'Hybrid' top down bottom up health system innovation in rural China: A qualitative analysis.

Tailoring innovations to fit local needs formed a severe challenge for the three 'best practice' counties studied. A 'change of mindset' to actively take initiative and assume autonomy was needed to advance. Top down supervision and extensive support of experts was required to overcome the barriers. The studied counties finally achieved sustainable improvements and developed double loop learning capabilities beyond HXI objectives. Taken together, the above findings suggest that the continuum of healthcare reform implementation approaches in which hybrid approaches reside-from bottom up to top down-has two dimensions: a content dimension and a procedural dimension. Enabled by top down procedures, counties were able to bottom up tailor the content of best practice innovations to fit local needs.