A realist perspective on the use of research evidence in health policymaking

The achievement of “evidence-informed” policy is an aspiration espoused by policymakers, academics and citizens alike, but governments have faced considerable challenges in pursuit of this ideal. The methodological orientation known as scientific realism, in which outcome patterns in the social world are understood as manifestations of the operation of social mechanisms in specific conducive contexts, is increasingly popular in the social sciences, including within public health and social policy. Yet, little research to date has examined evidence-informed health policymaking through a realist lens. This thesis addresses this gap. The purpose of this thesis is to explore the usefulness and explanatory value of realist approaches for the study of the use of evidence by health policymakers, and the influence of complex interventions designed to institutionalize the systematic application of evidence to health policymaking. The thesis presents two qualitative syntheses and a primary case study in pursuit of this aim. Following a survey of relevant literature (Chapter 1) and a discussion of methodological foundations (Chapter 2), a comprehensive systematic review of qualitative research on evidence-informed health policymaking is summarized (Chapter 3). The latter forms the basis for the subsequent two chapters, a thematic synthesis on the factors affecting evidence use by health policymakers (Chapter 4) and a realist synthesis on the institutionalization of evidence-informed policymaking (Chapter 5). The thesis then pivots from synthesized secondary evidence to original primary research. A qualitative realist case study on the knowledge transfer work of the West African Health Organization (WAHO) is presented (Chapter 6), culminating in the proposal of a realist program theory setting out explanations for how and under what conditions their flagship program – WAHO’s Knowledge Transfer Platform – influences the use of evidence in national health policymaking in West Africa. The thesis closes with a pair of essays that provide lessons, interpretations and critical reflections, both methodological (Chapter 7) and practical (Chapter 8).