System innovations in the making: hybrid actors and the challenge of up-scaling

The article addresses the problem of how to create sustainable change in health care. It builds on two on-going case studies which examine endeavours to develop system innovations for delivering high quality services more efficiently. The early stages of these innovation processes are studied through the lens of multiple-level model of change. The model suggests that change takes place as the outcome of linkages between external pressures to the current regime, policy measures, and local initiatives. The results highlight the critical role of hybrid actors for 1) assuring the societal quality of the innovation, and 2) developing the embryo to be relevant beyond the local level. The up-scaling of an innovation embryo entails that local actors adopt a wider perspective and that policy makers support the spreading of local innovations. The findings are useful for policy makers and local developers.