Multi-actor collaborations in primary health care implementation: a Social Network Analysis of the primary health care strategy in Ghana

Bottom-up theory demonstrates that networks of actors play important roles in policy implementation, yet limited attention has so far been paid to the influence that actor networks might have on the implementation of PHC strategies and outcomes. This study examined the roles actor networks play in the implementation of Community-based Health Planning and Services (CHPS) in Ghana, focusing on the nature and patterns of relations and structure and strength of prevailing collaborations. This was a cross-sectional study using a social network analysis methodology in eight districts across two regions in Ghana. The study population was implementers of CHPS from the community, district, regional and national and development partners. Data were obtained using a modified pre-tested closed-ended social network questionnaire. To establish collaborative relationships, knowledge of other actors and the degree of communication on issues related to CHPS implementation were surveyed. Data were analysed using Gephi software version 0.9.2. The analysis demonstrated existing actor networks of Community Health Committees (CHCs), Community Health Officers (CHOs), Community Health Volunteers (CHVs), Sub-district, and district-level networks, including local government actors and political leaders, as well as regional, national, and development partner actors in CHPS implementation. The nature of relations showed isolated networks of CHCs, CHVs, and sub-districts across both regions. Patterns of interactions revealed that CHO networks collaborate with each other, while CHCs primarily collaborate with CHOs. Overall, weak collaborative relationships were noted among the actor networks (network density < 10%). The results suggest segmented, decentralized networks with limited involvement of critical actors, including community-level, local government, political leaders, national-level and development partners in CHPS implementation. The network analysis highlights weak collaborative relationships among actor networks in CHPS implementation, a practice which negatively impacts its implementation experience. The study highlights pathway to strengthen cohesion and improve collaborative relationships in addressing CHPS as a PHC strategy.