Co-design in healthcare with and for First Nations Peoples of the land now known as Australia: a narrative review.

Increasing use of co-design concepts and buzzwords create risk of generating 'co-design branded' healthcare research and healthcare system design involving insincere, contrived, coercive engagement with First Nations Peoples. There are concerns that inauthenticity in co-design will further perpetuate and ingrain harms inbuilt to colonial systems.Co-design is a tool that inherently must truly reposition power to First Nations Peoples, engendering both respect and ownership. Co-design is a tool for facilitating cultural responsiveness, and therefore a tool for creating healthcare systems that First Nations People may judge as safe to approach and use. True co-design centres First Nations cultures, perspectives of health, and lived experiences, and uses decolonising methodologies in addressing health determinants of dispossession, assimilation, intergenerational trauma, racism, and genocide.Authentic co-design of health services can reduce racism and improve access through its decolonising methods and approaches which are strategically anti-racist. Non-Indigenous people involved in co-design need to be committed to continuously developing cultural responsiveness. Education and reflection must then lead to actions, developing skill sets, and challenging 'norms' of systemic inequity. Non-Indigenous people working and supporting within co-design need to acknowledge their white or non-Indigenous privileges, need ongoing cultural self-awareness and self-reflection, need to minimise implicit bias and stereotypes, and need to know Australian history and recognise the ongoing impacts thereof.This review provides narrative on colonial load, informed consent, language and knowledge sharing, partnering in co-design, and monitoring and evaluation in co-design so readers can better understand where power imbalance, racism, and historical exclusion undermine co-design, and can easily identify skills and ways of working in co-design to rebut systemic racism. If the process of co-design in healthcare across the First Nations of the land now known as Australia is to meaningfully contribute to change from decades of historical and ongoing systemic racism perpetuating power imbalance and resultant health inequities and inequality, co-designed outcomes cannot be a pre-determined result of tokenistic, managed, or coercive consultation. Outcomes must be a true, correct, and beneficial result of a participatory process of First Nations empowered and led co-design and must be judged as such by First Nations Peoples.