Implementation of the community health system innovatiON project in low- and middle-income countries 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 policy, health system and community levels using tracer chronic conditions that included non-communicable diseases (NCDs) (diabetes and hypertension), and a 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. Meetings with different stakeholders were carried out between 2017 and 2018 to propose context- relevant interventions oriented to address the challenges of providing care for people affected by NCDs and NTDs. During the meetings, participants provided feedback regarding problems and potential solutions for chronic care and health services in general and proposed possible areas of intervention. Upon completion of all the meetings, each country identified the main components to be included in their interventions that were focussed on communities, health workers and facilities. The suggested intervention components in Mozambique include: (i) radio and pamphlets to inform population about hypertension, (ii) development of facility based guideline/algorithm, training in hypertension and clear communication, and group discussions on challenges and opportunities to manage chronic diseases, and (iii) establishment of a medical appointment system for people with chronic diseases.
Taking the work forward, this proposed project 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), 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). The COHESION - I project had two objectives: (i) The implementation and evaluation of the context specific co-created interventions in three countries – Mozambique, Nepal and Peru (Component 1). (ii) Explore the possibilities to translate the experience and the lessons learnt to other countries (India) for adaptation of the project in a different context (Component 2)

Component 1
We propose to work in six communities in Mozambique, Nepal and Peru. Two communities (A&B) where we worked between 20017 - 2019 as part of the formative work 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 a co-designed only intervention of the same duration, the idea being evaluate if interventions that were co-created in other communities will work in new communities with similar characteristics. 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 primary healthcare 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.

Component 2
In India, we will follow the approach taken in 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 non-communicable diseases and neglected tropical diseases. The co-created interventions will be pilot tested in the field for feasibility, acceptability, and preliminary effectiveness. If the COHESION approach proved to be locally adaptable in India, a protocol for the COHESION methodology will be developed that can be adapted to different settings.