emphasis on contribution has prefigured a more general move to self-expression and self-empowerment of those who receive health and welfare services.

Conclusion

Community participation and leadership is a central tenet across disciplines. South and Phillips [17] discussed in their research some of the policy and practice implications of community engagement in public health. They stimulated debate on the evaluation of community engagement and augured what is needed is a paradigm shift from viewing the involvement of communities as an errant form of public health action, to seeing communities as an essential part of the public health system. This means moving from evaluation being exclusively focused on the linear causal chain between the intervention and the target population, to seeking to build understanding of whether and how the lay contribution has impacted on the social determinants of health, including the system through which the intervention is delivered. The implications have a connection to other professions such as social work.

Using the principles of co-production, the two programs described above achieved levels of empowerment, experiential change, and beneficial outcomes that were unprecedented and profound. They are testaments to what can be achieved when people receiving services are given the opportunity to take meaningful action towards outcomes they, supported by staff, determine in response to needs they have the power to define.

The use of co-production as a framework is expanding in Great Britain and Europe. It is hoped that it will become more widely applied in the United States, and with it, the potential for the growth and empowerment of individuals and communities that struggle against the lack of agency that so often follows their experiences of loss and unmet needs.

Competing Interest:

The authors declare that they have no competing interests.

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