Hospital Twinning Partnership for Health System Strengthening in Rural China: A Mixed-Methods Implementation Study Using WHO Building Blocks and CFIR Framework

Hospital twinning partnerships have emerged as a strategy for health system strengthening, yet evidence on their implementation in domestic settings within low- and middle-income countries remains limited. This study examined a hospital twinning partnership between West China Hospital and Dafang County People’s Hospital in western China to identify partnership components and implementation determinants, complemented by assessment of implementation outcomes. A mixed-methods implementation study was conducted using the World Health Organization health system building blocks and the Consolidated Framework for Implementation Research (CFIR). Data were collected through semi-structured interviews (n = 10), structured surveys (n = 63), and administrative records. Partnership elements were mapped to the building blocks, while CFIR constructs were rated to identify facilitators and barriers. Qualitative and quantitative findings were integrated to provide a comprehensive understanding of implementation determinants. Partnership elements spanned all six building blocks, with particular emphasis on leadership and governance, service delivery, and health workforce development. Key facilitators included source credibility and reputation of the supporting hospital, government support, and a two-way partnership philosophy. Barriers included IT infrastructure limitations, inadequate external funding, intervention complexity, sustainability pressure, and cultural inertia toward change. Implementation outcomes showed improvements in service capacity, workforce development, and organizational culture, with observable changes extending to township health centers within the County Medical Consortium. The findings from this study suggest that structured domestic hospital twinning partnerships may serve as a promising approach to rural health systems. The comprehensive approach addressing multiple health system building blocks, combined with mechanisms for extending support to primary care facilities, offers a replicable model for health system strengthening in resource-limited settings.