Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine Health Policy

cy and Planning 2012;27:438–446

ß The Author 2011; all rights reserved. Advance Access publication 12 August 2011 doi:10.1093/heapol/czr055

How to do (or not to do) . . . a social network

analysis in health systems research
Karl Blanchet1* and Philip James2
1
International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, UK and 2School of Environment and Life
Sciences, University of Salford, Salford, UK
*Corresponding author. International Centre for Eye Health, London School of Hygiene and Tropical Medicine, Keppel Street,
London, WC1E 7HT, UK. E-mail: Karl.Blanchet@lshtm.ac.uk

Accepted 9 June 2011

The main challenges in international health are to scale up effective health

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interventions in low- and middle-income countries in order to reach a higher
proportion of the population. This can be achieved through better insight into
how health systems are structured. Social network analysis can provide an
appropriate and innovative paradigm for the health systems researcher, allow
new analyses of the structure of health systems, and facilitate understanding of
the role of stakeholders within a health system. The social network analysis
methodology adapted to health systems research and described in detail by the
authors comprises three main stages: (i) describing the set of actors and
members of the network; (ii) characterizing the relationships between actors;
and (iii) analysing the structure of the systems. Evidence generated through
social network analysis could help policy makers to understand how health
systems react over time and to better adjust health programmes and innovations
to the capacities of health systems in low- and middle-income countries to
achieve universal coverage.
Keywords Health systems research, health systems, research methods, social networks,
social sciences

KEY MESSAGES
 The complexity and embeddedness of health systems create very similar challenges for analysis to the ones generated by
social networks.

 Social network analysis can serve the interests of health systems researchers by providing concrete measures and tools to
define health systems.

 Evidence generated through social network analysis could help policy makers understand how health systems react over
time and how ties between actors can influence the diffusion of innovations.

Introduction
Since the launch of the Millennium Development Goals
(MDGs) in 2000 (United Nations 2000), health systems have
become a priority focus for researchers, managers and decision
makers, and efforts have been increasingly invested to improve
the capacity of local health systems with the aim of achieving
the MDGs by 2015 (Murray and Frenk 2000; Sachs et al. 2004;
Reich et al. 2008). The message from the international experts
who came together as part of the 2008 G8 Summit held in
Japan was very clear: health system strengthening and
disease-specific strategies were no longer seen as competing
approaches but were complementary interventions (Fukuda
2008; G8 Health Expert Group 2008).

438
 SOCIAL NETWORK ANALYSIS IN HEALTH SYSTEMS RESEARCH
However, today, researchers, managers and decision makers
face two major challenges with regards to health systems:
describing with accuracy the subject of their study and
understanding how the structure of health systems can influ-
ence health outcomes (Figueras et al. 2008; Jensen 2008). What
is a health system? And how do dynamic and diverse health
systems influence the delivery of health services and the
production of health outcomes? In health systems research,
social networks have implicitly been at the heart of the
definition of health systems (Merrill et al. 2008; Wholey et al.
2009). According to the World Health Organization (2000), a
health system is defined as all the organizations, people and
actions whose primary intent is to promote, restore or maintain
health. Kohn et al. (2000) made the link between social
networks and health systems even more explicit in their own
definition of the health system. They saw a health system as a
network of actors who aim to provide health care: ‘In health
care, a system can be an integrated delivery system, a centrally
owned multihospital system, or a virtual system comprised of
many different partners over a wide geographical area’ (Kohn
et al. 2000, p. 52).
In a globalized world, health systems in low- and middle-
income countries (LMIC) have become multi-scale and dynamic
entities. In the context of this paper, scales are defined as the
spatial, jurisdictional and administrative dimensions used to
study the structure of the health system (Ostrom et al. 1999;
Gibson et al. 2000; Cash et al. 2006). For example, regional
health authorities have the responsibility to monitor the health
situation of the whole region but need to collect data from
different spatial and administrative scales of the regional health
system (villages, sub-districts and districts). In a health system,
scales can be defined by the catchment areas of every health
organization involved in the delivery and management of
health care. The interconnections between actors from different
spatial, administrative or jurisdictional scales are the result of
the multiplicity and diversity of actors intervening in the health
sector and the close interactions between traditional and
modern medicine, between formal and informal sectors,
between international, national, regional and local actors, and
between public and private sectors (Bloom 2001; Mackintosh
and Koivusalo 2005). In addition to this pluralism, the
development of information technologies has accelerated the
interactions between global health systems and local health
systems, and increased the dynamics of health systems
(Morgan 2005). An issue that emerges from this new situation
is how the nature and structure of health systems might be
captured in such a complex environment. In the race to reach
the MDGs, it has been recognized that the capacities of most
health systems constituted key obstacles to generate effective
and equitable health outcomes amongst the populations of
LMIC (Waage et al. 2010).
In the present paper, the authors will demonstrate that
seeing health systems as social networks can help to define
the boundaries of health systems and understand the cor-
relation between health systems’ performance and network
parameters in LMIC. Better understanding of health systems
will improve the effectiveness and coverage of health pro-
grammes in developing countries (World Health Organization
2010a).
439
Social networks in health care
Social network analysis (SNA) is defined as a distinctive set of
methods used for mapping, measuring and analysing the social
relationships between people, groups and organizations (Scott
1999; Borgatti et al. 2009). Using mathematical algorithms
(Marsden 1990) and software (e.g. UCINET) (Borgatti et al.
2002), researchers have analysed how patterns of relationships
between actors within a system can facilitate or constrain the
individual decisions and actions of actors, as well as system
functions and adaptive capacities (Wasserman and Faust 1994).
In a graphic representation of social networks (Figure 1), SNA
illustrates an actor (e.g. an individual, a family, a community or
an organization) by a node and the relationships between
actors by ties (Marsden 1990; Degenne and Forsé 1999; Borgatti
and Cross 2003; Batley and Larbi 2004; Islam 2007).
Relationships between actors can be as diverse as friendship,
trust or knowledge transmission (Folke et al. 2002).
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Beyond being a method, SNA is also viewed as a paradigm
that has its own international society (the International
Network for Social Network Analysis) and its own scientific
journal (Social Networks). SNA provides an avenue for analysing
and comparing formal and informal information flows in a
system. SNA recognizes the complexity and dynamics of
networks and their influence on behaviour and decisions
(Borgatti et al. 2009). SNA has proved that it can be used to
help understand the nature of relations between actors within a
system and how these relationships influence the structure of a
system (Webb and Bodin 2008; Borgatti et al. 2009). Although
SNA and health care have long been interconnected, SNA has
not been applied yet to health systems research in LMIC, which
remains a nascent field of investigation.
Social network theories have a long history in health care.
Social network theories were born in public health in 1934
when, after an epidemic in a New York school, Moreno tried to
understand why the epidemic spread so quickly amongst the
pupils (Moreno 1934). Moreno (1934) was also the first to
represent graphically the relationships between pupils and their
social position with each other. In order to model systems,
social networks theoreticians applied mathematical and graph-
ical techniques to illustrate and understand the complexity of
human and organizational relationships.
The role of networks has become crucial in health care during
the 21st century with the emergence of informational and
technological innovations, and with the recognition from health
managers that hospitals were no longer the unique place where
health care was delivered (Greenhalgh 2008). Health care
providers have acknowledged the role of other actors—medical
and non-medical, private and public—and the positive impact
of multi-scale and multi-disciplinary network-based initiatives
involving medical staff working in hospitals, health staff posted
in primary care health facilities or community-based workers
(Atkinson 2002; Bloom and Standing 2008).
Applying SNA in health systems research encounters a
number of challenges, such as capturing the dynamics of
systems, the limits of a social network and the effects of
multi-scale events that affect several spatial scales of the health
system (e.g. the increase of the price of oil has an impact on the
delivery of health care services at regional, district and
community levels). Therefore, innovative approaches were
440 HEALTH POLICY AND PLANNING
Figure 1 Example of social network: the case of the eye care programme in the Brong Ahafo region, January 2010. Each square represents an actor
and the arrow a relationship between two actors (i.e. the existence of a flow of information between two actors). (Source: Karl Blanchet)
introduced combining social network theories and other
approaches that could potentially generate new knowledge
when applied to health systems (Cumming et al. 2010). At the
individual level, social scientists showed that social networks
determined the level of co-operation between individuals:
individuals tend to collaborate more easily with their direct
neighbours. SNA researchers also showed that, although
individuals are connected with a limited number of people,
people in the world are all indirectly connected by a number of
ties that on average does not exceed ‘six degrees’ (Watts and
Strogatz 1998). This high degree of connectivity between
individuals and organizations has implications for the level of
interdependence and embeddedness between networks.
Individuals connected through a social network tend to have
similar beliefs and values (McGuire 2000; Kiesler and
Cummings 2002; Uzzi and Gillespie 2002). Scholars found
that there was a relationship between the structure of
networks, the type of links between actors (i.e. bonding
between actors of the system or bridging links with other
systems) and the resilience of social–ecological systems (Folke
et al. 2005). At the network level, SNA has also been used to
analyse the patterns of diffusion of innovations and in
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particular how the structure of a network or system determined
the degree of adoption of innovations. This was applied in
various fields such as farming or business (Rogers 1995).
Literature on social networks is now relatively vast. SNA has
had concrete applications in many fields including health
behaviour, health prevention, organizational management or
group behaviour (Valente 2010). How SNA can serve the
interests of health systems researchers by providing concrete
measures and tools to define health systems is described in the
following sections.
The main characteristics of social
networks and health systems
Health systems research aims to understand health governance
in a context characterized by a multitude of diverse actors
(World Health Organization 2009). Governance is one of the six
functions of health systems along with service delivery,
financing, human resources, technology and health information
systems (World Health Organization 2010b). Lebel et al. (2006)
proposed a conceptual framework to describe the six main
 SOCIAL NETWORK ANALYSIS IN HEALTH SYSTEMS RESEARCH 441

characteristics of the ‘good’ governance of social–ecological
systems. Of these six characteristics, three can be applied to the
governance of health systems: (i) capacity to engage effectively
with and handle multiple- and cross-scale dynamics; (ii)
capacity to anticipate and cope with uncertainties and surprises;
and finally (iii) capacity to combine and integrate different
forms of knowledge. To illustrate the utilization of network
tools to health systems, the authors will show how these three
system properties can be analysed by using five different
network properties: two properties related to the structure of
the network and three properties related to the position of
actors.
First, in terms of general structure of a network, two
properties are particularly used in SNA: cohesion and shape
(Borgatti et al. 2009). Cohesion describes the number of
connections within a network and includes sub-properties
such as density and fragmentation. More dense networks
have a higher number of connections between actors. Shape
The brokers in a health system will help co-ordinate actors in
times of crises or shocks and build bridges between different
groups of the system (Burt 2003; Newman and Dale 2005).
Other actors essential to the diffusion of innovations, such as
opinion leaders, champions or change agents, can be identified
through the number of links they have with their peers or
non-peer actors at different levels of the health system (Berner
et al. 2003). For example, opinion leaders, i.e. people who can
influence other people0 s views (Rogers and Cartano 1962), have
the highest numbers of ties within a network. Identifying
opinion leaders and building a programme through these key
people can help to diffuse innovations in a network, e.g.
utilization of medical guidelines (Lomas et al. 1991) or HIV
risk-reduction practices (Sikkema et al. 2000). Centrality,
reachability and betweenness are the most well-known
node-related properties (Freeman 1977). The definitions of
these quantitative measures are presented in Table 1.

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relates to the overall distribution of ties and distinguishes the
core actors from the peripheral ones (Borgatti et al. 1990).
The core actors are highly connected with each other while the
peripheral actors have loose links.
A second application of SNA in health systems research is in
the analysis of the role and position of specific actors. Health
systems research focuses on the role of actors within a health
system (World Health Organization 2009) and in the diffusion
of knowledge and innovations, such as in the management of
epidemics (Rogers 1995; Latkin et al. 2003; Helleringer and
Kohler 2005). However, work in health systems research is still
at an early stage and the available tools such as stakeholder
analysis (Glassman et al. 1999; Brugha and Varvasovszky 2000)
provide limited analysis of the role of actors in a health system.
SNA could be an appropriate analysis tool to generate an
actor-level analysis of health systems (Borgatti and Foster
2003). SNA can also be a valuable tool to uncover the most
influential players in a system (Valente and Pumpuang 2007;
Riggan and Supovitz 2008).
One finding from SNA is that the position of an actor in a
network determines their capacity to access and diffuse
knowledge and information or, in other words, control the
flow of information (Borgatti et al. 2009). SNA provides tools to
identify a knowledge broker, i.e. individuals who create links
between users and researchers (Thompson et al. 2006).
How to design a social network
analysis
The methodology described below is one approach to SNA, but
other study designs could be used and explored by interested
researchers. In the following sections, particular attention is
paid to adapting SNA design to health and more specifically to
health systems research in LMIC. The methodology presented in
this paper was elaborated and tested by the authors in a study
conducted between 2008 and 2010 in the Brong Ahafo region of
Ghana. That study aimed to analyse the influence of district
hospital directors’ social networks on their capacity to make
management decisions.
The SNA methodology developed by the authors consists of
three main stages: (i) describing the set of actors and members
of the network; (ii) characterizing the relationships between
actors; and (iii) analysing the structure of the systems (see
Box 1).
Describing the list of actors and members of the
network
The first stage of SNA consists of describing the actors and
members of the network. Actors are defined as persons,
informal groups of people or formal organizations who may

Table 1 Definition of key network measures

Characteristic Measure
Betweenness Betweenness is a measure that indicates how much a node is located in the path between other actors or how much a node
connects other nodes with each other (Freeman 1977).
Centrality The degree of centrality represents the number of ties a node has (Freeman 1979). If a node has many ties compared with
actors, this indicates that this node has a central position in the network. Centrality can also characterize the shape of a
whole network.
Density Density is defined as the number of existing ties divided by the number of possible ties.
Distance Distance measures the number of ties that separate two actors. If two nodes are directly connected, the distance is one. If
these two nodes are separated by one node, the distance is two.
Reachability Reachability defines the degree by which a node can be reached by other nodes. If a certain number are unreachable by some
actors, it means that the network is fragmented. Reachability corresponds to the number of steps maximally needed to
reach from one node to any other node in the network.
442 HEALTH POLICY AND PLANNING

Box 1 The three main stages of the social network analysis applied to health systems research
Stage 1 Defining the list of actors and members of the network
(i) Step 1: List all stakeholders involved in a system based on a detailed review of project proposals and
documents;
(ii) Step 2: Complement the list of actors with information collected through interviews with key respondents.
Stage 2 Defining the relationships between actors
(i) Step 1: Display the list of actors in a table;
(ii) Step 2: Interview key informants to identify the relationship between actors;
(iii) Step 3: Indicate in the table the existence or absence of a relationship between actors. In each square of the
table, a ‘0’ is written when there is no supply of and no demand for information between two actors. The
square is filled with ‘1’ when there is a flow of information between the two actors (either a demand or
supply of information).
Stage 3 Analysing the structure of the system: measuring five key network properties with the help of the UCINET software:
(i) Betweenness
(ii) Centrality
(iii) Density
(iv) Distance
(v) Reachability

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influence a project’s outcomes and the system’s resilience both
through their interactions, and through individual or collective
actions (Freeman 1979; Grimble and Wellard 1997; Brugha and
Varvasovszky 2000).
The pluralistic nature of health systems means that the
diversity of actors involved in a health system is broad and that
the boundaries of the system can remain blurred (Bloom et al.
2007). The actors involved in a system can be identified by
combining two different but complementary methods proposed
by Grimble and Chan (1995): (i) the list of stakeholders
involved in a system can be pre-defined by the researcher based
on a detailed review of project proposals and documents; (ii)
this list of actors is complemented by information collected
through interviews with key respondents.
To increase the validity of findings and reduce the incidence
of recall bias (e.g. making sure that any actor part of the system
will not be omitted), a third step was added by the authors:
every interviewee is asked to identify additional actors on the
basis of their answers to the following questions adapted from
Salam and Noguchi (2006): (a) who gained or lost during the
health intervention? (b) Who is expected to gain or lose as a
result of the health intervention’s success? A final set of actors
that are involved in the project is established. These actors
become the key informants of the study.
Characterizing the relationships between actors
Relationships between actors can be of different kinds. They
depend on various social factors such as trust, conflicts or
knowledge sharing (Wasserman and Faust 1994; Folke et al.
2005; Manring 2007). However, all these factors rely on a key
process: the circulation of information between and within
social networks (Bodin et al. 2006; Manring 2007). Studying
information flow mechanisms between actors and within
networks can help to understand the social processes influen-
cing health system dynamics and reactions.
The second stage of SNA consists of identifying the existence
of flows of information between actors or, in other words, the
demand (receiving information) and supply (providing
information) of information between individuals. This infor-
mation can be collected through interviews. The people inter-
viewed are the actors identified during the first stage of the
process. A robust method for generating self-reported ties is to
use recall lists (Marsden 1990): a list of all organizations in the
field with adjoining empty columns in which respondents can
mark their different relations to others (Diani 2003). An
alternative is to use a paper card for every actor. The pieces
of paper are displayed in front of each interviewee.
The interviewee is asked about the demands for information:
Do you receive information from this actor? If the interviewee
answers ‘Yes’, then the investigator can ask additional ques-
tions to collect more qualitative information about the type of
information received. For example, what kind of information do
you receive? What is the frequency of your contacts? How do
you receive it: by phone, through visits, letters. . .?
The same questions are systematically asked about every actor
identified. Once this is completed, the investigator starts again
at the beginning of the pile of cards (or the table) and asks
about the supply of information: do you provide information to
this actor? If the answer from the interviewee is ‘Yes’, the
investigator can ask more questions about the type of infor-
mation provided and the way the information is circulated.
Data collected are recorded in the information flow matrix
elaborated by Brinkerhoff (2004) (see example in Table 2): one
matrix for demand of information and a second one for supply
of information. Each respondent thus generates a row of 1’s
and 0’s for each of the two network relations (demand and
supply of information): ‘1’ symbolizing the existence of
demand/supply of information, and ‘0’ signifying no informa-
tion flow between the two actors.
The third stage in the proposed method consists in analysing
the ties between actors and the structure of the network.
Analysing the structure of systems: the use of
software packages
The properties of the networks are analysed using the
algorithms available through specialized software packages
 SOCIAL NETWORK ANALYSIS IN HEALTH SYSTEMS RESEARCH 443

Table 2 Example of information flow matrix showing the supply of information between actors. The actors listed in column 1 supply information
to actors listed in row 1. ‘0’ represents ‘absence of supply of information’ and ‘1’ represents ‘existence of supply of information’.

Supply of information between actors listed in User Regional Regional Hospital Community-based
column 1 with actors listed in row 1 Directorate doctor manager organization
User 0 0 1 1
Regional Directorate 1 1 0
Regional doctor 1 0
Hospital manager 1
Community-based organization

Table 3 Features identified as important for the adaptive management of natural resources and the ways in which they are linked to social network
structure

Characteristics of health systems Corresponding social network variables

Capacity to engage effectively with and Reachability: A measure that describes the capacity to reach many actors to get access to or
handle multiple scales circulate information (Oh et al. 2004).
Distance: The shorter the distance between actors, the faster the diffusion of information.

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Capacity to anticipate and cope with
uncertainties and surprises
Capacity to combine and integrate different
forms of knowledge
Distance between actors is calculated by the number of ties separating two actors.
Centrality: A network with a central structure has more capacities to co-ordinate actors and
provide a rapid response (Leavitt 1951; Fujimoto et al. 2009).
Betweenness: Rapid response can only be obtained when actors are quickly informed of
events or shocks. This requires close links between actors to quickly diffuse information
(Granovetter 1973; Reagans and McEvily 2003).
Reachability: The diversity of knowledge can be achieved through relationships with actors
that belong to other spheres or other sub-networks (Steel and Weber 2001).
Density: Actors in a dense network have more difficulties accessing diverse forms of
knowledge as most actors have very similar backgrounds and values (Granovetter 1973;
Frank and Yasumoto 1998; Valente et al. 2007).

such as UCINET 6, designed by academics for research purposes
(Borgatti et al. 1999).
Through this method, two matrices are generated: one matrix
for demand of information and one matrix for supply of
information. The two matrices are then combined to generate a
single matrix (Marsden 1990). The final matrix is the result of
the addition of the two links. In summary, the new link is
N ¼ A þ B, A and B being the value of the link in the demand
matrix and the supply matrix. The new network is transformed
into a symmetrical and dichotomized network (i.e. without
direction of links and no strength, just zeros and ones). The
new matrix of the system is inserted into the software UCINET
(Borgatti et al. 2002) that helps analyse the properties of the
network.
Calculations are run by the software. The network measure
calculated is then analysed to understand how health systems
are governed. For example, in order to be able to find
multi-scale solutions to multi-scale problems, the actors of a
network need to be able to get access to information from
various types of actors and not only from their close colleagues
and neighbours. This means getting access to stakeholders who
have access to different sources of information and different
types of power (Oh et al. 2004). Access to various sources of
information requires a high level of reachability and short
distances between actors. Table 3 describes the links between
network measures and the systems’ properties.
As a final result, health systems are then represented by
graphs showing the nature of actors involved and the
relationships between these actors. The analysis provides
valuable information to decision makers and managers on
what key influent actors were excluded from the systems and
what new relationships should be encouraged to facilitate
collaboration between key players. The analysis of the structure
of health systems provides information on the properties of the
system (e.g. density, centrality). Describing the strength and
weaknesses of the structure of health systems can help decision
makers predict how an innovation can be diffused within the
system and what is the best strategy to adopt to circulate
information.
Conclusion
Health systems are seen as a combination of various systems
embedded within each other, such as public and private
systems, local, regional and global systems or social and
organizational systems (Snijders and Doreian 2010). An event
at the level of one sub-system can have an impact on another
sub-system and influence the behaviour of network actors. The
complexity and embeddedness of health systems create very
similar challenges for analysis to the ones generated by social
networks (Laumann et al. 1983). Today, the main priorities in
international health are to scale up effective health interven-
tions in LMIC in order to reach a higher proportion of the
population. The present paper described the origin of SNA, the
added value it can represent in health systems research, health
444 HEALTH POLICY AND PLANNING
service management and health policy, and how it can be used
to analyse the relationships between actors and the social
position of actors and their degree of influence. Evidence
generated through SNA could help policy makers understand
how health systems react over time and how ties between
actors can influence the diffusion of innovations. However,
additional issues need to be addressed by researchers when
studying health systems in LMIC: (i) the dynamics of systems
and networks (actors and relationships between actors are in
constant evolution); (ii) the factors that determine the struc-
ture of health systems and are correlated to contextual factors;
(iii) the relationships between the structure of a health system
and the structure of other systems, in which the former is
embedded in. Progress can be made in health systems research
with the help of SNA and in-depth insight can be brought to
make better sense of how health systems react to shocks.
Funding
The study was funded by the Swiss Red Cross.
Conflict of interest
None declared.
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