ABSTRACT
Top-down control can force people to align their activities, but in doing this it often stifles bottom-up creativity. Bottom-up community development can facilitate local team-working and innovation, but in doing this it can inhibit learning from other places. Both top-down and bottom-up approaches are needed for whole-system harmony. Seasons of care, seasons of health promotion and seasons of participatory action research can be integrated through an annual cycle of activity. Seasons of care, health promotion and participatory action research can frame annual cycles of collaborative learning and coordinated change within which participants enhance each other's contributions. Aligning routinely gathered data to geographic localities helps to develop comparative case studies. Discussions between case-study sites help to cross-pollinate ideas, and generate a healthy combination of competition and collaboration. Real-time strategic change is a form of large group event that is particularly suited to a health system. It involves facilitated debate between different leadership teams as though in a role play.
