Social network analysis of stakeholders in China's hierarchical medical system: toward a collaborative governance framework for enhanced integration

Background The Hierarchical Medical System (HMS) in China aims to streamline healthcare delivery through structured patient referrals across primary, secondary, and tertiary care. However, the weak collaboration among stakeholders, such as government agencies, medical institutions, and patients has become a significant barrier to its effective implementation. Methods This study employed Social Network Analysis (SNA) to explore the social network characteristics and functional positioning of key stakeholders in the HMS. A systematic literature review was conducted to identify 14 primary stakeholders, followed by a survey of 631 experts to assess the relationships between these stakeholders. The expert judgments were used to construct a relationship matrix, which served as the basis for network analysis. Results Our findings revealed that stakeholder collaboration within the HMS operates as a moderately connected network, characterized by limited integration and low participation from both patients and primary healthcare institutions. This lack of engagement is a primary barrier to the effective implementation of the system. Among the core stakeholders, including the Health Committee, Finance Bureau, Development and Reform Commission, and Healthcare Security Administration, there was insufficient cohesion and coordination, which weakened the overall network. This lack of integration significantly hampers policy synergy and reduces implementation efficiency. Conclusions A collaborative governance framework is proposed to address these challenges. By fostering greater engagement among stakeholders and empowering patients to voice their needs, the system can achieve better integration, equity, and responsiveness. This framework aims to improve system efficiency and policy implementation, facilitating more effective governance and better healthcare outcomes.