Local Dynamics of Collaboration for Maternal, Newborn and Child Health: A Social Network Analysis of Healthcare Providers and Their Managers in Gert Sibande District, South Africa

Document Type : Original Article


1 School of Public Health, University of the Western Cape, Cape Town, South Africa

2 Institute of Tropical Medicine, Antwerp, Belgium

3 South African Medical Research Council Health Services to Systems Unit, University of the Western Cape, Cape Town, South Africa


Accountability for maternal, newborn and child health (MNCH) is a collaborative endeavour and documenting collaboration dynamics may be key to understanding variations in the performance of MNCH services. This study explored the dynamics of collaboration among frontline health professionals participating in two MNCH coordination structures in a rural South African district. It examined the role and position of actors, the nature of their relationships, and the overall structure of the collaborative network in two sub-districts.

Cross-sectional survey using a social network analysis (SNA) methodology of 42 district and sub district actors involved in MNCH coordination structures. Different domains of collaboration (eg, communication, professional support, innovation) were surveyed at key interfaces (district-sub-district, across service delivery levels, and within teams).
The overall network structure reflected a predominantly hierarchical mode of clustering of organisational relationships around hospitals and their referring primary healthcare (PHC) facilities. Clusters were linked through (and dependent on) a combination of district MNCH programme and line managers, identified as central connectors or boundary spanners. Overall network density remained low suggesting potential for strengthening collaborative relationships. Within cluster collaborative patterns (inter-professional and across levels) varied, highlighting the significance of small units in district functioning.

SNA provides a mechanism to uncover the nature of relationships and key actors in collaborative dynamics which could point to system strengths and weaknesses. It offers insights on the level of fragmentation within and across small units, and the need to strengthen cohesion and improve collaborative relationships, and ultimately, the delivery of health services.


  1. Sheikh K, George A, Gilson L. People-centred science: strengthening the practice of health policy and systems research. Health Res Policy Syst. 2014;12:19. doi:1186/1478-4505-12-19
  2. UN General Assembly. Transforming Our World: the 2030 Agenda for Sustainable Development. United Nations; 2015:1-35.
  3. Torfing J, Peters BG, Pierre J, Sørensen E. Interactive Governance: Advancing the Paradigm. USA: Oxford University Press; 2012.
  4. Melo V. Collaborative Efforts for Sustainable Development: Surveying the Literature on Multi-Stakeholder Initiatives to Realize the Sustainable Development Goals. Task Team on CSO Development Effectiveness and Enabling Environment; 2018. doi:13140/rg.2.2.19706.75209
  5. Long JC, Cunningham FC, Braithwaite J. Bridges, brokers and boundary spanners in collaborative networks: a systematic review. BMC Health Serv Res. 2013;13:158. doi:1186/1472-6963-13-158
  6. Ssengooba F, Kawooya V, Namakula J, Fustukian S. Application of social network analysis in the assessment of organization infrastructure for service delivery: a three district case study from post-conflict northern Uganda. Health Policy Plan. 2017;32(8):1193-1202. doi:1093/heapol/czx071
  7. Srinivasan U, Uddin S. A social network framework to explore healthcare collaboration. In: Healthcare Informatics and Analytics: Emerging Issues and Trends. IGI Global; 2014.
  8. Steihaug S, Johannessen AK, Ådnanes M, Paulsen B, Mannion R. Challenges in achieving collaboration in clinical practice: the case of Norwegian health care. Int J Integr Care. 2016;16(3):3. doi:5334/ijic.2217
  9. Zamboni K, Baker U, Tyagi M, Schellenberg J, Hill Z, Hanson C. How and under what circumstances do quality improvement collaboratives lead to better outcomes? a systematic review. Implement Sci. 2020;15(1):27. doi:1186/s13012-020-0978-z
  10. Kilo CM. Improving care through collaboration. Pediatrics. 1999;103(1 Suppl E):384-393.
  11. Lannon CM, Peterson LE. Pediatric collaborative networks for quality improvement and research. Acad Pediatr. 2013;13(6 Suppl):S69-74. doi:1016/j.acap.2013.07.004
  12. Schneider H, George A, Mukinda F, Tabana H. District governance and improved maternal, neonatal and child health in South Africa: pathways of change. Health Syst Reform. 2020;6(1):e1669943. doi:1080/23288604.2019.1669943
  13. Waiswa P, Manzi F, Mbaruku G, et al. Effects of the EQUIP quasi-experimental study testing a collaborative quality improvement approach for maternal and newborn health care in Tanzania and Uganda. Implement Sci. 2017;12(1):89. doi:1186/s13012-017-0604-x
  14. Clemmer TP, Spuhler VJ, Berwick DM, Nolan TW. Cooperation: the foundation of improvement. Ann Intern Med. 1998;128(12 Pt 1):1004-1009. doi:7326/0003-4819-128-12_part_1-199806150-00008
  15. Cross R, Parker A. The Hidden Power of Social Networks: Understanding how Work Really Gets Done in Organizations. USA: Harvard Business Review Press; 2004.
  16. Mikkola L, Suutala E, Parviainen H. Social support in the workplace for physicians in specialization training. Med Educ Online. 2018;23(1):1435114. doi:1080/10872981.2018.1435114
  17. Hopkinson JB, Hallett CE, Luker KA. Everyday death: how do nurses cope with caring for dying people in hospital? Int J Nurs Stud. 2005;42(2):125-133. doi:1016/j.ijnurstu.2004.06.004
  18. De Brún A, McAuliffe E. Social network analysis as a methodological approach to explore health systems: a case study exploring support among senior managers/executives in a hospital network. Int J Environ Res Public Health. 2018;15(3):511. doi:3390/ijerph15030511
  19. Blanchet K, James P. How to do (or not to do) ... a social network analysis in health systems research. Health Policy Plan. 2012;27(5):438-446. doi:1093/heapol/czr055
  20. Braithwaite J. Between-group behaviour in health care: gaps, edges, boundaries, disconnections, weak ties, spaces and holes. A systematic review. BMC Health Serv Res. 2010;10:330. doi:1186/1472-6963-10-330
  21. Chambers D, Wilson P, Thompson C, Harden M. Social network analysis in healthcare settings: a systematic scoping review. PLoS One. 2012;7(8):e41911. doi:1371/journal.pone.0041911
  22. Kawonga M, Blaauw D, Fonn S. Exploring the use of social network analysis to measure communication between disease programme and district managers at sub-national level in South Africa. Soc Sci Med. 2015;135:1-14. doi:1016/j.socscimed.2015.04.024
  23. Mundt MP, Gilchrist VJ, Fleming MF, Zakletskaia LI, Tuan WJ, Beasley JW. Effects of primary care team social networks on quality of care and costs for patients with cardiovascular disease. Ann Fam Med. 2015;13(2):139-148. doi:1370/afm.1754
  24. Malakoane B, Heunis JC, Chikobvu P, Kigozi NG, Kruger WH. Public health system challenges in the Free State, South Africa: a situation appraisal to inform health system strengthening. BMC Health Serv Res. 2020;20(1):58. doi:1186/s12913-019-4862-y
  25. Maphumulo WT, Bhengu BR. Challenges of quality improvement in the healthcare of South Africa post-apartheid: a critical review. Curationis. 2019;42(1):e1-e9. doi:4102/curationis.v42i1.1901
  26. Mukinda FK, Van Belle S, George A, Schneider H. The crowded space of local accountability for maternal, newborn and child health: a case study of the South African health system. Health Policy Plan. 2020;35(3):279-290. doi:1093/heapol/czz162
  27. Mukinda FK, Van Belle S, Schneider H. Perceptions and experiences of frontline health managers and providers on accountability in a South African health district. Int J Equity Health. 2020;19(1):110. doi:1186/s12939-020-01229-w
  28. Massyn N, Padarath A, Peer N, Day C. District Health Barometer 2016–2017. Durban: Health Systems Trust; 2017.
  29. Bergh AM, Bac M, Pattinson RC. Changing priorities in maternal and perinatal health in Gert Sibande district, South Africa. S Afr Med J. 2019;109(11):838-840. doi:7196/samj.2019.v109i11.14098
  30. Valente TW, Pumpuang P. Identifying opinion leaders to promote behavior change. Health Educ Behav. 2007;34(6):881-896. doi:1177/1090198106297855
  31. Granovetter MS. The strength of weak ties. Am J Sociol. 1973;78(6):1360-1380.
  32. Scott J. Social Network Analysis. 4th ed. London: SAGE Publications; 2017.
  33. Button LA. Effect of social support and coping strategies on the relationship between health care-related occupational stress and health. J Res Nurs. 2008;13(6):498-524. doi:1177/1744987107087390
  34. GEPHI – Introduction to network analysis and visualization. 2015. http://www.martingrandjean.ch/gephi-introduction. Accessed June 2020.
  35. Prell C. Social Network Analysis: History, Theory and Methodology. London: SAGE Publications; 2012.
  36. Valente TW, Fujimoto K. Bridging: locating critical connectors in a network. Soc Networks. 2010;32(3):212-220. doi:1016/j.socnet.2010.03.003
  37. Dixon-Woods M, Pronovost PJ. Patient safety and the problem of many hands. BMJ Qual Saf. 2016;25(7):485-488. doi:1136/bmjqs-2016-005232
  38. Mukinda FK, George A, Van Belle S, Schneider H. Practice of death surveillance and response for maternal, newborn and child health: a framework and application to a South African health district. BMJ Open. 2021;11(5):e043783. doi:1136/bmjopen-2020-043783
  39. David HM, de Araújo Faria MG, Dias JA, da Silva TF, Souza VM, dos Santos Dias R. Social network analysis in primary health care: an integrative review. Acta Paul Enferm. 2018;31(1):108-115. doi:1590/1982-0194201800016
  40. Granovetter M. The strength of weak ties: a network theory revisited. Sociol Theory. 1983;1:201-233. doi:2307/202051
Volume 11, Issue 10
October 2022
Pages 2135-2145
  • Receive Date: 20 December 2020
  • Revise Date: 07 June 2021
  • Accept Date: 11 August 2021
  • First Publish Date: 08 September 2021