The S4A program focuses on building evidence about system alignment strategies that are successful in advancing health equity in American communities.  We recognize that promising ideas for system alignment can come from many sources, including settings and experiences outside the U.S.  As such, we encourage applications that utilize ideas, evidence, and inspiration from international settings to inform their work within the U.S. 

We also recognize that the opportunities and challenges encountered in aligning medical, social and public health systems within the U.S. may be very different from the issues faced in other countries due to unique historical and contemporary developments in policy, politics, economics, institutions, culture and society. Similarly, the forms of structural racism and inequity that have become embedded within U.S. health and social systems derive from historical and contemporary developments that are specific to U.S. contexts and cultures, and may not reflect the situations found in international contexts.  As such, system alignment strategies that are successful in international settings may not work the same way in American communities, or may need to be adapted for unique American systems, contexts and community needs. 

For all of these reasons, we anticipate that is unlikely that the S4A program will support a system alignment study that is implemented exclusively outside of the U.S., because the findings from such a study will be unlikely to be immediately generalizable, translatable and usable in U.S. communities – at least not without subsequent study to support adaptation and testing within the U.S.  Nevertheless, if you believe that your international study idea would produce evidence that is immediately translatable and useable within U.S. contexts, then we encourage you to contact the S4A National Program Office in advance of submitting your application to discuss your ideas and receive additional guidance.