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Global Health Research, Anthropology and Realist Enquiry Methodological Musings Global Health Research, Anthropology and Realist Enquiry Methodological Musings Sara Van Belle ABSTRACT: In this article, I set out to capture the dynamics of two streams within the fi eld of global health research: realist research and medical anthropology. I critically discuss the de- velopment of methodology and practice in realist health research in low- and middle-income countries against the background of anthropological practice in global health to make claims on why realist enquiry has taken a high fl ight. I argue that in order to provide a contribution to today’s complex global issues, we need to adopt a pragmatic stance and move past disciplin- ary silos: both methodologies have the potential to be well-suited to an analysis of deep layers of context and of key social mechanisms. KEYWORDS: ethnography, global health, low- and middle-income countries, medical anthropology, realist evaluation In recent years, realist enquiry became increas- (Van Belle et al. 2016). It aims at opening the black ingly popular in health programme evaluation and box between intervention and outcome by developing research as well as in healt h systems and policy re- explanations that take into account actors, contexts search in low- and middle-income countries (LMIC), and mechanisms in a confi gurational approach. Re- o en conducted by researchers from these countries cently, realist evaluation has evolved into a broader (Abejirinde et al. 2018; Kwamie et al. 2014; Prashanth fi eld of enquiry, moving beyond programme evalu- et al. 2014). In the process, questions were raised ation and encompassing reviews, syntheses and about the similarities and diff erences between real- realist research (Emmel et al. 2018). Health profes- ist enquiry and anthropological enquiry. Both ap- sionals and health practitioners are also a racted proaches are case-oriented and compare across cases. to this type of enquiry, applying it to the evaluation Cases are selected based on their richness and varia- and researching of operational issues. Part of the ap- tion. Both approaches consider the embeddedness peal of realist enquiry is that it provides a systematic of social action in context as a sine qua non of their approach to learning and that it suits complex inter- application: the context triggers certain mechanisms, ventions rather well. According to Geoff Wong and which in turn produce social action. Finally, both colleagues (2010), complex interventions ‘consist of methods use retroduction (backwards tracing from multiple human components that interact in a non- an empirically observed phenomenon to the mecha- linear fashion to produce outcomes which are highly nisms that produced this phenomenon) to a certain context-dependent’. In this defi nition, actors (and extent to explain social phenomena. their unpredictable behaviour), their interactions and Realist evaluation is an evaluation methodology their relationships make an intervention ‘complex’ from the family of theory-based evaluations, and is (Marchal et al. 2012). increasingly used to evaluate interventions in the Other methods commonly used to engage with fi eld of healthcare and international development the complexity of health systems and the delivery of Anthropology in Action, 26, no. 1 (Spring 2019): 42–51 © Berghahn Books and the Association for Anthropology in Action ISSN 0967-201X (Print) ISSN 1752-2285 (Online) doi:10.3167/aia.2019.260105 This article is distributed under the terms of the Creative Commons A ribution Noncommercial No Derivatives 4.0 International license (h ps://creativecommons.org/licenses/by-nc-nd/4.0/). For uses beyond those covered in the license contact Berghahn Books. Global Health Research, Anthropology and Realist Enquiry | AiA healthcare in LMIC include social science research nial past (Hannerz 2016). A er some meandering, I methods, such as grounded theory, participatory ended up in a department of public health of a Euro- action research, and ethnography (Green and Thoro- pean global health research institute in the mid-2000s good 1994; Liampu ong 2012). Ethnography has as a lecturer in medical anthropology and sociology. I been successfully applied to make sense of and im- found that medical anthropology practice applied to prove upon the management of health systems and health service delivery in LMIC was strangely devoid the implementation of health policies. Due to its prac- of the evolution described above. What happened titioners’ engagement with meaning, applied medical with post-colonialism in global health research? anthropology has a critical role to play in enabling community-based health systems that are founded upon people’s values and beliefs. Indeed, the Dec- Gridlock in Global Health Research: laration of Alma-Ata of 1978, with its focus on the The Enduring Struggle between Disciplines engagement of communities, provided a role for anthropologists in facilitating the responsiveness of Within tropical medicine (and in its leading schools healthcare services to community needs (Manderson in the United Kingdom), anthropology (in the Anglo- et al. 2016b). phone tradition) was traditionally understood as one In this article, I discuss critically the current devel- of the disciplines that contributed to disease control opment of methodology and practice in realist health programmes (Pool and Geissler 2005). Originally, research in LMIC against the background of applied medical anthropologists were to identify the local anthropological practice in global health to make meanings of disease, translate these into communica- claims on why realist enquiry has been taken up so tion and health-promotion strategies and manage the readily. I set out to capture the dynamics in these relationships with the community in the implemen- methodological streams within the fi eld of current tation of programmes (Heggenhougen and Pedersen global health research. I argue that realist enquiry 1997; Koss-Chioino 1997; Manderson 1998; Sommer- has been readily embraced because its philosophical feld 1998). Anthropologists were henceforth ‘increas- position between positivism and social constructiv- ingly employed in departments of tropical medicine, ism presents an easier entry point for biomedically hygiene and international health with an increasing trained practitioners than does applied anthropo- focus on community-based research in infectious dis- logical enquiry. I do not claim to be comprehensive ease control’ (Heggenhougen and Pedersen 1997). The in detailing disciplinary evolution – this is merely a historical trajectories of global health research institu- starting point for discussion. tions contributed to this state of aff airs, eff ectively ‘locking them in’ to a particular practice of interdis- ciplinary interaction (Foxon 2002). For some, social An Anthropologist’s Personal Journey scientists were ‘being employed as the handmaidens (in Methodology) of biomedicine’ (Parker et al. 2016). Interdisciplinary relationships and disciplinary power appeared to be I trained as a cultural anthropologist and political deeply engrained in academic institutions as part of scientist in the mid-1990s at the height of the cul- their organisational culture, and they were particu- tural studies movement in the United Kingdom and larly resistant to change. the emergence of the fi eld of post-colonial studies Compared to the Anglophone tradition of ap- (Gandhi 1998). These infl uences transformed the cur- plied medical anthropology, a diff erent route seems riculum of the master’s degree in anthropology at to have been taken by the Francophone tradition, my Belgian university, a change exemplifi ed by the where the discipline of medical sociology integrated fact that the master’s degree title ‘anthropology’ was with anthropology, thereby dampening the biomedi- dropped and changed to ‘comparative cultural stud- cal dominance in the fi eld (Carricaburu and Ménoret ies’. This move broadened the domain of enquiry to 2004). Francophone socio-anthropologists carried out include, amongst other important topics, the study research on, for instance, health systems and power of migration. Not much later came the start of a re- within healthcare organisations (Jaff ré and Olivier invention of anthropology as a discipline towards de Sardan 2003). Typically, they followed the path of a ‘globalised’ anthropology, which expanded its re- critical studies, incorporating the theories of Michel search subject and explored subjects such as migrant Foucault and Pierre Bourdieu (Fassin 2000) and identities, global networks, the digital revolution, critiquing the instrumentalisation of anthropology gender, and social exclusion, leaving behind its colo- (Gruénais 2012). Interesting recent developments in- | 43 AiA | Sara Van Belle clude current work on socio-ecological systems (Sterk intervention triggers the mechanisms that explain et al. 2017), on ecohealth (Dakubo 2010), and on the how people responded to the intervention (or not) emerging discourse on planetary health and sustain- and thus created the outcome, thereby increasing the ability science (Brouselle and Butzbach 2018; Pa an- external validity of the results. This is why it is impor- yak and Haines 2017). Embracing an agenda broader tant to test the programme theory across a number of than health and fi rmly embedded in complexity sci- sites. Figure 1 presents the realist research cycle. I re- ence, these approaches address global problems and fer you to Sara Van Belle and colleagues (2016) and to appear to be less vexed by interdisciplinary struggle
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