ABSTRACT:
Globally, health systems continue to struggle to reduce persistent health inequities, with prevention often under-resourced and narrowly framed. Dominant approaches to “scaling up” tend to prioritise the replication of discrete programmes, assuming interventions effective in one setting can be transferred elsewhere with limited adaptation. This presentation explores a different understanding of scale, grounded in long-term, place-based community health practice. Drawing on a decade of evaluation of Healthy Families New Zealand (HFNZ), a government-funded, equity-oriented initiative operating across ten diverse communities, the presentation examines how local agency can be strengthened to support prevention system change. Rather than delivering predefined programmes, HFNZ has invested in locally embedded teams with systems-thinking capability, working alongside iwi, local government, and community organisations to influence the conditions shaping health. Evaluation findings indicate that change has been uneven and incremental, relying less on rapid outcomes and more on the development of relationships, trust, and shared ways of working. This relational infrastructure has supported communities to identify locally relevant priorities, test actions, and adapt over time. Beyond local practice, HFNZ teams have contributed to shifts in organisational policy, commissioning practices, and funding conversations, particularly where local insights have informed regional and national decision-making. From this perspective, scaling is not the replication of interventions but the spread of capabilities, relationships, and enabling structures that support locally driven action. Flexible funding, investment approaches that allow evolution, space for “safe-to-fail” experimentation, shared decision-making, and Māori and Pacific ways of understanding health and place have been critical enablers. We argue that global prevention efforts may benefit from shifting attention away from programme fidelity towards investment approaches that prioritise learning, adaptation, and local agency. Supporting community-led systems to evolve offers a more realistic pathway towards sustainable and equitable community health.