Understanding the Adoption of a Health Innovation through Realist Evaluation : The Case of the Introduction of Pulse Oximeters in Primary Health Centers in Four West African Countries (Burkina Faso, Guinea, Mali, and Niger)

Abstract

Respiratory infections are one of the leading causes of child mortality in low- and middle-income countries, primarily due to the difficulty in detecting hypoxemia and limited access to oxygen. Hypoxemia, defined as abnormally low oxygen saturation in the blood, is a key indicator of severity and an important predictor of mortality. However, its diagnosis remains challenging without appropriate devices such as pulse oximeters (PO). Early detection of hypoxemia at the first level of the healthcare system could facilitate decisions to transfer patients to hospital facilities equipped to provide care such as oxygen therapy. Yet, POs are often unavailable at this level. To date, studies on pulse oximetry in primary healthcare settings in low- and middle-income countries remain very limited, and many questions about its implementation remain unanswered (Graham et al., 2024).This research evaluates the introduction of POs during routine consultations for children under five years of age in 202 primary health centers (PHCs) across four West African countries: Burkina Faso, Guinea, Mali, and Niger. We draw on theoretical and empirical literature on the diffusion of health innovations as well as a realist evaluation approach to analyze the individual adoption of POs at the decentralized level. The realist evaluation approach, developed by Pawson and Tilley (1997), focuses on understanding the explanatory mechanisms of how an intervention works and the specific contexts in which they are triggered. It allows us to understand not only whether the intervention is effective but also why, how, and in which contexts it operates.Our thesis makes two main contributions. The first is linking the realist approach, still underutilized in economic sciences, with political economy. We address this connection from two perspectives. From an ontological standpoint, we highlight the links between critical realism (Bhaskar, 1975) and heterodox approaches in economics, drawing pa