Evaluating civil society's complementary role in healthcare Challenges and opportunities of realist evaluation in complex service ecosystems

Paper in proceeding, 2026

Social innovation initiatives are often claimed to contribute value across ecosystem levels, yet their evaluation remains methodologically challenging. This paper examines a patient-led civil society organization (CSO) in Swedish cancer rehabilitation using realist evaluation to reveal mechanisms of value creation across macro, meso, and micro levels.

Drawing on documents (n=54), interviews (n=4), and participatory CMO development with cancer-affected visitors and CSO representatives, the analysis identified mechanisms operating at multiple levels: "meeting one's flock" and creative expression enabling individual wellbeing; public-nonprofit partnerships facilitating organizational collaboration; and policy mandates legitimizing system-level change. These mechanisms interact bidirectionally—macro context activating meso partnerships, enabling micro value creation, with outcomes feeding back to transform institutions. However, constraining mechanisms (anonymity preventing follow-up, organizational cultures hindering collaboration) revealed asymmetric value distribution.

The paper demonstrates how participatory realist evaluation operationalizes ecosystem theory, enriches understanding of civil society's complementary healthcare role, and shows that supporting social innovation requires attention to enabling and constraining mechanisms.