The use of scientific evidence in health policy decisions: Notes on ontologyAbstract
The use of scientific evidence in the formulation and implementation of policies has become an internationally recognized guiding principle for decision-making in health. Amid discussions on the sustainability of health systems and the context of multiple crises, a critical perspective on this debate is imperative. In this essay, we present initial critical-reflective notes on the context of knowledge production within the framework of modern science and the use of scientific evidence in health policy decisions. We adopt historical-dialectical materialism and critical realism as theoretical, methodological, and ontological frameworks, supported by a rapid review of the scientific literature on the topic. We discuss elements of the dominant scientific paradigm, which neglects the ontological foundations of science as a socio-historical praxis; the landscape of evidence-informed policy production in Latin America, its advancements, and its emphasis on methods and techniques; and critical realism as an alternative capable of supporting the social character of science and the existence of an objective reality independent of interpretation. The realization of health as a right served as the guiding objective-image for the discussion. We argue for the necessity of shifting the emphasis from methodological concerns and epistemological disputes to an ontological approach.
Keywords:
Health Policy; Evidence-Informed Policy; Critical Realism; Methods; Public Health.
Resumo
O uso de evidências científicas na formulação e implementação de políticas tem se consolidado internacionalmente como um princípio orientador para a tomada de decisão em saúde. Em meio a discussões sobre a sustentabilidade de sistemas de saúde e ao contexto de múltiplas crises, torna-se imperativo um olhar crítico para esse debate. Neste ensaio, realizamos apontamentos crítico-reflexivos iniciais sobre o contexto da produção de conhecimentos nos marcos da ciência moderna e acerca do uso de evidências científicas nas decisões em políticas de saúde. Utilizamos como referencial teórico-metodológico e ontológico o materialismo histórico-dialético e o realismo crítico; e, como subsídio para o debate, realizamos revisão rápida da produção científica no tema. Foram discutidos elementos do paradigma científico dominante, que negligencia as bases ontológicas da ciência como práxis sócio-histórica; o panorama da produção em políticas informadas por evidências na América Latina, seus avanços e ajustamento a métodos e técnicas; e o realismo crítico como alternativa capaz de sustentar o caráter social da ciência e a existência de uma realidade objetiva independente da interpretação. A materialização da saúde como direito foi a imagem-objetivo de referência da discussão. Entendemos como necessário o deslocamento da ênfase em questões metodológicas e disputas epistemológicas para uma investida ontológica.
Palavras-chave:
Política de Saúde; Política Informada por Evidências; Realismo Crítico; Métodos; Saúde Pública.
Introduction
The use of scientific evidence in the formulation and implementation of health policies has become consolidated as a guiding principle shaped by advances, contradictions, and challenges. In light of discussions on the sustainability of health systems and the context of multiple crises, a critical perspective on health policies and the elements that engender them becomes imperative.
The debate on the use of scientific evidence in policies emerged within the field of policy analysis. In health, it originated in Evidence-Based Medicine (EBM), initially focused on clinical practice and later adapted to health systems, culminating in terms and approaches such as “evidence-based health” and “evidence-based practices.” Originally directed toward Health Technology Assessment (HTA), this approach expanded to health policies under the premise that scientific evidence should inform decisions in order to improve health conditions and the efficiency of resource use (Pereira; Galvão; Silva, 2019; Brasil, 2020).
The evidence-based policy movement gained momentum in the 1990s, but was criticized for disregarding the complex nature of decision-making processes. This situation led to the reformulation of the concept into “evidence-informed policies (EIP),” recognizing that political decisions involve disputes of interest and are not determined solely by evidence. “However, overcoming the gap between knowing and doing in the field of health policies and, consequently, in health-system management remains a contemporary challenge addressed to governments and societies” (Brasil, 2020, p. 7).
The EIP approach is grounded in a systematic and transparent process that considers evidence from diverse sources and the complexity of decision-making in health policy. Initiatives led by the World Health Organization (WHO) have encouraged countries to use scientific knowledge by creating platforms for knowledge translation and for disseminating methods and tools, thereby influencing the Brazilian agenda (Wichmann; Carlan; Barreto, 2016).
This essay proposes an initial critical reflection, situating the advances in the systematic incorporation of evidence into health decision-making processes and problematizing the dominant scientific paradigm, which neglects the ontological foundations of knowledge production and social relations in their totality. We focus on the Brazilian and Latin American context, considering the contradictions in which the categories of science, health, politics, and society are engendered within this social formation.
We adopted the theoretical-methodological framework of historical-dialectical materialism (Paulo Netto, 2011) for an analysis of reality that includes all social processes, and Critical Realism was employed as an ontological framework (Bhaskar, 1997; Hamlin, 2020). This elaboration dialogues with the interests of Science, Technology, and Society (STS) - which rejects the view of science as neutral, criticizes the idea of technology as applied science, and disapproves of technocracy - and Collective Health, taking the social determination of health as central. The guiding element of the discussion is the set of conditions necessary for the full realization of health as a right in Brazil.
Brief notes on science, health, and society
Modern science emerged with the paradigmatic rupture of the feudal social order and developed alongside the rise of the capitalist mode of production, grounded in the production and accumulation of commodities and centered on the private ownership of the production means - a process we can locate in the sixteenth century. From the perspective of historical-dialectical materialism, which guides this essay, the mode of production exerts structural determination over social relations, requiring an analysis of the contradictions of capitalist society that determine the production of science.
According to Löwy (2006), the assumptions of modern science, in the wake of Cartesian rationalism and Baconian empiricism, were consolidated in positivism. Despite its historical variations, positivism conceives science as the only valid form of apprehending reality and the only means capable of solving social problems, gaining prominence in the nineteenth century. This view ignores the historical-social conditioning of knowledge, arguing that the study of social events should be neutral, objective, and free of value judgments, following the methods of the natural sciences.
Health was likewise apprehended as subject to the natural laws of the external environment, which was reflected in the foundations of Traditional Epidemiology as a discipline investigating the health-disease process. The positivist nature of epidemiology is manifested in the factor-based approach, which fragments reality and conceals social determination, despite the important role of this traditional instrument in producing knowledge and practices concerning the health-disease process, as well as the paradigmatic-change initiatives surrounding Social Epidemiology (Castiel, 1990).
The systematization of critiques of the positivist approach in health and the demonstrations that health and disease conditions have a historical-social nature originated in critiques of the degrading conditions experienced by workers in early industrial capitalism. Yet its development, as we know it today, is grounded in Latin America, with the medical-social current, in a tense historical-political-economic context, which proposed an analysis of the health-disease process as an objective material event as it is expressed in the pathological profile of human groups. These profiles tend to differ according to the combinations of the social relations of production and the development of productive forces (Laurell, 1982).
According to Dardot and Laval (2016), in order to understand capitalism in its heterogeneous social morphology and modes of domination, it is necessary to grasp it in its historical present, especially after the transformations promoted by neoliberalism. This has spread the logic of capital across all social relations and spheres of life, becoming the “new reason of the world.”
Particularly in recent decades, contemporary society has been experiencing profound transformations in forms of materiality and in the sphere of subjectivity, given the complex relations between these forms of being and existing within human sociability. The crisis experienced by capital, as well as its responses - of which neoliberalism and the productive restructuring of the era of flexible accumulation are expressions - have brought about, among many consequences, profound mutations within the world of work (Antunes, 2009, p. 17).
Hence the need to problematize the still predominant tendency to apprehend the history of Medicine as a succession of scientific discoveries and technological innovations. This concept, detached from the totality of social relations, obscures the fact that medical practices are shaped by economic and politico-ideological structures. Medicine is taken here as an example because it is a social practice that easily becomes clothed in an alleged neutrality that would atomize it from other social relations. This mythical view confuses Medicine with science, setting it in a hermetic and superior way, as something “more than work.” This perception is influenced by the scientific and technological apparatus surrounding it, its historical persistence, and the convergence between the interests of capital and the possibilities of Medicine under capitalism. Breaking with the notion of neutrality is crucial to understanding the relations between science, health, and the structural determinations of society (Donnangelo; Pereira, 1976; Mendes-Gonçalves, 1992).
Health, illness, and death are distributed unequally across social groups, reflecting unequal access to rights and political participation. This, in addition to making explicit the political character of this field, reveals a contradiction: the potential of scientific knowledge, which could serve human needs and broaden the meanings of life, is not fully realized under capitalism. As science and technology become integrated into social relations, they reflect predominant interests and values that prioritize efficiency in production, consumption, and profit for the benefit of the small groups that concentrate capital.
According to Frigotto (2006, p. 244), “science, technique, and technology are the object of a dispute between antagonistic projects of social modes of producing human existence.” The incorporation of science and technique for the advancement of productive forces did not culminate in workers’ appropriation of this potential, nor did it mean more leisure time or human life’s expanded possibilities and meanings. Instead, it became centered on the reproduction of capital, which manifested itself in different ways depending on the position occupied by countries in the international division of labor.
Latin America was historically positioned in a subordinate and dependent manner within capitalist relations, specializing in the production of primary commodities that serve as inputs for the industry of central countries. In this dynamic of dependent capitalism, countries with peripheral economies became consolidated in producing primary goods, which have low added value and demand intensive labor, deepening technological and scientific dependence vis-à-vis central capitalism countries. This structure of dependence, which determines a specific form of development for Latin America, helps explain the disparities in techno-scientific capacities between central and peripheral nations, reflecting and reproducing the structural inequalities of the global capitalist system (Marini, 2000).
Science is not autonomous, ahistorical, or detached from social reality, but conditioned by historical time. The production of knowledge under capitalism, consubstantiated by antagonistic class interests, tends to be instrumentalized and fragmented, and producing knowledge on the health-disease-care processes does not escape this determination. A critical analysis of the debate on incorporating scientific evidence into health policy decisions is necessary. Following Lukács (2013), what is decisive for a critical analysis in this debate are not the predominant economic motives in the historical explanation of scientific production, but rather the standpoint adopted of the indissoluble totality.
Beyond pragmatically and instrumentally apprehending what scientific evidence is, where it is, and how to search for and interpret it so that it may serve the policy formulation and implementation process, it is essential to keep in view: what is the world like? How do we produce knowledge on the basis of the figure of the world we assume?
Just as anyone who adopts a philosophical position regarding produced science, when we ask “what is the world?” we are referring to ontology, which addresses the nature of being and reality, or what is real. When we ask “how do we gain knowledge about the world?” we are referring to epistemology, which studies knowledge, its bases, boundaries, and validity. Methodology, in turn, asks “how do we investigate the world?” That is, through which techniques, procedures, and methods (Fryer, 2020).
Duayer, Escurra, and Siqueira (2013) help us to question knowledge production in the field of health, which invests heavily in method and epistemological divergences while neglecting ontology.
[...] every claim to knowledge presupposes an idea, however general, of the constitution of the object about which knowledge is claimed. Consequently, impugning ontology means adopting, uncritically, substantive conceptions of the world. By contrast, admitting the inescapable character of ontology implies the need to investigate the conceptions that ground our ideas and the practices they make possible (Duayer; Escurra; Siqueira, 2013, p. 18).
Assuming that ontological representations are central to social praxis, ontological critique must be imperative. Lukács (2013) draws attention to the fact that capitalist social structures generate and require false ontological representations on the part of subjects, so that these same structures may be reproduced. The organization of society influences individuals’ ontological representations, and “these representations play an extremely influential role in the social praxis of human beings, often condensing into a real social power” (p. 71).
Which ontological representations support the production of knowledge that predominates in the field of health? Which ontological perspectives underlie action in health decision-making? On what ontological foundations are the models of incorporating evidence into the formulation and implementation of policies informed?
Frequently rendered invisible, the answers to these questions may lead both to the maintenance of social inequalities and to the construction of more equitable paths. They may result in emancipatory societal and health projects or, on the contrary, reinforce subservience and oppression. Duayer, Escurra, and Siqueira (2013) believe that errors in theory about what the world is like impose failures on practices, since there is an inescapable nexus between the figure of the world and human-social practice.
To this end, we argue that the issue of using evidence in policy decision-making should not be treated merely as an instrumental, technical, and methodological matter. We suggest a shift in emphasis that brings the ontological question to the fore, articulated with the epistemological one, distancing itself both from science in a utilitarian and salvationist sense and from generalized and irrationalist relativism.
The historical-scientific path reveals elements that may support political decisions, with human life’s fullness as the guiding image-objective. Yet there is no intrinsic and naturally inherent power in scientific evidence that would allow it to assume an absolute, neutral, and unquestionable character. It is the understanding of the contradictions that enclose the scientific debate that may produce a more consistent and coherent path for approaching the gap that currently exists between science and decision-making in health policy.
Experiences of health and disease are always connected to the time, space, and rules of a society; therefore, since health is a social process, it can only be understood when linked to its historicity. An ahistorical analysis of an essentially historical object is unsustainable; it is necessary to dwell on the ways of life of the majority of the population, the means they may use to confront illness, and how these means are distributed under capitalism.
To this end, in a country with profound social inequalities, founded on colonial and slave-based foundations, built on large estates and highly concentrated income, any analysis of health-disease-care conditions, as well as of possibilities for intervention, presupposes a critical reading of social formation. In Brazil, social inequalities and, therefore, health inequities are shaped by the racial question, imbricated with gender relations and social class, which has not been taken as an analytical key in the production of health knowledge and practices, thereby perpetuating historical unviability and injustices.
Far from questioning that health policies should be informed by scientific evidence, this brief approximation sought to affirm the place and contradictions of modern science in apprehending reality and health as a historical-social practice. Different ontological postures regarding reality generate distinct analyses, as well as different conceptions of policies, programs, and health outcomes. Ignoring these determinations may lead to advances in the reproduction of the methodological rigor on which decisions are anchored, yet with severe limitations in effectively contributing to improved living and health conditions.
We should emphasize the need for active vigilance regarding the technocratic and managerialist capture of the meanings and mechanisms of evidence-informed practices, especially in contexts of increasing outsourcing of public health services. The incorporation of evidence does not occur in a political vacuum, which allows the neoliberal drive to instrumentalize this practice as a tool to sustain the fallacy of effectiveness, under which “doing more with the same resources” prevails, preserving dominant conditions.
This setting becomes denser and more contradictory amid the dispute-ridden discussion surrounding the Health Economic-Industrial Complex (CEIS), which has determined the practices of agents and agencies in health, and whose predominant discourse - driven by the reheating of developmentalism in its social guise - signals a certain salvationism anchored in the fiction that scientific-technological development and innovation may serve as the vector for reversing the country’s historical position of dependence toward national sovereignty.
Overview of technical-scientific production on evidence-informed health policy in Latin America
Health decisions taken intuitively, unsystematically, and without transparency criteria are still common. Yet every choice of path to be followed is supported by a set of hypotheses and kinds of knowledge from varied types and sources.
More often than not, health decision-making processes are informed predominantly by the desires and interests of specific people and groups, with an insistence on choosing to address public health problems through solutions whose negligible or even deleterious effects have already been demonstrated by scientific studies. The response to dengue as a public health problem is one example of this. There is insistence on a vector-centered approach, while the social, sanitary, environmental, political, and economic conditions - known through numerous pieces of evidence that allow the disease to persist - are neglected. That said, the knowledge and evidence available about health problems do not make decisions; they may only inform them. Health decisions are multidetermined political processes.
In the context of EIP, “evidence” is defined as the set of information used to support a decision. “Scientific evidence,” in turn, is information that presents some level of proof supported by scientific methods. Types of evidence include: i) data produced through service delivery; ii) tacit knowledge; iii) expert knowledge; iv) observed experiences; v) institutional documents; and vi) scientific studies. Each type of evidence has specific relevance, application, and use at different moments of the decision-making process (Pan American Health Organization [PAHO], 2022).
Although it may seem obvious that information, discoveries, and new interpretations of events arising from scientific findings should contribute to decision-making on health systems, the low presence and influence of scientific evidence in the process of policy formulation and implementation persists (Brasil, 2020; Chapman et al., 2021). It may take about 15 to 20 years for the billions of dollars invested in health-related research to be translated into programs and public policies, which has been taken as a problem of high priority for policy formulation (Brownson; Colditz; Proctor, 2017).
The points above should not lead to the mistaken conclusion that science exists to provide the necessary answers for the future of humanity. It is necessary to demystify the utilitarian and reductionist notion of science as a mere instrument or input for practice. Certainly, science, here taken as synonymous with scientific investigation, implies the search for knowledge that may support our practices, but not necessarily immediate practices (Duayer, 2013).
The distance between what is known and what is done is known in the international literature as the “know-do gap.” International-level movements have sought to understand the factors that influence it, as well as ways of reducing it. However, overcoming the challenges for implementing produced knowledge is a task that requires multiple fronts of action, and the literature on the subject widely recognizes that integration among decision-makers, researchers, and society in general plays a strategic role (Menon; Stafinski, 2005).
Difficulties in articulating managers and researchers, as well as biases and pressures in scientific publishing, are challenges in integrating evidence into the decision-making process, such as: evidence is not the only factor that can influence policy formulation; evidence is not valued as support; available evidence is not relevant to the problem to be addressed; evidence is not easy to use; it is not available in a timely manner; and no mechanisms are available to facilitate its use by decision-makers (Brasil, 2020).
The process of moving what is known through scientific research into concrete action in a given context is called Knowledge Translation (KT). It is a “dynamic and interactive process that includes synthesis, dissemination, exchange, and ethically sound application of knowledge to improve health, provide more effective health services and products, and strengthen the health system, serving as the bridge between researcher and decision-maker” (Brasil, 2020, p. 11). KT aims to establish strategies for communicating evidence to decision-makers and to the population, especially in contexts requiring rapid responses.
Guided by KT assumptions, Evidence-Informed Decision-Making (EIDM) is a process that may involve diverse groups of activities, such as: development of clinical protocols and therapeutic guidelines; health technology assessment; data analysis and modeling; monitoring and evaluation; implementation research; and the formulation of evidence-informed policies (PAHO, 2022).
In Latin America, there have been advances in the institutionalization of these practices, at varying degrees of maturity, with dependence on guides and tools produced in the Global North still present, requiring adaptation to local contexts. Brazil and Chile, for example, have developed methodological guidelines using international standards adapted to their own realities (Boeira et al., 2023).
This raises the following question: “What is the thematic profile of technical-scientific production on Evidence-Informed Health Policies in Latin American countries?” To answer it, a rapid review was carried out, using terms such as “Política Informada por Evidências,” “Evidence-Informed Policy,” and “Política Informada por la Evidencia,” producing a mapping of articles and institutional documents on March 25, 2024, based on the Regional Evidence Portal (BVS) and PubMed. Although this article is mainly a critical essay, this search was conducted in order to support the discussion, using the stages of the rapid review method, though not following it in full rigor. Of the 611 records identified, 58 were selected for analysis, whose abstracts were read and analyzed.
The analyzed materials are concentrated in two dimensions: specific public health problems and the improvement of methods and tools for incorporating evidence. In the first, the topics addressed included antimicrobial resistance, systemic arterial hypertension, judicialization, health promotion, height deficit in children under 5 years of age, COVID-19, cesarean sections, work in PHC, normal delivery, breast cancer, public procurement of medicines, overcrowding in emergency hospital services, diabetic foot, biological medicines, congenital syphilis, health policies for families, social participation, mental health, obesity, and dengue.
In the second, the topics addressed were institutionalization (organizational culture, institutionalization devices, competency profiles in EIP, capacities in EIP, EVIPNet); methods and tools (guides, checklists, protocols, step-by-step procedures; SUPPORT, 4A); models and experiences of incorporating research into decision-making (challenges in the Americas, successful experiences); knowledge translation and communication strategies; training processes in EIP; knowledge translation and conceptual frameworks in EIP; approximation between researchers and decision-makers; and the use of qualitative evidence in EIP.
The studies show advances in EIP that support the mediation of diverse interests and contingencies in decision-making. However, integrating evidence into a dynamic and contradictory context remains a challenge with respect to making scientific results compatible with political and administrative demands. Training initiatives have produced good results. Guides, checklists, and protocols have proven useful for operationalizing EIP for decision-makers, but the institutionalization of EIP is reported as an ongoing challenge requiring action on multiple fronts simultaneously.
Thematic diversity points to broad possibilities for the application of EIP, but it may also signal fragmentation, insofar as it responds to isolated problems and shows little articulation with the structural determinations of health. Studies focused on institutionalization, operationalization, and technical training predominate, together with decision-support devices, which may reflect a tendency to frame EIP as a methodological challenge. This perspective is implicitly aligned with the notion that public policies are spaces of technical decision-making, even though the explicit theoretical grounding of EIP assumes that decision-making is traversed by disputes of interests, power asymmetries, and historical processes.
From a critical standpoint, the separation between technique and politics is an unsustainable contradiction. Social, political, and economic structures determine which forms of knowledge are legitimized, which issues are prioritized, and which interests are preserved. In the analyzed production, there is no explicit debate problematizing science as social production, emphasizing its ontological component, and bringing to light the conditioning factors of the production of the knowledge itself used in decision-making. Nevertheless, the important role that EIP production has played is acknowledged, insofar as it sheds light on the problem of informing decisions, offers instruments that allow the vocabulary of management to meet that of scientific evidence, and identifies and implements options with a lower degree of uncertainty.
We did not intend here to examine such production in depth, but rather to obtain a temporally situated portrait from some databases in order to support the reflections of this essay, which pointed to something in common with predominant health production: the primacy of method. We also emphasize that the issues raised here are not addressed to a particularity of EIP production. EIP was taken as a compass to guide the discussion in this essay, given the metanalytical character it allows in this debate. We understand that the nonappearance of historicity and the questions of being in science are shared with the scientific production that predominates in diverse social practices, and fundamentally in the health field in a broad sense. Duayer (2023) affirms that the ontological dispute is the underlying issue of all fundamental questions for humanity.
Incorporating scientific evidence into health decision-making: questions of method and ontology
The EIP approach proposes a systematic and transparent process for accessing, evaluating, adapting, and applying research evidence in decision-making processes, thereby making them informed by what are assumed to be the best available data. It is not limited to scientific evidence, but also considers other types of evidence regarding population needs, values, costs, and resource availability (Brasil, 2020). The challenge lies in apprehending the complex context in which decisions are made and their multiple underpinning factors.
It is unquestionable that the process of formulating and implementing health policies occurs amid contradictions and historical, political, and cultural particularities. In Latin America, different paradigms of health-disease, social protection, and the organization of health systems coexist. In common, these countries show profound social inequalities contextualized within peripheral capitalism and within the incessant neoliberal privatizing agenda that shapes social policies. Thus, the historicity of the State and of the countries’ social formation must guide any analysis of the relations among science, scientific evidence, and health policies.
Initiatives to qualify health policies through the incorporation of evidence have gained prominence in international debate, with a notable presence in Latin America and the Caribbean. Brazil stands out as the country in the region with the greatest progress in the production, translation, and use of evidence in health-sector decision-making, with several initiatives and evidence centers in governments, universities, and civil society organizations. This has been more evident at the federal level, while state and municipal instances have advanced in a more incipient way (Barreto et al., 2022).
In 2005, the World Health Organization launched the Evidence-Informed Policy Network (EVIPNet). This network operates in more than 50 countries as a knowledge translation platform aimed at promoting the development of EIP through the regular use of scientific evidence in policy formulation and implementation. EVIPNet-Brazil was institutionalized within the Ministry of Health in 2009 (Wichmann; Carlan; Barreto, 2016).
EVIPNet-Brazil seeks to advance through the local capillarization of Health Evidence Centers (NEv). The first NEv was created in 2010 in Piripiri, Piauí, to support health decisions. The network trains professionals, produces evidence syntheses, and promotes deliberative dialogues (Wichmann; Carlan; Barreto, 2016).
In 2021, the WHO, in partnership with PAHO, held a meeting of the Regional EVIPNet Americas Network to discuss the challenges of Latin America and the Caribbean, resulting in the document “EVIPNet Call for Action,” which synthesizes the directions of the coalition of partners formed during the COVID-19 pandemic (PAHO, 2021).
Even with this movement underway, the health and economic race for COVID-19 treatments, amid a tangled web of interests, exposed the independence of the decision-making process from scientific evidence and brought fetishized conceptions of science to light. This situation translated into a salvationist attribution to science and technological optimism as a panacea, detached from a totalizing analysis of the crises deepened by the pandemic.
The coordination among health, science, and society generated dissident understandings, at times glorifying science as a neutral source, at times plunging into denialist relativism. The latter characterized the management of the pandemic in Brazil, in which the federal government instrumentalized the health emergency to justify the rollback of social rights and counter-reforms, opposing “economy” and “health” and fostering conspiracy theories (Granemann, 2021).
The formulation and implementation of health policies involve multiple causal mechanisms and non-linear social processes, requiring broad theoretical-methodological models that make it possible to understand the contexts underlying change and to problematize the production of evidence in health (Costa; Magalhães, 2019).
Critical realism was developed by Roy Bhaskar and addresses contemporary debates in the philosophy of science by avoiding traditional epistemological extremes and valuing dialogue with the social sciences. This approach is relevant for analyses in health, as it adopts a conception of reality stratified into three domains: the empirical (sensible experiences), the factual (observable and non-observable events), and the real (underlying mechanisms that produce events) (Hamlin, 2000; Costa; Magalhães, 2019; Bhaskar, 1997). In this perspective, science is “a human activity aimed at discovering, through a mixture of experimentation and theoretical reason, the entities, structures, and mechanisms (visible or invisible) that exist and operate in the world” (Outwhite, 1983, p. 322 apud Hamlin, 2000).
Although the assertion of “doing the best we can with the scientific production we have” seems reasonable, given the urgency of health demands, ontological critique is necessary in the production, use, and dissemination of science, under penalty of distancing ourselves from a notion of world-figuration compatible with the materialization of health as a right.
According to Duayer (2023), ignoring the real world has consequences; negligence toward the ontological question sooner or later exacts its price. The uncritical apprehension of science, which rejects realism and denies ontological objectivity, feeds irrationalism, which in turn rejects reason and sustains the coordinates of hegemonic ideology and the dominant neoliberal belief system. This legitimizes inequalities and perpetuates relations of dependence, subordinating peripheral countries to the knowledge and technologies produced in capitalist centers, devaluing local knowledges and epistemological alternatives, as well as world-figurations, that could confront the dynamics of exploitation. Far from being neutral, science and technology may become instruments of domination.
Assuming and, above all, practicing such a critical attitude is impossible without dismantling the practically unanimous confusion between epistemological relativism and ontological relativism. Epistemic relativity refers solely to the fact, recognized by all sides involved in the controversy, that our knowledge is relative because it is social, historical, and so on. The problem is that the theoretical currents that predominate today deduce ontological relativism from epistemological relativism. In other words, from the transitory and relative character of our knowledge, it is inferred that it cannot be objective. Thus, from epistemological relativism, they deduce antirealism, or the parity of all ontologies. As a bonus, they obtain, as a corollary, judgmental relativism, that is, the conception according to which opposing ideas, theories, and so forth cannot be objectively compared, because, just as beauty is in the eye of the lover, truth is in the perspective of whoever asserts it (Duayer, 2023, p. 78-79).
Here we affirm, even at the risk of necessary tautology, a realist approach to the real world: “there exists a real world that is wholly and absolutely independent of all our representations, all our thoughts, feelings, opinions, language, discourse, texts, and so on” (Searle, 2000, p. 14). Nevertheless, antirealism appears contemporarily in several modalities, among which four arguments stand out: perspectivism, conceptual relativity, discontinuity in the history of science, and underdetermination of theory by evidence.
Following the thought of Searle (2000), Duayer (2023) explains that, for perspectivism, our access to the real is always mediated by opinions, attitudes, and assumptions. This is not a problem, since all knowledge implies a perspective. The problem lies in concluding that, because of mediation, the real would be unknowable, admitting it only from an impossible “perspective of none.” Conceptual relativism, linked to perspectivism, infers that, since our access to reality is mediated by our concepts, external and independent realism would be false.
The historical discontinuity of science, based on Kuhn, suggests that paradigm shifts alter scientific worldviews and world-figurations, creating new realities incompatible with previous ones. Finally, the underdetermination of theory by evidence argues that empirical evidence is never sufficient to determine a choice among theories, since multiple theories may be compatible with the same dataset, thereby mistakenly inferring that there is no reality independent of theory.
Realism brings to light the limitations of the philosophical positions mentioned above and is committed to knowing the world in which we live in its constitutive structures, serving as an alternative to positivist constructions of rationality, described throughout this text, and to postmodern approaches (Costa; Magalhães, 2019). These latter approaches - whose thorough treatment exceeds the limits of this essay - reject grand historical narratives, which are supposedly universalist and totalizing, in favor of the plurality of narratives and representations valid in their context, without reference to an underlying objective reality (Carnut, 2019). At first glance, this notion may seem to favor the analysis of rigid categories from multiple perspectives, but it displaces critical realism from the debate and may culminate in a radical relativism that is paralyzing for critique and political action.
Nonetheless, historical-dialectical materialism is part of the foundations of the Brazilian Health Reform and has influenced the way health is conceived as a social event. Amid criticisms of actually existing socialism, there was a turn toward postmodern thought, which is substantially present in Collective Health, with authors affiliated to a greater or lesser extent with this perspective, such as Durozoi and Roussel, Le Breton, Bourdieu and Helman, and Foucault (Carnut, 2019). A field is thus configured in which there is a marked plurality of ontological and epistemological perspectives that, on realist grounds, does not imply admitting ontological relativism.
What is admitted here is the diverse ways of knowing and representing the world in the field of health, while defending that the health-disease-care process has objective causal mechanisms that operate independently of the ways in which they are understood. Critical realism, by affirming that knowledge is fallible and socially situated - and that this does not prevent reference to an objective reality - offers potential support for an ontological understanding that integrates and critiques different approaches, seeking a deeper comprehension of reality and, therefore, of the production of science as social praxis.
Final considerations
The notion of neutrality - as a value of science - alongside the persistent biomedical paradigm - as a conception of health - compose an ideological dyad that weakens the commitment to health as a right. Working conditions, scientific literacy, and the gaps in training for health as a social process in institutions of education, research, care, and management favor the reproduction of this positivist view.
Concepts of health should be articulated with the sociohistorical context in order to denaturalize the determinations of human health. Collective Health, by its very raison d’être, is a privileged field for the production of knowledge and practices for this analytical composition immersed in the social ‘whole.’ However, within Collective Health
[...] there is an attempt to create formulations coordinated with the social and the historical. However, in most cases, a complete critique is not achieved. [...] there is great difficulty in overcoming the empirical dimension of studies in favor of a deeper construction, such as what we understand to be theoretical-conceptual formulations (Silva; Schraiber; Mota, 2019, p. 14-15).
The social and the historical in health are affirmed through ontological scrutiny of social practices. The coherence between the ontology underlying scientific practice and knowledge production must guide the choice of methods and techniques of investigation, and not the reverse. Thus, the development of institutional capacities to address scientific evidence must include revising science as a mere instrument and lifting the interdiction on ontology.
Reducing the gap between research and decision-making practice in health policy is a global challenge, albeit with historical particularities. We should even recognize that this gap must partly be maintained, considering science as a historical process and health policies as social practices.
Promoting a culture of evidence-informed decisions may improve the analysis of problems; the identification of solutions consistent with health needs; the implementation, monitoring, and evaluation of interventions; and may also favor organizational learning. However, for critical transformation, sociohistorical contextualization is required, along with a radicalization of the conception of science and a flexible action plan adapted to the specificities of each context. This is a structural task and should not fall exclusively upon EIP practices.
Realist syntheses (or reviews) emerge as an operational possibility that lifts the interdiction on the ontological dimension. This is a qualitative approach that seeks to develop theoretical models and offer bases for intervention practices and policies in complex social contexts. It aims to explore how and why certain interventions work (or fail) in different settings, focusing on the interaction between context, mechanisms of action, and observed outcomes, taking realism as its ontological assumption (Pawson, 2006). In Brazil, it is still a method with limited dissemination (Yonekura et al., 2019).
The idea that only neutral knowledge is objective must be challenged. The propagation of this false premise weakens the construction of deeper and more transformative understandings of reality on the basis of the knowledge humanity produces. For science to imply the broadening of the meanings of human life and to constitute a critical practice of intervention in the world, it is essential to incorporate subjectivity and historicity transparently into the scientific process, and to confront denialism, but also scientism and relativism.
Data Availability Statement:
The survey data is available in the body of the document
References
- ANTUNES, R. Os sentidos do trabalho: ensaio sobre a afirmação e a negação do trabalho. São Paulo: Boitempo, 2009.
- BARRETO, J. O. M. et al. Evidence-Informed Policymaking in Brazil: Mechanisms for broadening horizons. Accepted for Publishing. 2022.
- BHASKAR, R. A realist theory of science 2. ed. London: Verso, 1997.
-
BOEIRA, L. et al. Institucionalizando a formulação de políticas informadas em evidências na América Latina e Caribe. Integration and Implementation Insights, 2023. Disponível em: https://i2insights.org/2023/05/09/evidence-informed-policy-making-in-lac/#portuguese-version_boeira Acesso em: 3 fev. 2025.
» https://i2insights.org/2023/05/09/evidence-informed-policy-making-in-lac/#portuguese-version_boeira - BRASIL. Ministério da Saúde, Secretaria de Ciência, Tecnologia, Inovação e Insumos Estratégicos em Saúde, Departamento de Ciência e Tecnologia. Diretriz metodológica: síntese de evidências para políticas. Brasília: Ministério da Saúde, 2020.
- BROWNSON, R. C.; COLDITZ, G. A.; PROCTOR, E. K. (ed.). Dissemination and Implementation Research in Health: Translating Science to Practice. 2. ed. Nova York: Oxford Academic, 2017.
- CASTIEL, L. D. Inefetividade e ineficiência: reflexões sobre a epidemiologia e os serviços de saúde de um estado de mal-estar social. Cadernos de Saúde Pública, Rio de Janeiro, v. 6, n. 1, p. 27-39, 1990.
- CARNUT, L. Para uma crítica ao pós-moderno: o social nas ciências da saúde e o papel da educação crítica - primeiras reflexões. Práxis Comunal, Belo Horizonte, v. 2, n. 1, p. 151-167, 2019.
- COSTA, D. M.; MAGALHÃES, R. Avaliação de programas, estratégias e ações de saúde: um diálogo com o realismo crítico. Saúde em Debate, Rio De Janeiro, v. 43, n. spe7, p. 189-203, 2019.
- DARDOT, P.; LAVAL, C. A nova razão do mundo: ensaio sobre a sociedade neoliberal. São Paulo: Boitempo, 2016.
- DONNANGELO, M. C. F.; PEREIRA, L. Saúde e sociedade. São Paulo: Duas Cidades, 1976.
- DUAYER, M.; ESCURRA, M. F.; SIQUEIRA, A. V. A ontologia de Lukács e a restauração da crítica ontológica em Marx. Revista Katálysis, Florianópolis, v. 16, n. 1, p. 17-25, 2013.
- DUAYER, M. Teoria social, verdade e transformação São Paulo: Boitempo: 2023.
- FRIGOTTO, G. Fundamentos científicos e técnicos da relação trabalho e educação no Brasil de hoje. In: LIMA, J. C. F.; NEVES, L. M. W. (org.). Fundamentos da educação escolar do Brasil contemporâneo. Rio de Janeiro: Editora FIOCRUZ, 2006. p. 241-288.
-
FRYER, T. Una breve guía para la ontología y epistemología: por qué todos debiesen ser realistas críticos. [S. I.], 2020. p. 1-27. Disponível em: https://tfryer.com/wp-content/uploads/2022/04/unabreveguicc81a_rc_final_220423.pdf Acesso em: 15 out. 2020.
» https://tfryer.com/wp-content/uploads/2022/04/unabreveguicc81a_rc_final_220423.pdf -
GRANEMANN, S. Crise econômica e a Covid-19: rebatimentos na vida (e morte) da classe trabalhadora brasileira. Trabalho, Educação e Saúde, Rio de Janeiro, v. 19, 2021. DOI: 10.1590/1981-7746-sol00305137.
» https://doi.org/10.1590/1981-7746-sol00305137. - HAMLIN, C. L. Realismo crítico: um programa de pesquisa para as Ciências Sociais. Dados, Rio de Janeiro, v. 43, n. 2, p. 373-398, 2000.
- LAURELL, A. C. La salud-enfermedad como proceso social. Revista Latinoamericana de Salud, México, v. 2, p. 7-25, 1982.
- LÖWY, M. Ideologias e Ciência Social: elementos para uma análise marxista. 17. ed. São Paulo: Cortez, 2006.
- LUKÁCS G. Para uma ontologia do ser social II São Paulo: Boitempo; 2013.
- MARINI, R. M. Dialética da dependência. In: SADER, E. (org.). Dialética da dependência: uma antologia da obra de Ruy Mauro Marini. Petrópolis: Vozes/CLACSO/Laboratório de Políticas Públicas, 2000, p. 105-165.
- MENDES-GONÇALVES, R. B. Práticas de saúde: processos de trabalho e necessidades. São Paulo: Cefor, 1992.
- ORGANIZAÇÃO PAN-AMERICANA DA SAÚDE - OPAS. Um guia para a tomada de decisões informada por evidências, inclusive nas emergências de saúde Washington, DC.: OPAS, 2022.
- PAULO NETTO, J. Introdução ao estudo do método de Marx São Paulo: Expressão Popular, 2011.
- PAWSON, R. Evidence-based policy: a realist perspective. London: Sage, 2006.
- PEREIRA, M. G.; GALVÃO, T. F.; SILVA, M. T. Saúde baseada em evidências Rio de Janeiro: Guanabara Koogan, 2019.
- MENON, D.; STAFINSKI, T. Bridging the “Know-do” gap in healthcare priority setting: what role has academic research played? Healthcare Management Forum, Philadelphia, v. 18, p. 26-32, 2005.
- SEARLE, J. R. Mente, linguagem e sociedade: Filosofia no mundo real. Rio de Janeiro: Rocco, 2000.
- WICHMANN, R. M.; CARLAN, E.; BARRETO, J. O. M. Consolidação da rede para políticas informadas por evidências - EVIPNet Brasil: relato da experiência nacional de construção de uma plataforma de tradução do conhecimento para o SUS. Bis, São Paulo, v. 17, n. 1, p. 18-31, 2016.
- YONEKURA, T. et al. Revisão realista como metodologia para utilização de evidências em políticas de saúde: uma revisão integrativa. Revista da Escola de Enfermagem da USP, São Paulo, v. 53, p. e03515, 2019.
Edited by
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Editors:
José Miguel Olivar, Marcos Castro Carvalho
