The article addresses the problem of how to create sustainable change in health care. It builds on two case studies that examine endeavours to develop system innovations so that they deliver high quality services more efficiently. The innovation processes are studied through the lens of a multiple-level model of change. The model suggests that change takes place as the outcome of linkages between external pressures on 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 so that it is 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 thus useful forpolicy-makers and local developers.