Szymon Brzósko, Robert Mołdach
CC BY-NC-ND 2.0
Co-creation Failure
Imagine a situation in which a hospital introduces a new model of care for patients with type 2 diabetes. The well-intentioned project team decides to engage patients themselves in the co-creation process. They organize workshops, surveys, and working groups where patients share their experiences, needs, and ideas. Everything seems promising – the new service is designed to be perfectly tailored to their realities.
However, after implementation, the reality turns brutal. Many patients feel overwhelmed by the sheer number of new recommendations and tools. Some forgo follow-up visits because, although their voices were “heard,” in practice they were ignored. The solutions implemented were more responsive to the needs of medical staff than the individuals themselves. Instead of improved quality of life, there is frustration; instead of improved health indicators, there is stagnation. Instead of success, there is failure, costing everyone: patients, the hospital, and the entire system.
This is a phenomenon that researchers call “co-creation dysfunction” – situations in which processes intended to increase public value lead to unintended negative consequences.
Why is this topic so important? Mark Moore’s Public Value Framework
The concept of “dis/value,” or the dysfunction or devaluation of the co-creation of public value, described by Eriksson, Williams, and Hellström in 2023, is gaining traction in the context of public policy management. To understand its deeper implications, it is worth considering the public value framework developed by Mark H. Moore, a pioneer in the field of public management. Moore’s model emphasizes that effective public management is based on a strategic triangle, consisting of three interconnected elements: public value, legitimacy and support, and operational capabilities.
Public value is at the core—it concerns outcomes desired by society, such as improved health, equity, or service efficiency. Legitimacy and support encompass support from key stakeholders, including politicians, citizens, and organizations, which provides the authorizing environment necessary for action. Operational capabilities, on the other hand, are the resources, skills, and processes that enable the actual achievement of goals.
Traditionally, when discussing co-creation, co-design, or co-innovation in public services, we focus solely on the positives. We assume that actively engaging citizens automatically increases public value, leading to more effective services because it takes into account the voices of those affected. Within Moore’s Triangle, co-creation could strengthen all elements: increasing value through better service alignment, building legitimacy through participation, and developing operational capabilities through new ideas. However, research shows that this is not always the case – sometimes the effect is quite the opposite, disrupting the triangle’s balance. Dysfunction can erode legitimacy when citizens feel cheated, weaken public value by reinforcing inequalities, and overwhelm operational capabilities if processes are poorly managed. Understanding this in the context of Moore’s model helps avoid pitfalls and build more sustainable public strategies.
What exactly is “dysfunction”?
Dysfunction/devaluation refers to the unintended negative effects and consequences of co-creating public services. Instead of positive outcomes, these interactions can destroy value or generate outcomes that are more harmful than beneficial. As the authors emphasize, dysfunction is an inevitable consequence of interactions between service providers and their users. This is not a flaw in the system, but rather a natural feature that must be anticipated and managed – especially in light of Moore’s triangle, where an imbalance between value, support, and capacity can lead to systemic failures.
In this context, the distinction between public value and private value, which often conflict during co-creation processes, becomes crucial. Public value, according to Moore’s model, refers to collective benefits desired by society as a whole – such as social justice, equal access to services, or the long-term efficiency of public systems. Private value, on the other hand, focuses on individual or group benefits that benefit specific individuals or entities, such as personal satisfaction, time savings, or financial gain. In co-creation processes, where public actors (e.g., state institutions) collaborate with private actors (citizens, NGOs, and businesses), these two value spheres can be both co-created and co-degraded.
For example, co-creation spaces and civil society can generate private value for selected individuals or groups, while the public sector is tasked with creating public and social value. In complex public service environments, the goals of public and private value often intersect, leading to the destruction of value at the interface between these spheres.
This conflict is part of a broader journey from “I” to “We”—that is, a shift from individual interests (a selfish “I” focused on private values) to collective harmony (a “We” based on public value). Co-creation of public services is theoretically intended to facilitate this transformation, building a bridge between personal needs and the common good through networked relationships in which value is created only through interactions between the parties.
However, the competition between private and public values can hinder this path: the individual “I” strives to maximize their own benefits (e.g., faster medical care for themselves), which can undermine the collective “We” (e.g., equal access for all). As a result, instead of integration, dysfunction emerges – private interests dominate, reinforcing inequalities, or public goals are ignored, leading to frustration and a devaluation of the entire process.
To illustrate this, think of a group of friends planning a vacation together. Everyone has a say, everyone participates in decisions – sounds ideal? Not necessarily. Such a “democratic” process often ends in arguments, compromises that satisfy no one, and vacations that are remembered rather negatively. In this scenario, private value (individual preferences, such as one friend’s choice of a beach for relaxation) competes with the group’s public value (the collective “We,” meaning a harmonious trip for all). If one participant’s “I” – for example, the stubborn pursuit of a luxury hotel – prevails, it can destroy collective joy, leading to the devaluation of the entire adventure. Similarly, in public services, the lack of management of this competition turns co-creation into a source of conflict, where the private benefits of some destroy public value for all.
Three Levels of Value Creation/Destruction
The process of value creation or destruction occurs at three levels, which can be analyzed through the lens of Moore’s strategic triangle, where dysfunction disrupts the balance at the individual, group, and societal levels.
At the individual level, concerning the patient or user, co-creation can bring a sense of self-efficacy, increased knowledge, a sense of belonging, and tangible improvements in health or life situation—thus strengthening public value. But it can also lead to frustration, disappointment, a lack of agency, and even a loss of self-esteem, which undermines the legitimacy of the process. The reasons? Poor communication, unprofessional staff behavior, poorly designed information, or time constraints. Take the example of consultations regarding a new bus line: residents spend evenings at meetings, fill out surveys, and feel they are co-shaping the future of the neighborhood. And then it turns out the route was pre-determined for technical reasons, and their opinions are thrown in the trash.
At the group level, encompassing communities or patient groups, the benefits include improved services tailored to specific needs, a better understanding of the problems of different groups, and more effective interactions between them – which builds operational capacity. However, devaluation occurs when services fail to address these needs, reinforcing existing inequalities and weakening social support. The main risk is the recruitment of people from economically, professionally, or socially advantaged backgrounds, even from minority groups, into co-creation processes – which creates a false impression of representativeness. Imagine a neighborhood council discussing a new preschool: the participants are primarily educated, affluent parents who can afford evening meetings. The voices of parents working shifts, single mothers, and those in financial hardship remain unheard.
Finally, at the societal level, concerning the public interest, positive effects include increased trust, improved system efficiency and innovation, and strengthened participatory democracy – harmonizing the entire Moorean Triangle. But devaluation occurs when broader values, such as justice, equal access, and public accountability, are violated, threatening legitimacy. The main threat is the blurring of public organizations’ responsibilities, which shift responsibilities onto NGOs, families, or associations. An example would be the system of “adopting” parks by residents: it sounds ecological and democratic, but in practice, wealthy districts have beautiful green spaces, while poor ones are neglected because residents lack the time and resources.
Lessons from Reality: Three Case Studies
Lessons from real-world experience emerge from three case studies from the healthcare sector, which researchers analyzed to demonstrate the mechanisms of dysfunction—and how they disrupt Moore’s strategic triangle.
In the first, concerning pulmonary rehabilitation in the UK, patients with lung disease co-created the program, but despite their involvement, many felt worse than before. This was due to poor communication among medical staff, unprofessionally prepared information, and a lack of understanding of how patient feedback was being used—resulting in low attendance, frustration, and poor well-being, weakening public value and operational capacity.
The second case study, concerning cancer prevention among immigrants in Sweden, encouraged research by engaging local leaders in co-design. A positive effect was a 42 percent increase in participation, but recruitment of the most integrated immigrants with better economic and social circumstances was problematic. As a result, the most vulnerable groups remained outside the system, undermining the legitimacy and equity of Moore’s triangle.
The third example is a cancer support center in Sweden, where cancer patients co-created and ran a meeting space. The physical center was established, which was a success, but the challenges were similar: better representation for “better-off” patients, and in Swedish culture, funding public services through private charity raises suspicion. The risk is the blurring of public organizations’ responsibilities, shifting services to friends, family, and associations—which can exclude certain groups and create value for some while destroying it for others in the system, thus disrupting the entire strategic triangle.
An Analogy with Quality Improvement Methodology: “Balancing Measures”
The concept of co-creation “dysfunctions” is reflected in quality improvement methodologies in medicine, particularly in the concept of “balancing measures,” which originate from approaches to quality management in healthcare, such as the IHI (Institute for Healthcare Improvement) model. Balancing measures are tools used in service improvement processes to identify and monitor unintended negative consequences of changes introduced that are intended to improve a specific aspect of the system—for example, reducing wait times for appointments. Their origins lie in Lean and Six Sigma methodologies, which were adopted in healthcare in the 1990s to ensure that improvements in one area (e.g., efficiency) do not result in harm in another (e.g., access to services). Balancing measures are crucial to a holistic approach to change management because they force us to look beyond the primary goals and consider potential collateral costs.
Similarly, the co-creation dysfunction described by Eriksson and colleagues suggests that initiatives such as co-creation, while intended to generate public value, can also have detrimental effects if not managed appropriately. This parallel resonates with Moore’s strategic triangle, where an imbalance between public value, legitimacy, and operational capacity leads to the erosion of system value. For example, introducing a new queuing system may reduce waiting times for appointments (public value), but if it excludes patients who do not use the internet, it undermines legitimacy (lack of social support) and exposes operational capacity limitations (e.g., lack of alternative access channels). Balancing measures in this case could include monitoring the percentage of patients excluded from the system to identify and minimize negative impacts.
Both concepts—dysfunction and balancing measures—encourage a holistic approach to avoid the “tragedy of co-design” and ensure a positive balance of efforts. The common denominator is an awareness of the pitfalls and unintended consequences that can undermine the initiative’s success. Through meaningful monitoring and risk management, Moore’s Triangle can be better balanced, ensuring that co-creation not only generates value but also minimizes its destruction.
What to do? A guide in the context of Moore’s Triangle and the public value chain.
To manage dysfunction in co-creation processes, it’s worth leveraging best practice, integrating it not only with Moore’s strategic triangle—focusing on balancing public value, legitimacy and support, and operational capacity—but also with his concept of the public value chain (PVC). In Moore’s model, this chain describes the process of creating public value as a sequence of steps in which resources (including human and financial) are transformed into actions, and these are transformed into outcomes desired by society. A key role here is played by beneficiaries—direct recipients of services, such as patients or residents, who benefit from improved quality of life; obligates—those who bear costs or obligations, such as taxpayers who finance the system but do not always directly benefit; public spirit—collective engagement and civic enthusiasm that drives participation and builds trust; and supporting enablers or facilitators – partners such as NGOs, experts, or community leaders who facilitate progress by providing resources, knowledge, and motivation.
When considering the public value chain, it is crucial to identify who may be excluded at various stages: beneficiaries from marginalized groups (e.g., immigrants or the poor) may not receive benefits if co-creation processes favor the better-off; bondholders, such as taxpayers from lower social classes, may feel burdened by costs without influence, eroding legitimacy; a lack of public spirit among excluded groups weakens collective commitment, leading to stagnation; and an insufficient role of facilitators can stifle innovation by overloading operational capacity. Integrating these elements helps avoid dysfunction, ensuring that the value chain creates inclusive, not destructive, value.
Using best practice, start with key questions that relate directly to the value chain: who actually benefits from co-creation processes (beneficiaries?), whose voices remain unheard and why (bondholders or groups without public spirit?), where are the boundaries—when the harms outweigh the benefits (e.g., when the costs for bondholders exceed the benefits for beneficiaries), how to better represent the most vulnerable groups (including supporters), and how to eliminate institutional biases (by building public spirit). These questions help maintain legitimacy and balance in the value chain.
Before starting a project, identify risk groups—those who may be excluded from the value chain—e.g., beneficiaries without access to technology or bondholders ignored in consultations. Plan diverse recruitment channels instead of relying on standard channels (including supporters from local communities), and develop “balancing metrics” to measure negative impacts, such as the erosion of public spirit or an imbalance between benefits and costs. This strengthens operational capabilities and ensures the chain is seamlessly built.
During implementation, monitor the process continuously, without waiting until completion, regularly check that all voices are heard (including those of beneficiaries and bondholders), and build early warning systems for dysfunction, for example, through surveys measuring public spirit. Engaging supporters at this stage helps push the envelope, building public value, and preventing disruptions in the chain.
After completion, evaluate the actual outcomes, not just the positive ones – analyzing how the chain impacted beneficiaries (benefits), bondholders (costs), public spirit (engagement), and supporters (efficiency). Learn from the future and share experiences with other organizations. This ensures ongoing support and legitimacy, closing the loop in the public value chain in a sustainable manner.
Don’t Idealize Co-Creation: Realism in Moore’s Framework
Remember: citizen engagement is neither good nor bad in itself; it is a tool that can serve different purposes and deliver different outcomes. In the context of Moore’s strategic triangle, co-creation can be a powerful mechanism for enhancing public value, but only if balanced with legitimacy and operational capacity. Equally important is the perspective of the Public Value Chain, which emphasizes that value is created through a sequence of activities where beneficiaries (recipients of services), bondholders (cost bearers), public spirit (the public spirit driving engagement), and facilitators (partners supporting the process) must work together to avoid dysfunction. Imbalances in this chain—for example, excluding beneficiaries from marginalized groups, disproportionately considering the interests of certain groups in need, ignoring bondholders, or weakening public spirit—can lead to value destruction rather than creation.
This isn’t about abandoning participation, as that would be a disaster for democracy. It’s about doing it wisely, with full awareness of the risks and a willingness to manage them. Instead of blind faith in the power of participation, we need a mature, balanced approach that considers both the benefits and the risks—so that both Moore’s Triangle and the public value chain remain in balance. This means designing co-creation processes that strengthen public spirit, engage diverse beneficiaries and bondholders, and effectively utilize facilitators, ensuring that public value isn’t built at the cost of exclusion or frustration.
This isn’t pessimism, but realism, which can protect us from costly mistakes and truly improve the quality of public services, creating a coherent value chain that serves the entire society.