Co-Designing Improved Diabetes Care in Mendoza, Argentina

This case study describes the co-design process to strengthen diabetes care in the Primary Healthcare (PHC) system of Mendoza, Argentina. Type 2 diabetes (T2D) affects nearly 10% of the population in Argentina and contributes significantly to morbidity and mortality. Despite widespread access to healthcare, many patients struggle with poor disease control, leading to preventable complications. While wealthier individuals often seek private care, great disparities in access persist based on income, education, rurality, and ethnicity. Effective management of T2D relies on continuous monitoring and strong patient-provider interactions. 

This case study documents a co-design process involving patients, medical staff and policy-makers to strengthen diabetes care in Mendoza. We believe that detailing the strategies used to engage key stakeholders and helping them deal with their challenges will provide a practical framework for similar initiatives elsewhere, particularly in resource-constrained settings.

In 2009, the National Strategy for the Prevention and Control of Non-Communicable Diseases (NDC) was created to reduce risk factors and enhance care quality and access. However, Mendoza faces challenges in treating NCDs such as T2D at the PHC level,  including long waiting times, scheduling problems, and a lack of trust in some providers. Additionally, PHC providers often lack confidence in diagnosing and treating NCDs and have insufficient medication and diagnostic tests. Consequently, hospitals still treat patients with NCDs that, if better organised, PHC could manage.

In 2022, Mendoza’s Ministry of Health collaborated with the the Quality Evidence for Health System Transformation (QuEST) Network to develop and evaluate an intervention aimed at improving diabetes care at the primary level. The QuEST Network (https://www.questnetwork.org) is a global partnership of researchers, national governments, organizations, and development partners, dedicated to building the evidence to support transformation of health systems worldwide. This project sought to help Mendoza to develop appropriate strategies for treating NCDs such as T2D at the PHC level. 

Subsequently, we refined the co-designed outputs through collaborative research meetings, resulting in a set of themes that informed the final intervention package which was proposed in the project. 

This project is expected to result in multiple outcomes at different levels of the health system. Primarily, the intervention strategies aim to improve the management of Type 2 diabetes by enhancing the quality of care and achieving better clinical outcomes and patient experience in primary healthcare settings. The six co-designed strategies currently being piloted, such as the digitalisation of records, telemedicine integration, protected time slots for chronic care, and community-based physical activity programmes, are tailored to local needs and will be evaluated through a cluster-randomised trial in 12 of the 18 counties in Mendoza. If successful, the intervention could be scaled up across all primary care centres in the province and potentially extended to other chronic conditions. 

Additionally, the project promotes community participation, as seen in the emerging collaboration and social activity mapping under the social prescription strategy. This reflects one of the key objectives: building sustainable community engagement. Importantly, the use of a structured co-design process, novel in this context, demonstrated the feasibility and value of participatory methods in shaping policy-relevant, context-sensitive solutions. 

Success indicators of this initiative can be observed across several domains, including policy influence, system-level adoption, and changes in practice and community engagement. Most notably, the Delphi consensus process conducted prior to the co-design phase directly informed the drafting of a provincial law aimed at improving the healthcare system in Mendoza, an example of policy change catalysed by the project. Morevoer, the six co-designed intervention strategies are currently being piloted in selected centres and, if judged to be successful, are set to be scaled through a cluster-randomised trial involving 12 of the province’s 18 counties, with the prospect of province-wide adoption. 

Further expected outcomes include improved clinical management of diabetes, enhanced quality of care, better user and provider experience, and strengthened community engagement, particularly through strategies such as social prescription and mapping of community assets.

The participatory nature of the project itself is also an innovation in the local context. The use of co-design as a methodology has influenced attitudes and behaviours among health professionals, patients, and policymakers, enhancing ownership of changes and strengthening legitimacy of the strategies developed. 

Participating patients received a USD40 supermarket gift card and reimbursement of their transport costs to acknowledge their contributions. Transport costs were also covered for healthcare professionals and decision-makers. Professionals were issued with participation certificates, if requested.

Each co-design workshop required a budget of approximately USD 3,250, including about USD 400 for researchers’ airfares and USD 400 for their accommodation. Materials and printing costs accounted for an additional USD 150, along with USD 400 for professional facilitators’ fees. Transportation costs for patients, healthcare professionals, and decision-makers amounted to approximately USD 1,000;  patients’ supermarket gift cards cost USD 500 and catering cost USD 400. In addition to these financial resources, each workshop required around 30 hours of staff time for planning, facilitation, coordination, and follow-up activities. These investments reflect the project’s commitment to fostering inclusive and equitable participation in the co-design process.

Our initial review identified four main reasons for adopting co-production approaches in healthcare: bringing people together, valuing all knowledge, producing more relevant research, and improving health outcomes. However, there is still only limited evidence that co-production directly improved health outcomes due to a lack of robust intervention evaluations. Nevertheless, co-production appears to play a crucial role in mobilizing knowledge for health condition management. 

This case study shows the potential of the co-design method to develop person-centred interventions in primary care. Actively involving diverse stakeholders facilitated the identification of context-specific opportunities and shaped implementation strategies that could address gaps in service delivery. 

Several key lessons emerged from the co-design process. First, engaging stakeholders unfamiliar with this approach posed challenges. Some participants, particularly patients, did not initially expect an interactive, collaborative process in which their voices carried equal weight and this affected their participation, showing the need for clearer facilitation strategies.  Second, structural and systemic barriers remained a concern throughout the process and could undermine the feasibility of any co-designed intervention. Another challenge was the dominance of certain voices, despite facilitation efforts to promote balanced participation. However, the iterative planning of workshop sessions ensured that all participants felt prepared and safe to share their perspectives and allowed the research team to refine strategies. Flexibility and inclusivity were very important throughout. Finally, the use of creative exercises, such as role-playing and the superhero activity, although initially met with scepticism, significantly enhanced engagement and encouraged participants to think beyond conventional problem-solving approaches. 

Finally, several methodological limitations should be acknowledged. The recruitment of patients through healthcare professionals may have introduced selection bias, favouring individuals with more frequent engagement or positive relationships with the health system. Additionally, participating patients were already connected to the PHC system, potentially excluding the perspectives of more marginalised or disengaged individuals. To mitigate this, we also incorporated findings from the People’s Voice Survey, a province-wide telephone survey exploring how users and non-users relate to the health system. During the future pilot we will undertake community engagement efforts to ensure that disadvantaged populations are reached. Finally, patients did not participate in the final refinement sessions, which focused on operational planning with healthcare professionals and decision-makers; although appropriate for this stage, it may have excluded valuable user perspectives on feasibility and acceptability.