How Togo recharted its path to universal health coverage amid COVID-19

Authors: Emily Adams, Kéfilath Bello, Nathan Blanchet, Jean-Paul Dossou, Aboubakar Issa, Lior Miller, Cicely Thomas, and Cheickna Toure

As Togo’s government seeks to improve its national universal health coverage (UHC) roadmap, “co-creation” emerged as a promising approach for multi-sectoral stakeholders to validate systems challenges, discuss root causes, and create effective solutions together, while building trust and buy-in. Co-creation promotes innovation through participatory approaches that bring together diverse stakeholders, contextualized analysis, and shared decision-making and responsibility. But what happens when it is no longer possible to co-create in person? This blog describes how we adapted co-creation, mentoring, coaching, and collaborative learning approaches during COVID-19 to strengthen UHC in Togo.

Co-creation preparation and planning

Togo has a national roadmap to guide them towards equitable, accessible, and high-quality UHC for all, but this framework has yet to be fully implemented. Prior to COVID-19, Togolese UHC leaders and champions at the Ministry of Health and the Directorate of Social Protection conceptualized a 3-day in-person co-creation process to strengthen implementation of the existing UHC roadmap, in collaboration with the Health Systems Strengthening Accelerator (Accelerator), the African Collaborative for Health Financing Solutions (ACS), and regional partner CERRHUD (Centre de Recherche en Reproduction Humaine et en Démographie).

Preparation for the workshops began with an in-person in-depth situational analysis involving one on one discussions, outreach, and scoping visits with key stakeholders to understand the context, unpack challenges and opportunities, and identify the right players to involve in the process led by our local and regional coaches. The situational analysis also included a review of key literature, policies, and documentation on UHC in Togo. It provided framing of the issues and preliminary analysis of the root causes leading into the co-creation workshops and served as a resource for participants.

However, this preparatory work quickly ground to a halt as the COVID-19 pandemic emerged and it became clear that in-person convenings would no longer be feasible. R4D’s Nathan Blanchet wrote about this new challenge and proposed a solution that would “flatten a different curve”: by using technology and spreading the functions of a co-creation workshop over weeks or months instead of days, he imagined that we could still achieve many of the same goals virtually.

Togo Co-Creation in Numbers

Virtual adaptation

The first adaptation was timing – we certainly could not expect participants to spend three full days glued to their computer screens. We decided to break up the workshop into four co-creation sessions lasting 2.5 hours each and spread out over a one-month period. We also held two additional sessions for members of a multi-sectoral task force to finalize the UHC action plan.

Accelerator Co-Creation Approach

We knew that the virtual nature of the workshop would introduce new logistical challenges, so we created a detailed facilitation guide to ensure the sessions ran smoothly. We also did significant pre-work with the participants to efficiently utilize our limited time during the sessions. Our coaches (local consultant and regional partner CERRHUD) worked with directors within the Ministry of Health and Directorate of Social Protection to act as mobilizing champions by encouraging high levels of participation, raising the visibility of the co-creation process, and leading each session. We also reimbursed internet expenses to prevent Wi-Fi costs from being a prohibitive cost for participation.

During the first workshop, we began with a brief technology overview to ensure that everyone was comfortable with Zoom’s features. During the breakout sessions, real-time notetaking on a facilitator’s shared screen took the place of a whiteboard or sticky notes and allowed participants to build upon what had already been shared by their colleagues.

We regularly reinforced the material of each session and how it fit in with the broader co-creation process, reviewing our progress at the beginning of each session. The follow-up, both virtual and over the phone, via our in-country facilitator, helped maintain momentum and excitement, and sustain participation levels. The follow-up also included outreach of higher-level government officials who could help build government commitment.

In the table below, we compare how the ten essential functions of co-creation originally distilled in Blanchet’s blog were achieved in a fully virtual environment.

Key adaptations for shifting effectively from in person to virtual co-creation

    • Spreading the workshop over time
    • In-depth situational analysis beforehand to identify key challenges
    • Innovative and multidisciplinary engagement process with mobilizing champions
    • Use of online collaborative working tools to support collective root cause analysis and brainstorming on possible solutions
    • Refinement of action plan by self-selected Task Force
    • Sharing of identified bottlenecks with higher-level stakeholders
    • Continuous dialogue between actors throughout the entire process, steered by in-country facilitators

Reflections and lessons

Based on the experience from the Accelerator’s co-creation process in Togo, it is indeed possible for virtual co-creation to achieve many of the same goals as an in-person workshop, given appropriate adaptations to the local context. Not only did the process in Togo successfully engage a variety of stakeholders in the creation of a UHC action plan, it also succeeded in beginning the process of getting buy-in from the highest levels of government—including Togo’s new Delegated Minister for UHC, who was appointed in the middle of the co-creation process. One participant expressed that “the main utility of this workshop was in remobilizing the key actors and restarting a process which started a long time ago, but which had broken down.”

In the coming months, it is worth reflecting on what aspects of this virtual co-creation approach we would keep, even after the world returns to “normal.” Should co-creation become a hybrid model? This could allow some participants to be in the room and others spread across the country or even world. Hybrid models could create more opportunities for knowledge exchange; for example, by inviting a government official from another country that had success (or failure) with a similar challenge, stakeholders in the co-creation session could learn from past experiences and existing global knowledge. Similarly, this could provide more opportunities to involve people from remote areas, provided a small investment for their internet access. It is also worth considering if co-creation workshops should take the form of longer, spread out processes that take place over weeks or months rather than days. This longer approach could foster sustained excitement and engagement, provide more time to build trust and lasting linkages between stakeholders, and, ultimately, bolster countries’ endeavors toward UHC.