An alignment mechanism is an action or set of actions that helps medical, social, and public health systems operate in more integrated and coordinated ways, ultimately leading to improved health and health equity for a defined population group of interest. We view systems alignment as a deliberate process to coordinate the work of multiple independent systems and sectors, including the development of shared priorities and goals, shared governance and decision-making, shared financing and resource allocation, and shared data and information. See for example: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7362706/. S4A has studied a variety of novel approaches for aligning systems using rigorous scientific methods to determine their impact on health and health equity. But unfortunately, many promising ideas for systems alignment have yet to be rigorously studied.

The S4A program is interested in aligning delivery systems and/or financing systems that operate within the three broad domains of medical care, public health and social services. Delivery systems include the organizations, people, information, and materials used to deliver services.  Financing systems include the revenue sources, payment mechanisms, and flow of funds needed to deliver services.

Every program, service or intervention is implemented through a delivery system. A delivery system is the constellation of organizations, people, policies, and resources that allow the program to be implemented for members of the target population. Similarly, a financing system is the constellation of financial resources, funding mechanisms, funders, and payment policies that support implementation of a program or service. Applicants should articulate clearly how they define the delivery and/or financing systems to be aligned through their proposed research.

We define the social services sector to include any organization, program or service that works to address fundamental human needs in the community and promote social well-being. This sector includes organizations and programs that provide education, housing, income support, employment assistance, diversity and inclusion initiatives, food assistance, transportation, child and youth development, recreation and physical activity, legal assistance, disability support services, violence prevention, arts and cultural programming, criminal justice and juvenile justice services, and community and economic development.

We define the medical care sector to include any organization, program, or service that helps individuals obtain access to clinical services that prevent, treat, or manage diseases and injuries, including services for physical health conditions, mental health conditions, substance abuse, and developmental disabilities. This sector includes the providers, purchasers, insurers, and payers of these services as well as the suppliers of associated products and technologies, such as pharmaceutical products and health information technologies.

We define the public health sector to include any organization, program or activity that works to create the conditions in which people can live healthy lives, including activities to prevent disease and injury and promote health for the population at large. They include governmental public health agencies working at local, state, and federal levels, as well as nongovernmental organizations that contribute to the performance of core public health functions. A defining feature of public health systems is their focus on actions designed to protect and improve health at a population level rather than purely at an individual level through delivery of personal health services.  Public health systems implement activities to protect populations from communicable diseases, to prevent chronic disease risks and injuries, to promote healthy behaviors, and to reduce environmental health risks in the air, water, food, and built environment.

The S4A program funds rigorous scientific studies that are designed to evaluate the impact of initiatives that align medical, social, and public health systems. This 2024 call for proposals (CFP) will provide funding for a new cohort of research studies to produce new, actionable evidence for aligning across the three systems to address systemic racism.

Each study funded under this CFP must (1) identify a specific form of systemic racism that limits health and well being for affected populations; and (2) investigate a novel systems alignment strategy for solving the problem that engages relevant representatives from medical care, public health, and social services systems, as described in the S4A Research Agenda. The systems alignment strategy to be studied must engage all three types of systems that comprise the health and social ecosystem in American communities—medical care, public health, and social services. For definitions and examples of systemic racism and potential solutions, please read this review article. Read the full CFPfor more information about this specific funding opportunity.

Studies must evaluate proposed solutions that engage all three types of systems implicated in the S4A research agenda: 1) medical care; 2) public health; and 3) social services.

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.  

An applicant organization may submit more than one LOI as long as each LOI is distinct in terms of the study aims, scientific approach and research team. The Impact Award category is open only to applicants who have completed a pilot test or other type of preliminary research study and can provide documentation of results that confirm the feasibility of the proposed approach and its acceptability to key stakeholders within the relevant medical, social, and public health systems. Because of the small number of awards available under this CFP, it is unlikely that an applicant organization will receive multiple awards under this CFP. 

Health equity is achieved when everyone has the opportunity to live their healthiest life possible regardless of who they are, where they live, or how much money they make. Funded studies must focus on system alignment mechanisms that have the potential to improve health equity.

Alignment mechanisms that aim to promote efficiency, reduce costs, or improve outcomes without improving health equity are not responsive to this CFP. Studies must examine the ability of the system alignment mechanism to contribute to an environment in which everyone has the opportunity to achieve their full health potential, and in which no one is disadvantaged from achieving this potential because of social position or circumstance.

Applicants are encouraged to follow recommendations of the National Academy of Medicine regarding strategies for measuring health equity, available at: https://www.nap.edu/read/21899/chapter/5. Measures should quantify differences in health outcomes, risks, or determinants across key population subgroups of interest such as those based on race, ethnicity, gender, socioeconomic status, disability status, geography, or other subgroups that experience differences in opportunity, social position or power.

This CFP is not appropriate for applicants who primarily seek funding to implement their proposed solution. Because S4A is a research program, grantees are expected to use all or most of their grant funding to carry out the research study, rather than to implement the proposed solution. Applicants who propose to use part of their grant funding to support implementation may be at a competitive disadvantage relative to other applicants, for several reasons: (1) these applicants will have fewer resources available to carry out a scientifically rigorous research study; (2) these applicants will have greater difficulty demonstrating the feasibility of their proposed solution, because implementation will depend upon receipt of grant funding; and (3) these applicants will have greater difficulty demonstrating the sustainability of the proposed solution beyond the end of the grant period. 

LOIs must be submitted through the RWJF online system by February 7th, 2024 at 3:00pm ET. Late applications will not be permitted. You will be required to register at MYRWJF at https://my.rwjf.org before you begin the application process. Select applicants will be notified about invitations to submit a full proposal in March 2024. 

If you miss the deadline for the LOI, you will not be permitted to submit a full proposal. 

Applicants must be either public entities or nonprofit organizations that are tax-exempt under Section 501(c)(3) of the Internal Revenue Code and are not private foundations or non-functionally integrated Type Ill supporting organizations. Applicant organizations must be based in the United States or its territories. Awards will be made to organizations, not to individuals. Multi-organizational consortia are encouraged to apply if a single eligible organization is designated as the primary applicant responsible for maintaining consortium agreements with other participating organizations.

No, but subcontracts or partner relationships with for-profit entities or entities based outside the United States may require additional financial and/or legal due diligence.

Yes, an organization may submit more than one proposal as long as each proposal submitted is distinct in terms of both project and research team.

Yes, previously or currently funded RWJF grantees are eligible to apply for this funding opportunity, but the proposed project must be different from previously funded work.

Applicants will submit a 3-page Letter of Intent (LOIs) containing the project narratives briefly describing the specific form of systemic racism the proposed research will address and the connection to medical, social and public health systems, the systems alignment approach, and the proposed research design and methodology. LOIs will be reviewed by a review panel that includes members of the S4A National Advisory Committee, S4A staff, Robert Wood Johnson Foundation staff, and System Alignment Innovation Hub staff. See the CFPfor the specific review criteria.

We are looking for research teams from diverse health and social service fields that have expertise in the three broad types of delivery and financing systems implicated in the S4A research agenda: (1) medical care; (2) public health; and (3) social and community services and supports. This includes investigators from a variety of areas and disciplines, including but not limited to medicine, public health, social work, sociology, business, economics, education, transportation, housing, criminal justice, communication, public policy, political science, system science, and urban planning and community development. Because S4A is a research program, all applicants should ensure their team includes individuals with relevant expertise in scientific research design, data analysis methodologies, and scientific publication. Applicants from non-academic settings that do not have an embedded research unit are strongly encouraged to partner with a research institution to provide this expertise.

We especially encourage applications that include individuals having backgrounds and life experiences that are underrepresented on research teams.

Yes, interested applicants may apply for other RWJF grants. You must actively submit to other opportunities in which you are interested as proposals declined by S4A will not automatically be considered by other programs.

S4A is highly interested in studies that will test novel System Alignment Strategies and produce new scientific evidence about the feasibility, acceptability, and/or impact of these strategies in dismantling and disrupting systemic racism. HOWEVER, S4A is also interested in studies that can improve our understanding of specific forms of systemic racism that operate within or affect medical, social and public health systems, and fill important gaps in scientific knowledge about these forms of racism and how to disrupt them – as noted in Special Topics of Interest #1, described on Page 3 of the CFP document. If your LOI addresses Special Topic #1, your study might not focus on a specific systems alignment strategy. Instead, your study must identify important gaps in scientific knowledge and evidence about forms of systemic racism, describe how these gaps will be addressed by the proposed new research, and indicate how the new research will inform the development of new system alignment strategies to address systemic racism.

If you are proposing to test the impact of a proposed system alignment strategy on relevant measures of health and health equity, then you must have results from a pilot test of this system alignment strategy.  Pilot test results must demonstrate that it is feasible to implement your proposed system alignment strategy, and that the strategy is acceptable to relevant organizations and people who will help to implement the strategy – including representatives from medical, social, and public health systems and representatives from communities affected by the form of systemic racism under study.  If your LOI addresses Special Topic #1 (Page 3 of the CFP document), your study might not focus on a specific systems alignment strategy that can be pilot tested.  Instead of pilot test results, you must have documentation of results from another type of preliminary research study that demonstrate the scientific premise and/or the feasibility of your proposed research strategy.  For example, your preliminary research results may provide preliminary support for the hypothesis that a specific form of systemic racism results in inequitable health outcomes for affected populations, such that your proposed new research will seek to build upon this preliminary evidence and offer a more definitive test of this hypothesis.  Additionally, your preliminary research results may demonstrate the feasibility of key elements of your proposed scientific approach, such as your ability to recruit research participants, your ability to obtain needed data and data use agreements, your ability to achieve sufficient sample sizes needed for statistical power, the validity and reliability of the measures you will use, and your ability to secure the engagement and cooperation of representatives from relevant medical, social, and public health systems. 

For the Impact Award category, your LOI must describe pilot test and/or preliminary research results that confirm the feasibility and acceptability of your proposed research.  If your pilot test or preliminary research results are incomplete at the time of LOI submission but expected to be complete by the deadline for full proposal submission, then you should describe this situation in your LOI along with the current status of the pilot test or preliminary research progress.  Selected applicants may be invited to submit a full proposal if the LOI scores highly on selection criteria and the pilot/preliminary results are expected to be complete before the full proposal submission deadline. 

Make sure to use the LOI Template to write your LOI, because it contains specific instructions on what information to include and how to organize this information.  There are two different LOI templates, so make sure to use the correct template for the category of award to which you are applying: (1) Developmental Study LOI Template; (2) Impact Study LOI Template.   

Make sure to use the LOI Template to write your LOI, because it contains specific formatting instructions and specifications including maximum page numbers, margin sizes, font sizes, and line spacing.  There are two different LOI templates, so make sure to use the correct template for the category of award to which you are applying: (1) Developmental Study LOI Template; (2) Impact Study LOI Template. 

You may upload a separate document containing references that are cited in your LOI, so that this reference list does not count against the 3-page LOI limit.  Please review the LOI Template for additional instructions on how to format your reference citations.  There are two different LOI templates, so make sure to use the correct template for the category of award to which you are applying: (1) Developmental Study LOI Template; (2) Impact Study LOI Template.   

Yes, when you submit your LOI using the RWJF online system, you will answer several questions, including a question asking about which Priority Topic of Interest your LOI addresses.  Note that the three Priority Topics of Interest are described on Page 3 of the CFP document.

Yes BUT you will need to specify which ONE of the three Priority Topics provides the best fit with your proposed research.  Note that the three Priority Topics of Interest are described on Page 3 of the CFP document.   

Yes, you may propose a research study to address other topics, as long as your research focuses on a system alignment strategy that helps medical, social, and public health systems work together to dismantle and disrupt for forms of systemic racism embedded within these systems. 

Yes, we encourage you to participate in one of our CFP webinars, and attend one or more of the weekly CFP Office Hour sessions. You can ask questions and obtain general feedback about your ideas.  More information about registering for these sessions can be found here.  Additionally, if you are a community-based organization (rather than a university or research institution), you can utilize a variety of technical assistance resources and supports available through the S4A System Alignment Innovation Hub.  Please reach out early because available assistance opportunities may be limited in the days leading up to the LOI submission deadline. 

If you are a community-based organization (rather than a university or research institution), you can utilize a variety of technical assistance resources and supports available through the S4A System Alignment Innovation Hub.  This Hub may be able to provide assistance and guidance for identifying a suitable research partner for your organization.  Additionally, Johns Hopkins University maintains the Accelerating Collaborations for Evaluation Matching Service which may be able to assist with finding research partners.  The S4A program also can discuss general strategies related to finding a research partner during our weekly CFP Office Hour sessions or via email.  As a general strategy, we encourage you to reach out to the universities and research institutions that operate in your region, including institutions that are part of the NIH Clinical and Translational Science Awards (CTSA) programwhich focuses on community engagement in health research.  Please reach out early because available assistance opportunities may be limited in the days leading up to the LOI submission deadline.

No, budgets are not required and cannot be submitted at the LOI stage.  However, you should keep in mind the funding limits for each type of award category when developing your research idea and LOI.

Systemic racism and structural racism are forms of injustice resulting from historical and contemporary laws, policies, and practices that perpetuate unfair treatment of people from racial and ethnic minority groups and indigenous communities. We use systemic racism and structural racism interchangeably in this CFP.  These forms of racism are deeply embedded in the institutions, delivery systems, and financing systems that shape the distribution of power and resources across American society.  Examples include: barriers to political participation such as political district gerrymandering, inequities in access to polling locations, and restrictive timeframes and mechanisms for ballot casting; lack of representation on governing boards and decision-making bodies; residential segregation by household race, ethnicity and income; inequities in access to capital and financial resources; maldistribution of health and social resources such as clinics, libraries, parks, teachers, sidewalks, and public transportation; environmental injustices such as exposure to polluting industries, hazardous infrastructure, and climate risks; and inequities in information such as the lack of disaggregated data about health and social needs and program effectiveness for specific racial and ethnic minority populations and indigenous communities.  Additional examples include racial patterning in the implementation and enforcement of public policies and administrative practices that require some level of discretionary decision-making, such as law enforcement use of force, incarceration, bail, probation, eviction, expulsion, child protective services actions, child support enforcement, occupational health and safety enforcement, employee recruitment, hiring and training practices, property valuation and tax assessments, medical necessity determinations, medical billing and debt collections, housing voucher acceptance, eligibility determination for Medicaid and other social assistance programs, hospital community benefit activities, and awarding of grants and contracts that fund health and social service programs. 
 
For more detailed definitions, examples, and potential solutions, see this review article:  https://www.healthaffairs.org/doi/10.1377/hlthaff.2021.01394. We encourage applicants to study how forms of systemic racism intersect and interact with other forms of marginalization and inequity in American society, such as those related to sexual orientation, gender identity, disability status, socioeconomic status, educational attainment, immigration and refugee status, national origin, language and literacy, religious affiliation, tribal membership, and rurality.

S4A is a research program that places a high priority on producing scientifically rigorous and credible evidence.  We encourage partnerships between community-based organizations and research institutions to ensure that your research team has the necessary scientific expertise, systems knowledge, implementation capacity, and community expertise to carry out the proposed research.  If your organization is responsible for developing and implementing the proposed System Alignment Strategy that you wish to study, then you are likely to realize important benefits by partnering with an external research institution such as a university or independent research center.  In these cases, an external research partner can provide a neutral and independent perspective on the System Alignment Strategy, and can provide protections against some common sources of research bias such as social desirability bias and motivated reasoning bias.  Additionally, an external research partner may allow your research study to achieve higher levels of credibility with external audiences, and avoid perceptions of research bias, lack of neutrality, or conflicts of interest.  Finally, an external research partner may allow for efficient division of labor by allowing one partner to focus primarily on implementation of the System Alignment Strategy, while allowing the other partner to focus primarily on implementation of research activities.  Of course, all partners should play active and equitable roles in the research design, interpretation of results, and translation of results into actionable strategies for dismantling and disrupting systemic racism.

The simple answer is “Yes” and also “the more partners, the better.” We encourage research-community partnerships to ensure that your research team has the necessary scientific expertise, systems knowledge, implementation capacity, and community expertise to carry out the proposed research.  Community partners are likely to be essential in identifying forms of systemic racism that can be addressed plausibly through multi-sector collective action, and developing innovative System Alignment Strategies to address these problems and meet the needs of people experiencing systemic racism.  Community partners are also likely to be essential in developing a feasible, relevant and responsive research design to study the implementation and/or impact of the System Alignment Strategy.  Finally, community partners are likely to be essential in interpreting research results and developing action strategies based on these results to dismantle and disrupt systemic racism beyond the study settings.   S4A focuses on aligning the efforts of medical, social and public health systems, so you will benefit by having community partners located in each of these types of systems -- especially community partners that serve people experiencing forms of systemic racism that operate through these systems.  Of course, all partners should play active and equitable roles in the research design, interpretation of results, and translation of results into actionable strategies for dismantling and disrupting systemic racism.