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The “case” for case studies: why we need high-quality examples of global implementation research

• Blythe Beecroft   ORCID: orcid.org/0000-0002-6254-421X 1 ,
• Rachel Sturke 1 ,
• Gila Neta 2 &
• Rohit Ramaswamy 3  

Implementation Science Communications volume  3 , Article number:  15 ( 2022 ) Cite this article

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Rigorous and systematic documented examples of implementation research in global contexts can be a valuable resource and help build research capacity. In the context of low- and middle-income countries (LMICs), there is a need for practical examples of how to conduct implementation studies. To address this gap, Fogarty’s Center for Global Health Studies in collaboration with the Cincinnati Children's Hospital Medical Center and the National Cancer Institute is commissioning a collection of implementation science case studies in LMICs that describe key components of conducting implementation research, including how to select, adapt, and apply implementation science models, theories, and frameworks to these settings; develop and test implementation strategies; and evaluate implementation processes and outcomes. The case studies describe implementation research in various disease areas in LMICs around the world. This commentary highlights the value of case study methods commonly used in law and business schools as a source of “thick” (i.e., context-rich) description and a teaching tool for global implementation researchers. It addresses the independent merit of case studies as an evaluation approach for disseminating high-quality research in a format that is useful to a broad range of stakeholders. This commentary finally describes an approach for developing high-quality case studies of global implementation research, in order to be of value to a broad audience of researchers and practitioners.

Peer Review reports

Contributions to the literature

Reinforcing the need for “thick” (i.e., context-rich) descriptions of implementation studies

Highlighting the utility of case studies as a dissemination strategy for researchers, practitioners, and policymakers

Articulating the value of detailed case studies as a teaching tool for global implementation researchers

Describing a method for developing high-quality case studies of global implementation research

Research capacity for implementation science remains limited in low- and middle-income countries (LMICs). Various stakeholders, including NIH-funded implementation researchers and practitioners, often inquire about how to apply implementation science methods and have requested additional resources and training to support implementation capacity building. This is in part due to a dearth of practical examples for both researchers and practitioners of how to select, adapt, and apply implementation science models, theories, and frameworks to these settings; how to evaluate implementation processes and outcomes; and how to develop and test implementation strategies. The need for detailed documentation of implementation research in all settings has been well established, and guidelines for documentation of implementation research studies have been created [ 1 , 2 ]. But the mere availability of checklists and guidelines in and of themselves does not result in comprehensive documentation that is useful for learning, as has been pointed out by many systematic reviews of implementation science and quality improvement studies ([ 3 , 4 ]). It has also been observed that documentation alone is not enough, and there is a need for mentors to translate abstract theories into context-appropriate research designs and practice approaches [ 5 ]. Because of the especially acute shortage of mentors and coaches in LMIC settings, we propose that documentation with “thick” descriptions that go beyond checklists and guidelines are needed to make the field more useful to emerging professionals [ 6 ]. We suggest that the case study method intended to “explore the space between the world of theory and the experience of practice” [ 7 ] that has been used successfully for over a century by law and business schools as a teaching aid can be of value to develop detailed narratives of implementation research projects. In this definition, we are not referring to the case study as a qualitative research method [ 8 ], but as a rich and detailed method of retrospective documentation to aid teaching, practice, and research. In this context, our case studies are akin to “single-institution or single-patient descriptions” [ 9 ] called “case reports” or “case examples” in other fields. As these terms are rarely used in global health, we have used the words “case studies” in this paper but reiterate that they do not refer to case study research designs.

Fogarty’s Center for Global Health Studies (CGHS) in collaboration with the Cincinnati Children's Hospital Medical Center and the National Cancer Institute (NCI) is commissioning a collection of implementation science case studies that describe implementation research focusing on various disease areas in different (LMIC) contexts around the world. These case study descriptions will provide guidance on the process of conducting implementation science studies and will highlight the impact these studies have had on practice and policy in global health contexts. This brief note makes a case for using case studies to document and disseminate implementation research, describes the CGHS approach to case study development and poses evaluation questions that need to be answered to better understand the utility of case studies. This effort is intended to develop a set of useful examples for LMIC researchers, practitioners, and policymakers, but also to assess and improve the use of case studies as a tested documentation methodology in implementation research.

The “case” for case studies

A preliminary landscape analysis of the field conducted by CGHS found that there are not many descriptions of global implementation science projects in a case study format in the peer-reviewed or gray literature, and those that exist are embedded in the content of academic teaching materials. There is not a cohesive collection, especially relating to health, that illustrates how implementation research has been conducted in varied organizations, countries, or disease areas. This new collection will add value in three different ways: as a dissemination strategy, as a tool for capacity building, and as a vehicle for stimulating better research.

Case studies as a dissemination strategy

Case studies have independent merit as an evaluation approach for disseminating high-quality research in a format that is useful to a broad range of stakeholders. The Medical Research Council (MRC) has recommended process evaluation as a useful approach to examine complex implementation, mechanisms of impact, and context [ 10 ]. Guidelines on documentation of implementation recommend that researchers should provide “detailed descriptions of interventions (and implementation strategies) in published papers, clarify assumed change processes and design principles, provide access to manuals and protocols that provide information about the clinical interventions or implementation strategies, and give detailed descriptions of active control conditions” [ 1 ]. Case studies can be thought of as a form of post hoc process evaluation, to disseminate how the delivery of an intervention is achieved, the mechanisms by which implementation strategies produce change, or how context impacts implementation and related outcomes.

Case studies as a capacity building tool

In addition, case studies can address the universal recognition of the need for more capacity building in Implementation Science , especially in LMIC settings. Case studies have been shown to address common pedagogical challenges in helping students learn by allowing students to dissect and explore limitations, adaptations, and utilization of theories, thereby creating a bridge between theories presented in a classroom and their application in the field [ 11 ]. A recent learning needs assessment for implementation researchers, practitioners, and policymakers in LMICs conducted by Turner et al. [ 12 ] reflected a universal consensus on the need for context-specific knowledge about how to apply implementation science in practice, delivered in an interactive format supported by mentorship. A collection of case studies is a valuable and scalable resource to meet this need.

Using case studies to strengthen implementation research

Descriptions of research using studies can illustrate not just whether implementation research had an impact on practice and policy, but how, why, under what circumstances, and to whom, which is the ultimate goal of generating generalizable knowledge about how to implement. Using diverse cases to demonstrate how a variety of research designs have been used to answer complex implementation questions provides researchers with a palette of design options and examples of their use. A framework developed by Minary et al. [ 13 ] illustrates the wide variety of research designs that are useful for complex interventions, depending on whether the emphasis is on internal and external validity or whether knowledge about content and process or about outcomes is more important. A collection of case studies would be invaluable to researchers seeking to develop appropriate designs for their work. In addition, the detailed documentation provided through these case descriptions will hopefully motivate researchers to document their own studies better using the guidelines described earlier.

Developing and testing the case study creation process: the CGHS approach

Writing case studies that satisfy the objectives described above is an implementation science undertaking in itself that requires the engagement of a variety of stakeholders and planned implementation strategies. The CGHS team responsible for commissioning the case studies began this process in 2017 and followed the approach detailed below to test the process of case study development.

Conducted 25+ consultations with various implementation science experts on gaps in the field and the relevance of global case studies

Convened a 15-member Steering Committee Footnote 1 of implementation scientists with diverse expertise, from various academic institutions and NIH institutes to serve as technical experts and to help guide the development and execution of the project

Developed a case study protocol in partnership with the Steering Committee to guide the inclusion of key elements in the case studies

Commissioned two pilot cases Footnote 2 to assess the feasibility and utility of the case study protocol and elicited feedback on the writing experience and how it could be improved as the collection expands

Led an iterative pilot writing process where each case study writing team developed several drafts, which were reviewed by CGHS staff and a designated member of the Steering Committee

Truncated and adjusted the protocol in response to input from the pilot case study authors teams

Developed a comprehensive grid with the Steering Committee, outlining the key dimensions of implementation science that are significant and would be important areas of focus for future case studies. The grid will be used to evaluate potential case applicants and is intended to help foster diversity of focus and content, in addition to geography

Implementing the process: the call for case studies

In March of 2021, CGHS issued a closed call for case studies to solicit applications from a pool of researchers. Potential applicants completed the comprehensive grid in addition to a case study proposal. Applicants will go through a three-tier screening and review process. CGHS will initially screen the applications for completeness to ensure all required elements are present. Each case study application will then be reviewed by two Steering Committee members for content and scientific rigor and given a numerical score based on the selection criteria. Finally, the CGHS team will screen the applications to ensure diversity of implementation elements, geography, and disease area. Approximately 10 case studies will be selected for development in an iterative process. Each case team will present their case drafts to the Steering Committee, which will collectively workshop the drafts in multiple sittings, drawing on the committee’s implementation science expertise. Once case study manuscripts are accepted by the Steering Committee, they will be submitted to Implementation Science Communications for independent review by the journal. CGHS intends for the case studies to be published collectively, but on a rolling basis as they are accepted for publication.

Future research: evaluating the effectiveness of the case study approach

This commentary has put forth arguments for the potential value of case studies for documenting implementation research for researchers, practitioners, and policymakers. Case studies not only provide a way to underscore how implementation science can advance practice and policy in LMICs, but also offer guidance on how to conduct implementation research tailored to global contexts. However, there is little empirical evidence about the validity of these arguments. The creation of this body of case studies will allow us to study why, how, how often, and by whom these case studies are used. This is a valuable opportunity to learn and use that information to better inform future use of this approach as a capacity-building or dissemination strategy.

Conclusions

Similar to their use in law and business, case study descriptions of implementation research could be an important mechanism to counteract the paucity of training programs and mentors to meet the demands of global health researchers. If the evaluation results indicate that the case study creation process produces useful products that enhance learning to improve future implementation research, a mechanism needs to be put in place to create more case studies than the small set that can be generated through this initiative. There will be a need to create a set of documentation guidelines that complement those that currently exist and a mechanism to solicit, review, publish, and disseminate case studies from a wide variety of researchers and practitioners. Journals such as Implementation Science or Implementation Science Communications can facilitate this effort by either creating a new article type or by considering a new journal with a focus on rigorous and systematic case study descriptions of implementation research and practice. An example that could serve as a guide is BMJ Open Quality , which is a peer-reviewed, open-access journal focused on healthcare improvement. In addition to original research and systematic reviews, the journal publishes two article types: Quality Improvement Report and Quality Education Report to document healthcare quality improvement programs and training. The journal offers resources for authors to document their work rigorously. Recently, a new journal titled BMJ Open Quality South Asia has been released to disseminate regional research. We hope that our efforts in sponsoring and publishing these cases, and in setting up a process to support their creation, will make an important contribution to the field and become a mechanism for sharing knowledge that accelerates the growth of implementation science in LMIC settings.

Availability of data and materials

Not applicable.

Rohit Ramaswamy, CCHMC, Gila Neta, NCI NIH, Theresa Betancourt, BC, Ross Brownson, WASU, David Chambers, NCI NIH, Sharon Straus, University of Toronto, Greg Aarons, UCSD, Bryan Weiner, UW, Sonia Lee, NICHD NIH, Andrea Horvath Marques, NIMH NIH, Susannah Allison, NIMH NIH, Suzy Pollard, NIMH NIH, Chris Gordon, NIMH NIH, Kenny Sherr, UW, Usman Hamdani, HDR Foundation Pakistan, Linda Kupfer, FIC NIH

The first pilot case was led by the Human Development Research Foundation (HDRF) in Pakistan and examines scaling up evidenced-based care for children with developmental disorders in rural Pakistan. The second pilot was led by Boston College and investigates alternate delivery platforms and implementation models for bringing evidence-based behavioral Interventions to scale for youth facing adversity in Sierra Leone to close the mental health treatment gap.

Abbreviations

Low- and middle-income countries

Center for Global Health Studies

National Cancer Institute

Medical Research Council

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Beecroft, B., Sturke, R., Neta, G. et al. The “case” for case studies: why we need high-quality examples of global implementation research. Implement Sci Commun 3 , 15 (2022). https://doi.org/10.1186/s43058-021-00227-5

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Exploring drivers and challenges in implementation of health promotion in community mental health services: a qualitative multi-site case study using Normalization Process Theory

Affiliations.

• 1 DEFACTUM - Public Health and Health Services Research, Central Denmark Region, Aarhus, Denmark. [email protected].
• 2 Department of Public Health, University of Aarhus, Aarhus, Denmark. [email protected].
• 3 DEFACTUM - Public Health and Health Services Research, Central Denmark Region, Aarhus, Denmark.
• 4 The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark.
• PMID: 29361935
• PMCID: PMC5781336
• DOI: 10.1186/s12913-018-2850-2

Background: There is an increased interest in improving the physical health of people with mental illness. Little is known about implementing health promotion interventions in adult mental health organisations where many users also have physical health problems. The literature suggests that contextual factors are important for implementation in community settings. This study focused on the change process and analysed the implementation of a structural health promotion intervention in community mental health organisations in different contexts in Denmark.

Methods: The study was based on a qualitative multiple-case design and included two municipal and two regional provider organisations. Data were various written sources and 13 semi-structured interviews with 22 key managers and frontline staff. The analysis was organised around the four main constructs of Normalization Process Theory: Coherence, Cognitive Participation, Collective Action, and Reflexive Monitoring.

Results: Coherence: Most respondents found the intervention to be meaningful in that the intervention fitted well into existing goals, practices and treatment approaches. Cognitive Participation: Management engagement varied across providers and low engagement impeded implementation. Engaging all staff was a general problem although some of the initial resistance was apparently overcome. Collective Action: Daily enactment depended on staff being attentive and flexible enough to manage the complex needs and varying capacities of users. Reflexive Monitoring: During implementation, staff evaluations of the progress and impact of the intervention were mostly informal and ad hoc and staff used these to make on-going adjustments to activities. Overall, characteristics of context common to all providers (work force and user groups) seemed to be more important for implementation than differences in the external political-administrative context.

Conclusions: In terms of research, future studies should adopt a more bottom-up, grounded description of context and pay closer attention to the interplay between different dimensions of implementation. In terms of practice, future interventions need to better facilitate the translation of the initial sense of general meaning into daily practice by active local management support that occurs throughout the implementation process and that systematically connects the intervention to existing practices.

Keywords: Community mental health services; Context; Health promotion; Implementation; Normalization Process Theory.

Publication types

• Multicenter Study
• Research Support, Non-U.S. Gov't
• Attitude of Health Personnel
• Community Mental Health Services* / organization & administration
• Health Promotion / methods
• Health Promotion / organization & administration*
• Interviews as Topic
• Mental Disorders / rehabilitation
• Mental Disorders / therapy*
• Models, Theoretical
• Program Development
• Qualitative Research

SAP S/4HANA Implementation Challenges

If you’re now considering a switch to SAP, understanding SAP S/4HANA implementation challenges beforehand are important. Companies are now realizing threats to supply chain due to COVID-19, the pandemic. Between the recent economic dips in the stock market and increasing numbers in storefronts having to close their doors each day due to coronavirus, has companies concerned on how to better prepare for the future. The good news is that business will spike again, and we should all be prepared for that surge. On that note you may be one of the many that is experimenting with the rare opportunity of free access to SAP tools right now and are thinking about the opportunities that could be available to your company if S/4HANA was implemented when we are all able to collaborate in-person again. SAP S/4HANA can not only help your business and supply chain run smoothly during a “normal” season, but also when a company is thrust into uncertainty.

Most business users are aware of the key benefits and value adds that SAP S/4HANA provides users with including, but not limited to; simplification and centralization to management and administration, ease of use, cost effectiveness, innovation, improved performance and speed, and an overall simple transition from on-premise to cloud. But not all are aware of and ready to approach the potential challenges.

We  recognize that there are many business benefits, but also challenges to be addressed from implementing SAP S/4HANA in your business and its best to go into an implementation with a well-prepared mindset. By leveraging relevant experiences working with leading companies within the consumer products industry, many challenges can be overcome quickly with a value added partner backing your business. While every transition presents unique risks and challenges for each company and their team, some broad SAP S/4HANA Implementation challenges to be considered from our perspective include:

SAP S/4HANA Implementation Challenges with Data    As with any implementation, data will be a key challenge. While the details vary depending on the size of the company, product line, whether it is brownfield or a greenfield implementation of S/4, quality of data in the legacy system etc. data will remain in the front and center of an S/4 implementation. Different categories such as master data (Business Partner (Customer, Vendor), Materials (Articles in a retail scenario), BOMs, Recipes), Open Transaction data (AR, AP, Open POs, Open Sales Orders, Inventory etc.), Transaction data for reporting (YOY comparative reporting, Statutory reporting) need to be carefully evaluated and prepared for the implementation. See our blogs highlighting considerations around data here.

SAP S/4HANA Implementation Challenges with Architecture  As you move to a new digital platform with S/4, there are several considerations/questions around the overall architecture. Are we going for a cloud solution or on prem? If it is cloud will it be single tenant (renamed S/4 Essentials) OR multi-tenant (renamed S/4 Extended)? If it is on prem, can we host it ourselves or look for a 3rd party hosting provider? How would the employees access the system, laptops, iPads, mobile phones? Will our partners (vendors, customers) access the system as well? What kind of security will need to built in?

SAP S/4HANA Challenges with Training and Change Management  While we dealt with the more tangible and technical challenges in the previous sections, of equal importance are the training and change management aspects of an S/4 implementation. While you should see this as an opportunity to move to a more best practices based approach of conducting your business, this will be a change for stakeholders that have been doing things in a certain manner (and the quintessential response of ‘we are different’, ‘this is the way we have been doing it forever’). Careful engagement with the stakeholders to understanding of the change impacts with clear mitigations along with a robust training approach are critical. For more information on coming up with a robust training strategy see our blog here

SAP S/4HANA Implementation with resources  Most companies when considering a switch to SAP S/4HANA aren’t familiar enough to internally head up a project centered on a migration to this ERP platform and must search externally. Therefore, finding a partner that is knowledgeable and can demonstrate and provide their expertise, experience, support, toolkit, and client references is crucial when considering a partner to work with on the implementation.  Ensuring that you are working with someone who has extensive experience in this arena will be imperative in supporting your business properly, staying on timeline, and exceeding expectations for internal stakeholders for your organization.

We realize a move to SAP S/4HANA is a significant decision considering the implications to your business. Clarkston wants to help you unlock new business value with SAP’s Intelligent ERP , realize new benefits, and overcome challenges with ease. If you want to understand our client success stories, start a free trial with SAP S/4HANA, or have a conversation about implementing S/4HANA for your business, please contact us today to learn more.

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3 Successful ERP Implementation Case Studies

What do a maker of grooming products for men, a fast-growing moving business and a specialized shipping logistics provider have in common? All three had intractable challenges that were addressed by an enterprise resource planning (ERP) system.

In all cases, their journeys started with ERP implementations. Once up and running, these disparate companies got the results they needed: more sales without adding new employees, faster and more accurate payroll processing and the ability to deliver tens of thousands of orders per day without delays or errors, respectively.

What Is an ERP Implementation?

An ERP implementation is the process of installing enterprise resource planning (ERP) software, and then making sure your team is making the most of the technology. The process includes three main phases:

• Installing onsite software and/or contracting with a SaaS provider. Often, companies seek help from the vendor or an implementation partner specializing in ERP, the vertical industry or specialized use cases.
• Migrating data from your previous system or systems into the new ERP.
• Training the finance team to use the new software. That process may include knowledge transfer from employees who previously used the system or formal education from your implementation partner.

The success rate ERP implementations is improving thanks to a focus on user experience, specifically simpler interfaces, more configuration flexibility, mobile functionality and increased automation. In fact, IDC’s 2021 SaaSPath Survey showed that "ease of use" is the most important vendor selection criteria for those purchasing finance applications.

Best practices to ensure success include organizing a strong implementation team of leaders from all areas of your company, from sales to accounting to operations. Ask them: What problems would we like this new system to resolve?

When choosing the ERP, it’s important to ensure it can easily integrate with other financial systems, and those of your key partners, and that you can be up and running in a reasonable timeframe, preferably 90 days or less. Finally, make sure your finance policies and procedures are aligned to make the most of the new system.

Key Takeaways

An ERP implementation is a process: ERP vendors and reviewers alike recommend carefully evaluating ERP vendors and/or partners before beginning, as well as taking things one step at a time, setting expectations with realistic planning timeframes and a comprehensive checklist mapped to your company’s goals for the system.

Let’s look at three companies that found success with their ERP implementation projects, and their key lessons learned.

ERP Case Study #1: Fulton & Roark

Fulton & Roark , a retailer of men’s grooming products, is an example of a successful ERP implementation.

Prior to upgrading to full-featured ERP, the North Carolina-based business tracked its inventory in a spreadsheet and its financial data in desktop accounting software, Sage Live. When the company began doubling sales year-over-year, leadership felt its current processes weren’t keeping up. Spreadsheets couldn’t account for changing inventory costs, and the accounting software didn’t have the workflows necessary to record the cost of goods sold (COGS) , an important financial metric.

As a result, the Fulton & Roark team did double data entry — manually.

To centralize all work in one place, the company’s co-founders implemented NetSuite ERP . After a three-week implementation process, changes were immediate, according to team members. Finally, the Fulton & Roark team was able to:

• Catch and correct bookkeeping mistakes related to inventory.
• Stop working with external accountants, growing both unit and dollar volumes significantly with no extra headcount.
• Increase sales roughly 50% year-over-year without increasing headcount.
• Get a more accurate picture of margins and inventory, which helped grow its ecommerce operation.
• ERP implementations don’t have to drag on — Fulton & Roark’s team was up and working in about 20 days.
• The company’s story also emphasizes a major success factor: Getting management committed to an ERP project. In this case, the co-founders initiated the project, which consultants say often spurs employee adoption.

ERP Case Study #2: N&N Moving Supplies

N&N Moving Supplies, a family-run distributor of moving equipment and supplies, successfully implemented an ERP system after expanding from one location in Georgia to three locations in multiple states and more than quadrupling its workforce.

Running on QuickBooks and a third-party payroll provider, it was nearly impossible to keep accurate time records and reconcile payroll with general ledger accounts. So, N&N turned to ERP to manage its accounting and payroll processes. During the implementation process for NetSuite ERP, N&N worked with a NetSuite partner, NOVAtime, to add a time-clock solution to the main system.

With this in place, N&N was able to:

• Reduce payroll processing time by 84%.
• Balance accounts faster.
• Improve the accuracy of hours and vacation time counts.
• See labor-cost trends across its three locations.
• Give employees access to personalized ERP dashboards on iPads at each of its sites.
• N&N’s case study nods to another major implementation success factor: managing employee morale. ERP projects often fail when execs and other employees don’t feel a sense of buy-in. By providing personalized dashboards — and ideally explaining their benefits to employees before the implementation — N&N avoided this pitfall.
• The case study also shows that a third-party partner can be helpful in tailoring the ERP system to precisely fit your company’s needs.

ERP Case Study #3: Green Rabbit

Once upon a time, two friends launched a candy wholesale business. Then, they ran into a problem: shipping melt-prone chocolate bars during summer months. After the pals designed a heat-sensitive supply chain, other food companies turned to them for help. The duo rebranded as Green Rabbit, a supply chain logistics provider specializing in fast delivery of perishable goods.

That shift in strategy tested the company’s current processes, which relied on QuickBooks, Excel and email. Green Rabbit’s multiple databases couldn’t communicate with one another, making real-time data analysis impossible. The warehouse was often waiting on help from the IT team, too.

Green Rabbit chose NetSuite ERP, and the NetSuite professional services team got the company up and running on the system in three months.

Green Rabbit now:

• Helps customers ship candy, snacks and more across the country in 24 hours from one of three different warehouses, without inventory errors.
• Delivers tens of thousands of orders per day, without delays.
• Gets guaranteed error-free data from its ERP system, instead of risking errors from manually entered data.
• Could triple its order volume, if desired, without impact to its systems.
• When implemented correctly, ERP makes it easier to manage a complicated supply chain, as Green Rabbit’s case study shows.
• ERP is pivotal to growth. Green Rabbit implemented ERP after it grew substantially and because it anticipated further expansion.

Many growing companies like those profiled here ask: “What is the business case for ERP?”

Besides the takeaways from our case studies, it boils down to agility. When finance teams stop peering at dozens of spreadsheets and paper records, they can get strategic. By helping executive and business colleagues visualize data, growing firms can forecast future trends and adapt quickly to beat competitors.

ERP Success Factors

ERP systems can revolutionize businesses and ease their paths to growth, but successful applications of them share some common traits. The first is employee adoption and morale, which requires encouraging buy-in by presenting the ERP in a way in which it will directly benefit the end users. Providing dashboards and solutions tailored to each business makes this easier to do — and tagging in a third-party partner to help with a tailored implementation is an effective way to accomplish this. Also important is planning and executing the implementation efficiently , while having realistic expectations for the timeline.

#1 Cloud ERP Software

What Are the Challenges of ERP?

Implementing an ERP can mean overcoming obstacles. Two of the most commonly cited ERP challenges are:

Choosing the right vendor. Obviously, choosing an ERP system that doesn’t fit your company’s needs will likely result in a failed implementation. Many advisers recommend evaluating around five vendors before choosing which ERP to purchase.

Companies should choose a vendor that has experience with your company’s vertical, type (product or service) and size; can provide a hands-on demo; understands the tax laws and regulations that apply to your business; and is sure to be in business in five years.

• Getting employees to support the change. As mentioned, teams may resist the transition to ERP if you don’t show them why the new system will be helpful to them. Explain how ERP will make each team’s everyday tasks easier before the implementation begins and ensure plenty of time for training during the process.

Why Do ERP Implementations Fail?

ERP implementations can fail without proper risk management. In other words, leaders need to anticipate what might derail the project, then plan.

In one often-cited case, for example, a multinational distributor’s implementation epically failed, resulting in major shipping delays and lost sales. It turns out the company had operational issues before the implementation even began, as it had just acquired another company and was having trouble integrating the new subsidiary’s operations into its own. Company leadership should have managed that risk by identifying and fixing those operational issues before the ERP implementation began.

ERP implementation is a process. It requires lots of planning to ensure success. However, your company isn’t the first to go through it. Consider case studies of successful implementations, choose the right partner and your business will enjoy the benefits of the system, quickly.

If you’re considering an ERP implementation, schedule a consultation with NetSuite .

ERP Implementation Plan: Methodology and Process

Enterprise resources planning (ERP) solutions are designed to support an organization in just about every aspect of business operations by centralizing data and through automation. These platforms control internal…

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• Open access
• Published: 19 March 2021

Implementation science should give higher priority to health equity

• Ross C. Brownson   ORCID: orcid.org/0000-0003-4260-2205 1 , 2 ,
• Shiriki K. Kumanyika 3 ,
• Matthew W. Kreuter 4 &
• Debra Haire-Joshu 5  

Implementation Science volume  16 , Article number:  28 ( 2021 ) Cite this article

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A Letter to the Editor to this article was published on 31 January 2022

There is growing urgency to tackle issues of equity and justice in the USA and worldwide. Health equity, a framing that moves away from a deficit mindset of what society is doing poorly (disparities) to one that is positive about what society can achieve, is becoming more prominent in health research that uses implementation science approaches. Equity begins with justice—health differences often reflect societal injustices. Applying the perspectives and tools of implementation science has potential for immediate impact to improve health equity.

We propose a vision and set of action steps for making health equity a more prominent and central aim of implementation science, thus committing to conduct implementation science through equity-focused principles to achieve this vision in U.S. research and practice. We identify and discuss challenges in current health disparities approaches that do not fully consider social determinants. Implementation research challenges are outlined in three areas: limitations of the evidence base, underdeveloped measures and methods, and inadequate attention to context. To address these challenges, we offer recommendations that seek to (1) link social determinants with health outcomes, (2) build equity into all policies, (3) use equity-relevant metrics, (4) study what is already happening, (5) integrate equity into implementation models, (6) design and tailor implementation strategies, (7) connect to systems and sectors outside of health, (8) engage organizations in internal and external equity efforts, (9) build capacity for equity in implementation science, and (10) focus on equity in dissemination efforts.

Conclusions

Every project in implementation science should include an equity focus. For some studies, equity is the main goal of the project and a central feature of all aspects of the project. In other studies, equity is part of a project but not the singular focus. In these studies, we should, at a minimum, ensure that we “leave no one behind” and that existing disparities are not widened. With a stronger commitment to health equity from funders, researchers, practitioners, advocates, evaluators, and policy makers, we can harvest the rewards of the resources being invested in health-related research to eliminate disparities, resulting in health equity.

Peer Review reports

Contributions to the literature

There is an urgent call to address issues of equity, health, and social justice in the USA—driven in part by greater awareness of striking increases in economic inequality and the visibility and impacts of structural racism and associated societal problems.

Implementation science is an area of research with high potential to accelerate progress toward achieving health equity goals in both public health and healthcare.

We provide 10 recommendations to advance health equity as a priority of implementation science to address challenges in building the evidence base, developing new measures and methods, and addressing context.

Actions to address ours and other recent recommendations are likely to further health equity and implementation science.

There is growing urgency to tackle issues of equity and justice [ 1 , 2 ], which is driven by greater awareness of decades-long increases in income and wealth inequality [ 3 ] and the visibility and impacts of structural racism and associated societal problems [ 4 ]. Longstanding socioeconomic and racial/ethnic disparities in numerous health outcomes are prominent among these societal challenges and are now exacerbated by the impacts of the COVID-19 pandemic [ 5 ]. The focus on equity is spreading quickly across many sectors and in very public ways [ 6 ]. A renewed focus on social and structural determinants of health, including racism and discrimination, is also advancing within the scientific community [ 7 ].

Health equity is a framing that moves away from a deficit mindset of what society is doing poorly (disparities) to one that is positive about what society can achieve [ 8 ]. Beginning in Europe, there has been growing attention on health equity—the commitment to reduce and ultimately eliminate health disparities [ 9 , 10 , 11 , 12 ]. In the UK, Whitehead framed health inequities as not only avoidable but also unjust [ 13 ]. Braveman and colleagues pointed out that achieving health equity involves closing health gaps between those less and those more advantaged while also improving the health of the population overall [ 9 ]. Health inequity is addressed through a range of approaches: changing large-scale policies to offset historical injustices, changing policies and practices within healthcare settings, and changing organizational or community contexts that influence health.

A clear distinction is needed between systems, programs, or policies that are equitable , that is, accounting for systematic social disadvantage and injustice, and those that might seem fair because they use the language of equality . Viewing everyone equally assumes, incorrectly, that all population groups have similar circumstances, resources, and opportunities for achieving good health. For example, changing policies that target longstanding injustices fosters equity by improving social and economic conditions, such as poverty and the opportunity structure for education, housing, employment, and access to healthcare.

Implementation science is an area of research with particular potential to accelerate progress toward achieving health equity goals [ 14 ]. Implementation science seeks to understand and influence how scientific evidence is put into practice for health improvement [ 15 ]. It offers an explicit response to the decades of scientific progress that generally have not translated into equitable improvements in population health [ 16 ]. Applying the perspectives and tools of implementation science has potential for immediate improvement of health equity. Moreover, a greater emphasis on health equity could attract new and more diverse scientific talent to fully invest in implementation science solutions.

Although a focus on disparities and/or health equity has long been an emphasis of implementation science, a more explicit priority on health equity is timely [ 14 , 17 , 18 , 19 , 20 ]. Elements of health equity are now being more prominently considered in implementation science models (aka, frameworks, theories), in the context of implementation of interventions, and in study methods. Recent conceptual models, such as the Health Equity Implementation Framework [ 20 ], have begun to examine more deeply a broad array of social determinants of health, rather than simply adding a disparities component to the large set of existing implementation science frameworks [ 21 ]. Incorporating a strong equity focus in implementation science requires not only a deliberate emphasis on the needs, culture, and history of the populations and communities [ 22 , 23 ], but also more critical analyses and deeper understanding of systems and policies, including care delivery and provider attitudes from which inequities might arise. Equity-centered research relies on meaningful engagement and partnership with multiple stakeholders, builds on existing resources, develops shared goals, and integrates knowledge and action that lead to a fairer distribution of power and the benefits of an intervention for all partners [ 23 , 24 , 25 ].

In this article, we propose a vision for making health equity the highest priority in implementation science, and thus a central indicator of the field’s success. This means actively seeking and positively addressing issues of diversity and disadvantage to improve the relevance, effectiveness, equity, and impact of implementation science. We identify and discuss challenges in current approaches to addressing health disparities in the context of implementation science and provide recommendations to move the field forward to achieve health equity. While our article is focused largely on public health and health equity challenges in the USA, we draw upon literature and experiences from other regions of the globe.

Key challenges

Here, we address three important challenges for health equity in implementation science. We propose that each can be overcome, and provide a set of recommendations with specific steps to address them.

To identify relevant literature for this article, a review of reviews was conducted using searches for English-language documents published between January 2015 and February 2021. Electronic databases searched included PubMed, Google, and Google Scholar. Keywords included “health equity,” “heath disparities,” “health inequalities,” “implementation,” and “social determinants of health.” Following screening of titles and abstracts, full papers were reviewed and examined for the following information: focus of the study; type of review (i.e., narrative review, review of systematic reviews, scoping review, systematic review, umbrella review); and selected findings of relevance to health equity and implementation science.

Limitations of the evidence base

There are at least two important limitations of current scientific evidence that must be overcome to achieve health equity goals: (1) too few evidence-based interventions (EBIs) adequately include a systems approach or address upstream social determinants and (2) the lack of diversity in study samples and settings limits applicability of research findings in ways that unintentionally benefit some populations more than others, potentially exacerbating health inequities.

In implementation research, an EBI is central [ 26 ]—often addressing some well-established risk factor (e.g., tobacco use, lack of cancer screening) [ 27 , 28 ]. However, the origins of many risk behaviors and exposures are shaped by adverse social determinants of health and root causes of inequities (e.g., structural racism, unjust allocation of power and resources). Even though we have a deep literature on the importance of social determinants [ 8 , 10 , 29 , 30 ], most repositories of EBIs are organized around downstream diseases and risk factors, with inadequate attention to upstream factors and solutions [ 31 ].

Approaches for developing EBIs characteristically follow a reductionist tradition, where the objective is to reconstruct reality by its linear, cause and effect parts [ 32 ], not acknowledging or attending to broader systems in which the risk behavior is embedded [ 33 ]. Typically, EBI deployment involves developing and testing an intervention by researchers in a specific population, identifying discordance between where and with whom the EBI was originally tested and a new setting and population of interest (contextual differences), and then adapting the EBI to fit [ 34 ]. A more practice-based, systems approach is needed for achieving equity. For example, a health equity approach recognizes that race-based discrimination through one system (e.g., housing) is reinforced in other interlocking systems (e.g., transportation, education) and identifies how these systems can undercut the effectiveness, in real-world practice, of an intervention developed in a best-case, controlled efficacy study. A systems-based approach identifies the leverage points within and across societal sectors with the highest potential for impact on health equity [ 35 , 36 ].

There is also evidence for an “inverse prevention law,” which suggests that those in most need of benefiting from an EBI may be the least likely to receive it [ 37 ]. When an EBI improves health across the general population, it may have an unintended consequence of increasing health inequities for some groups (e.g., low-income populations, certain minority groups) who were less likely to be reached or reached effectively [ 37 , 38 , 39 ]. Widening of disparities is a clear indication of the failure of science, practice, and policy to adequately achieve equity. In a review of public health interventions in high-income countries, Lorenc and colleagues found that certain interventions (media campaigns, workplace smoking bans) showed evidence of increasing inequities affecting lower socioeconomic groups [ 37 ]. In a policy-focused umbrella review, Thomas and colleagues studied a wide range of policy approaches across seven public health areas: tobacco, alcohol, food and nutrition, reproductive health services, the control of infectious diseases, the environment, and workplace regulations [ 39 ]. While most policies were shown to either reduce inequities or were neutral toward inequities, some appear to increase inequities (e.g., folic acid mass media campaigns, low emission zones in cities). Implementation of broad policy approaches thought to be universal may require adjustments to aspects of disadvantaged settings and populations to achieve equitable effects.

Underdeveloped measures and methods

The measures and methods for implementation science are evolving but to date with a limited emphasis on equity and, therefore, a lack of methods that are sensitive to equity issues. For example, upstream interventions which are often focused on policy changes are likely to decrease inequities if appropriately designed [ 37 ], but a review of measures of policy implementation found that none of the 170 measures used in a diverse set of studies had an explicit focus on equity [ 40 ].

Policy and other interventions that address fundamental health equity issues should be studied with the strongest designs possible. In some cases, the biomedical “gold standard” designs (e.g., the randomized controlled trial) can be used, including cluster-randomized trials [ 41 ] and stepped-wedge designs [ 42 ]. There is growing literature on how to conduct randomized trials that are equity-relevant [ 43 , 44 , 45 ]. In other cases, particularly when the independent variable (e.g., a policy) cannot be randomized, non-randomized designs and methods are appropriate (e.g., time-series designs, quasi-experiments, natural experiments, difference in difference studies) [ 41 , 46 ]. This range of study methods can help with understanding and addressing policies and equity-related issues in various contexts [ 41 ]. Also relevant are pragmatic trials that address issues of importance to key stakeholders by conducting research in real-world conditions, seeking to enhance external validity and other information relevant to transferability to other settings [ 47 ]. Such pragmatic approaches facilitate equity-driven implementation science due to their ability to assess multilevel impacts and an emphasis on who benefits and who does not benefit from an EBI [ 48 ].

Inadequate attention to context

Context is a central feature of implementation science, yet it is frequently poorly defined or goes unreported [ 49 ]. Often context relates to characteristics of a priority population of focus or the setting within which an EBI is being delivered [ 50 , 51 ]. Failure to fully account for context limits the applicability and generalizability of study findings to different populations, settings, and time periods [ 51 ]. Gaps in our current approaches to context include (1) inadequate attention to macro forces that shape implementation and (2) a need to re-visit the role of EBI adaptation.

To advance equity, we need to more fully account for (macro-level) historical, cultural, economic, and political forces that shape implementation in low-resource settings and communities within the USA and in other countries [ 14 , 52 ]. When implementing or scaling up an EBI, contexts should be conceptualized in terms of aspects of the intervention and its delivery that are likely to differ from those of the original study population in populations affected by inequities, focusing on those factors that are likely to influence intervention uptake, salience, and effectiveness. First, during implementation planning, a community assessment should account for historical, cultural, and system factors such as structural racism and mistrust of health systems [ 53 ]. Second, selection of an EBI is a critical part of implementation and should avoid the assumption that any EBI is good for anyone in any context [ 54 ]. And third, it is useful to consider contextual issues across all levels of a socio-ecological framework (individual, interpersonal, organizational, community, policy) [ 52 ]. Table  1 summarizes reviews of equity-relevant studies describing essential implementation contextual elements for interventions among disadvantaged populations and low-resource settings [ 55 , 56 , 57 , 58 , 59 ].

Contextual conditions drive adaptation—e.g., how an EBI needs to be adapted for a population different from the one with which it was originally developed [ 60 ]. However, it is worth re-examining the very concept of adaptation, which one could argue illustrates the relative failure of science to develop relevant solutions for disadvantaged populations. Too often, adaptation is an exercise in retrofitting EBIs to underserved populations and under-resourced settings. In a true equity approach to implementation, a goal might be a steady reduction in the need for EBI adaptation when more and more EBIs are developed in circumstances with the least, rather than the most resources.

Recommendations

To tackle these and related challenges, we offer 10 recommendations (Table  2 ). Each is directly linked to the challenges noted and is based on the existing literature and the authors’ experiences.

Improving the evidence base

Link social determinants with health outcomes.

Many funders of research in public health and healthcare delivery (including those in implementation science) tend to require studies that show effects on traditional clinical and behavioral outcomes (e.g., cancer screening rates, rates of depression, rates of infectious disease) [ 61 ]. A clear need for health equity in implementation science is the ability to understand pathways between social determinants of health and outcomes of relevance to various stakeholders, recognizing that the impact may be neither direct nor immediate, but still profound and measurable. There is a substantial and growing body of evidence linking interventions on social determinants of health to a broad range of health outcomes (Table  3 ) [ 4 , 38 , 39 , 62 , 63 , 64 , 65 , 66 , 67 , 68 ]. In primary care studies, there are multiple ways in which social determinants of health are increasingly being addressed (e.g., screening for social risk factors, linking patients with local resources) [ 69 ]. In addition, it is important to consider social determinants as potential moderators of health behavior change [ 70 ].

There are opportunities for researchers to more fully consider social determinants of health as they design studies. To inform future studies and to synthesize existing literature, several useful guidelines and evidence frameworks can be applied. For example, equity and social determinants are included in the APEASE criteria [ 71 ], the GRADE Evidence to Decision framework [ 72 , 73 ], and an expanded version of CONSORT [ 74 , 75 , 76 , 77 ].

Build equity into all policies

Policies, in the form of laws and administrative regulations, have profound effects on population health and health equity. Policy implementation is an under-studied area, particularly in the USA [ 78 , 79 ]. Research on policy implementation seeks to understand the complexity of the policy process to increase the likelihood that research evidence is a meaningful part of policy decisions. In this section, we focus on “Big P” policies (i.e., laws, administrative rules, and regulations), although in a later section, “small p” policies (i.e., organizational changes, non-governmental professional guidelines) are briefly considered.

Lessons can be drawn from the Health in All Policies (HiAP) movement which recognizes that our greatest health challenges are complex and strongly determined by policy and social determinants [ 80 , 81 ]. The HiAP approach seeks to incorporate health considerations in decision-making across sectors and policy topics. We propose a new framing as Equity in All Policies (EiAP), in which equity is a primary consideration, not merely one of many considerations. An EiAP approach would include analyzing barriers to policy change, the impacts of policy decisions on equity, both retrospectively and prospectively, with a particular emphasis on aspects of policy design that can privilege or disadvantage certain population groups [ 39 , 82 , 83 ]. Lack of evidence often is not the main barrier to policy action to address equity, more often political will is the biggest challenge [ 30 ]. To build political will, new approaches are also needed for framing and communicating the health equity benefits to various segments of policy audiences (e.g., progressive versus conservative) via audience research studies [ 84 ].

Improving measures and methods

Use equity-relevant metrics.

A public health adage is “what gets measured, gets done” [ 85 ]. Most existing measures focus on ultimate outcomes, such as disparities in health status, and do not directly measure factors that lie along the pathway to inequity or equity. Equity measurement should include three elements (1) an indicator of health or a modifiable determinant of health (e.g., living conditions, policies), (2) an indicator of social position (e.g., economic stability, educational attainment), and (3) a method for comparing health or a health determinant across social strata (e.g., a ratio of rates) [ 86 ]. Two groups of metrics need to be developed and used: (1) broad equity measures of social determinants of health that could be used to measure progress in communities and (2) measures specific to equity and implementation science for use in research studies.

At a population level, representing the success or failure of implementation, we need to expand our usual surveillance metrics (e.g., behavioral risk factors, mortality) and crude area-level measures (e.g., the Area Deprivation Index) to concentrate more on upstream factors. For example, surveillance systems should track social determinants such as third grade reading literacy, unemployment rates, incarceration rates, and the percentage of households that pay over 30% of their income for housing.

Within implementation research studies, we need to go deeper into the underlying causes of disparities, identify new metrics, and include these in our studies. For example, to measure disadvantage, many studies measure household income but few measure household wealth. The Black-White difference in median household income is 1.7-fold yet the difference in Black-White median household wealth is 10-fold [ 87 , 88 ]. To more fully measure equity, researchers need to develop measures that account for historical or life course disadvantage and metrics within multiple levels that account for the context for implementation [ 89 , 90 ]. A measurement approach for equity in implementation science assesses both quantity and quality—the simplest measurement occurs in quadrant 1 and the most comprehensive in quadrant 4 (Fig.  1 ) [ 91 ].

Four categories of measurement for equity and implementation science (adapted from MCH Evidence [ 91 ])

As equity-relevant measures are developed and refined, it will be helpful to apply existing taxonomies such as the set of eight outcomes developed by Proctor and colleagues (i.e., acceptability, adoption, appropriateness, feasibility, fidelity, implementation cost, penetration, and sustainability) [ 92 ]. Measures and methods within these eight categories will need to be adapted to account for contexts where disparities are developed and maintained (e.g., how to document feasibility in a low-resource setting).

Study what is already happening—more practice-based evidence

The importance of context is often devalued relative to the presumed “superiority” of the intervention itself. Our funding mechanisms tend to favor innovation over replication, even when many stakeholders are largely seeking to apply existing knowledge [ 93 ]. The research process does not always align with priorities of those experiencing inequities and often moves more slowly than innovations in practice and policy. In a study of implementation of mental health services, Aby found three important themes showing how participants experienced implementation: invisibility (e.g., not enough mental health providers of color), isolation (e.g., separation and lack of collaboration among key stakeholder), and inequity (e.g., feeling tokenized or unwelcome) [ 94 ].

To address these issues, it will be useful to place much more emphasis on studying implementation of ongoing health equity projects, often via natural experiments. Experience in low-resource settings shows that novel approaches sometimes thrive under constraints (i.e., creativity can thrive when choices are restricted) [ 56 ]. These real-world studies often involve natural experiments [ 95 , 96 ], which are particularly useful in studying social determinants designed to address inequities and enhance external validity [ 97 ]. Multiple state and local agencies across the USA are conducting health equity projects [ 98 ]. As an example, the Rhode Island Department of Health supports nine Health Equity Zones across the state to improve socioeconomic and environmental conditions across the state [ 99 ]. In Canada, as part of the Canadian Coalitions Linking Action and Science for Prevention (CLASP) initiative, First Nations, Inuit, and Métis community partners brought unique and important community perspectives and relationships to implementation projects [ 100 , 101 ]. These projects develop so-called “tacit knowledge” or “colloquial evidence” (pragmatic information based on direct experience and action in practice) [ 102 , 103 ]. They also contribute to the process of tailored implementation, which builds on real-world experiences to identify the most important determinants to address [ 104 , 105 ].

Integrate equity into implementation models

Models provide a roadmap—a systematic structure for the development, management, and evaluation of all parts of a study [ 21 ]. While there are over 100 models to guide implementation science research, only a handful explicitly include health equity [ 20 , 90 , 94 , 106 , 107 , 108 , 109 ]. These frameworks are informed by development and use of a larger set of models on health and equity [ 110 ].

To advance equity and implementation science, we need to identify gaps among existing models which in turn can guide model improvement. This analysis could assess (1) whether equity is an explicit focus of models (e.g., Is it an end goal?), (2) the degree to which social determinants are represented, (3) whether a set of core equity constructs could be identified within models, (4) whether models apply equally well to lower and higher resource settings, and (5) the degree of representation of disadvantaged groups and community stakeholders in the model. Model selection and adaptation can benefit by interactive webtools such as Dissemination and Implementation Models in Health Research and Practice [ 111 ].

Design and tailor implementation strategies

Implementation strategies are methods to enhance the adoption, implementation, sustainment, and scale-up of an innovation (often in the form of an EBI) [ 112 ]. Multiple taxonomies describe and organize commonly used implementation strategies that can target a range of stakeholders and multilevel contextual factors across different phases of implementation [ 113 , 114 ]. The design of implementation strategies should be guided by the growing body of evidence, pertinent theories and frameworks, and relevant stakeholders, including those from communities in which health disparities have been identified [ 113 , 115 ]. Ultimately, the goal is to understand who needs to do what in order to implement and sustain an innovation, what factors are likely to facilitate or impede those changes, and what strategies need to be in place in order to address anticipated or emergent challenges [ 116 , 117 ]. The implementation and scale-up of the U.K. Diabetes Prevention Programme show the importance of stakeholder engagement, addressing contextual conditions (e.g., staff turnover), and the value of incentives [ 118 ].

Development and use of implementation strategies should include explicit consideration of disparities, contextual conditions that may lead to inequitable outcomes (e.g., resources, history), and opportunities to promote equity by carefully designing and/or tailoring strategies. To date, relatively little emphasis has been placed on how well implementation strategies are responsive to health equity needs. There is ample opportunity to examine the extent to which strategies identified in prevailing taxonomies can be leveraged to address determinants of equity, and to develop and test novel strategies at multiple levels (e.g., individual, provider, organization, community) that may promote health equity. Adaptive designs for developing equity-relevant implementation strategies, such as the Sequential Multiple Assignment Randomized Trial (SMART) design [ 119 ], are likely to be useful in accounting for changing real-world conditions.

Giving greater attention to context

Connect to systems and sectors outside of health.

Many of the most important influences on health status and disparities occur in sectors outside of healthcare and public health (e.g., schools, housing, education, labor) [ 120 ]. These settings are crucial for implementation science in at least four ways: (1) they are highly experienced delivering services to underserved populations and thus have deep knowledge of how to do it well, (2) many of these sectors are already delivering exactly the kinds of non-health interventions that address social needs (as described in Table  3 ), (3) they provide access to high-risk populations where a health intervention might be added to a service (e.g., adding a smoking cessation intervention to services designed to meet social needs), and (4) the setting itself might be the focus for change and a secondary benefit is a health outcome (e.g., lower use of the emergency department among those who receive permanent supportive housing). Often, the missions and cultures of agencies in these sectors do not focus on health [ 121 ]. Therefore, our traditional approaches for forming partnerships need to be re-examined and altered [ 122 ].

Three principles show promise. First, an underlying premise is that justice is essential to achieving health equity [ 123 , 124 ]—not only justice in the health sector but justice across all sectors including housing and neighborhoods, safety, education, and economics and employment. Second, we need more “disease-agnostic interventions,” which are structural interventions, often outside the health sector, that address common risk factors that are linked with multiple disparities [ 125 ]. And third, systems science approaches that link sectors have been increasingly applied in public health to study and develop EBIs to address areas as diverse as global pandemics, vaccination system, cancer, and obesity [ 126 ]. To date, systems approaches have not been widely applied in health equity, although they show promise [ 127 ].

Engage organizations in internal and external equity efforts

Organizations are one of several central entities of influence in implementation science [ 128 ]. They may directly deliver health services or may involve community-level partnerships to influence disparities and population health. While health equity is a high priority for many public health organizations, there is sparse empirical data on the organizational commitment to equity issues and how that commitment is operationalized. For example, in a nationwide survey of U.S. practitioners in state health departments, only 2% reported working primarily on health equity and 9% reported that health equity was one of their multiple priority areas [ 129 ].

There are opportunities to more fully address issues in equity and implementation science in organizations [ 121 ]—both internally and externally. Within an organization, assessments of climate and culture can be conducted with an equity lens. For example, one could assess the perception of the commitment of leaders to equity; employee attitudes, motivations, performance on equity issues (including the presence of hidden biases [ 130 ]); internal policies supporting equity; and the diversity of an organization. Organizations could also evaluate existing programs and policies for their reach and impact on health equity. Externally, organizations can bring on new partners who have a shared commitment to equity, develop organizational policies that share decision-making and power with partners, make equity a stated goal of partnerships, and break down funding silos to address root causes. Equity-driven practice for organizations directs resources for those most in need [ 131 ].

Addressing cross-cutting issues

Build capacity for equity in implementation science.

Recent reviews of initiatives to build capacity in implementation science have shown a growing number of training opportunities across eight countries [ 132 , 133 , 134 ]. Capacity building for implementation science occurs in multiple formats including university degree programs, summer training institutes, workshops, and conferences [ 133 ]. Nearly all training programs to date have focused on capacity building among researchers (the “push” for implementation science) with little emphasis on practitioners or implementers (the “pull” for implementation science) [ 133 , 135 ], with few featuring an explicit focus on equity [ 136 ].

A full vision for equity-related training needs to be centered on who is being trained, how they are being trained, and where the work is occurring. To address the “who” element in training, programs need to include a larger percentage of early-career scholars who are from under-represented minority groups [ 137 ] and those working in disciplines outside of health. The “how” can include multiple parts including (1) how training is delivered to reach all audiences (including those outside the health sector), (2) whether equity is featured as an explicit part of core competencies, (3) how principles of community engagement are included in training [ 23 ], and (4) how progress toward equity is evaluated. The “where” issues include where research is occurring and how diverse communities, which are the settings for studies, are engaged in meaningful ways.

Focus on equity in dissemination efforts

Designing for dissemination is defined as “an active process that helps to ensure that public health interventions, often evaluated by researchers, are developed in ways that match well with adopters’ needs, assets, and time frames” [ 138 ]. There is a well-documented disconnect between how researchers disseminate their findings and how practitioners and policy makers learn about the latest evidence [ 93 ]. Experience in the population or setting of focus also matters—public health researchers with practice or policy experience are over four times more likely to report good or excellent skills in dissemination [ 139 ].

Equity-focused dissemination of research findings could include several core elements. At a systems level, funders should provide incentives for researchers to engage in meaningful ways with audiences experiencing disparities (e.g., through requirements for dissemination, supplemental funding). To improve dissemination processes, researchers should engage with equity-focused partners early and often in the research process [ 140 ]. Products for dissemination could be improved by refining messages that resonate with key stakeholders and developing communications materials in collaboration with the audience of focus that reflect the images, narratives, and outcomes of interest to populations experiencing disparities.

Approaches to achieving health equity are critical to ameliorating disparities resulting from social, economic, and racial injustice. Given that implementation science is a relatively young field [ 141 , 142 ], often focused on narrowly-defined EBIs, the lack of explicit attention on equity is not unexpected. As a new field, it is more malleable and should embrace the challenge of equity, a highly ambitious but critically important responsibility that would unquestionably demonstrate its value and provide an identity distinct from the many disciplines it draws upon.

Our premise is that every project in implementation science should include an equity focus. Equity begins with justice—health differences often reflect social injustices [ 123 ]. For some studies, equity is the main goal of the project and a central feature of the research questions, the conceptual model, project activities, and dissemination of findings. In other studies, equity is part of a project but not the singular focus. In these projects, we should, at a minimum, ensure that we “leave no one behind” and that existing disparities are not inadvertently widened.

Our recommendations offer a pathway for advancing health equity through implementation science. The ideas provided are critical but far from a complete “playbook” on what needs to happen and how goals might be accomplished. Along with other recent calls to action [ 14 , 20 ], we view these as first-generation concepts to immediately address health equity—ideas on which others can further advance and build upon. With a stronger commitment to equity from funders, researchers, practitioners, advocates, and policy makers, we can harvest the rewards of the resources being invested in health-related research to eliminate disparities, resulting in health justice.

Availability of data and materials

Not applicable.

Abbreviations

Acceptability, Practicability, Effectiveness, Affordability, Side-effects, and Equity

Consolidated Standards of Reporting Trials

Coronavirus disease 2019

Evidence-based intervention

Grading Recommendations Assessment and Development Evidence

Health in All Policies

Equity in All Policies

Sequential Multiple Assignment Randomized Trial

United States

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Acknowledgements

We thank Ana Baumann, Carol Brownson, Leopoldo Cabassa, Russell Glasgow, Jon Kerner, Byron Powell, and Rachel Tabak for helpful comments on the manuscript.

The findings and conclusions in this paper are those of the authors and do not necessarily represent the official positions of the National Institutes of Health, or the Centers for Disease Control and Prevention.

This work was supported in part by the National Cancer Institute (number P50CA244431), the National Institute of Diabetes and Digestive and Kidney Diseases (numbers P30DK092950 and R25DK123008), the Centers for Disease Control and Prevention (number U48DP006395), and the Foundation for Barnes-Jewish Hospital.

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Brownson, R.C., Kumanyika, S.K., Kreuter, M.W. et al. Implementation science should give higher priority to health equity. Implementation Sci 16 , 28 (2021). https://doi.org/10.1186/s13012-021-01097-0

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10 Common Management Challenges Solved by Scrum

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As a manager, tackling team and project challenges effectively can often seem like navigating a complex labyrinth. Fortunately, Scrum offers a structured framework that can guide you through. 

Here's how Scrum addresses ten common challenges that managers face, providing clear solutions through its empirical approach.

1. Unclear Priorities

Challenge : Teams often struggle with prioritizing tasks effectively. 

Scrum Solution : Scrum’s Product Backlog, guided by a clear Product Vision and Product Goal, establishes a strategic direction for the development initiative. Sprint Planning then breaks this down into actionable objectives via the Sprint Goal, which acts as a beacon during each Sprint, focusing efforts on high-value tasks. This layered approach ensures that priorities are not only clear but also aligned with the overall mission, enabling teams to make informed decisions about what to tackle next and ensuring that every task directly contributes to the goals. Additionally, the clear articulation of Goals helps in the discovery and management of unplanned work. When unexpected tasks arise, their urgency is evaluated against the relevance to the current Goals. This mechanism prevents distractions from derailing the team's focus, ensuring that only truly goal-aligned activities are prioritized, and not just those that appear urgent.

2. Changing Requirements

Challenge : Adapting to change can disrupt workflow and timelines.

Scrum Solution : Regular Sprint Reviews are fundamental for addressing changing requirements, as they allow the team incorporate feedback directly into the Product Backlog and to next development cycles. This feedback loop ensures that the product evolves in line with user needs and market dynamics. Additionally, the Daily Scrum meetings provide a daily opportunity for team members to re-align based on new information or challenges that arise, maintaining agility in day-to-day operations. The ongoing process of Product Backlog refinement also plays a critical role, as it allows for the continuous detailing and adjustment of backlog items to reflect new insights or priorities. This cyclical nature of Scrum—through Sprint planning, daily adjustments, and iterative reviews—enables teams to adapt swiftly and effectively to changing requirements, ensuring that the development initiative remains responsive and dynamic. Throughout these adaptive processes, the focus and commitment to the Product Goal and Sprint Goal remain paramount, guiding all efforts and decisions to ensure alignment with the overarching objectives of the initiative. This balance between maintaining focus and embracing adaptability is key to navigating changes effectively while driving towards successful outcomes.

3. Lack of Accountability

Challenge : Team members are unclear about their responsibilities.

Scrum Solution : Scrum distinguishes between accountabilities and responsibilities, providing a flexible framework that allows teams to define how best to fulfill these roles within their unique contexts. The clear definition of Scrum accountabilities enhances team focus and sets clear expectations for each member's contribution.

The Product Owner is accountable for maximizing the value delivered by the team. They order the Product Backlog based on priorities, dependencies, risks, and value, ensuring that the most critical and valuable increments are developed first. This strategic management of the backlog is key to guiding the team's efforts efficiently.

Developers are accountable for delivering "Done" increments—completed pieces of work that meet the high-quality standards established by the team's Definition of Done. This Definition of Done is crucial as it brings clarity and transparency to what "high quality" means for the team, ensuring that everyone understands the benchmarks for deliverables.

Meanwhile, the Scrum Master is accountable for fostering an environment conducive to effective teamwork, facilitating the right conversations, aiding discovery processes, and promoting both team growth and organizational agility. This role is pivotal in ensuring that the team remains agile and capable of adapting to changes swiftly while maintaining a high standard of work.

This structure ensures that quality is a collective responsibility—a "team sport"—with each member understanding their part in driving the team towards shared goals. The focus on delivering high-quality, Done increments underscores the commitment to excellence and continuous improvement, vital for maintaining accountability and achieving successful outcomes in any Scrum initiative.

4. Ineffective Communication

Challenge : Poor communication leads to misunderstandings and project delays. 

Scrum Solution : In Scrum, ineffective communication is countered by structuring purposeful conversations around each Scrum event. The Daily Scrum, specifically, enables developers to plan their day with a focus on achieving the Sprint Goal and creating Done Increments, integrating any new information that may influence their tasks. Sprint Planning concentrates discussions on outlining achievable objectives for the upcoming Sprint, aligning team efforts with the broader development initiative. Sprint Reviews facilitate a feedback loop with stakeholders, adjusting the course based on the product increment presented, while Sprint Retrospectives encourage the team to reflect on their processes and teamwork, promoting ongoing improvement.

Experienced managers recognize the importance of such focused conversations and often ensure they occur regularly; Scrum not only defines these essential interactions but also names them, enhancing clarity and effectiveness. However, Scrum provides the framework for these discussions without dictating the specifics—such as the focal points, stakeholders to involve, or decision-making methods. This allows teams to tailor the framework to their specific needs, ensuring that communication remains both relevant and effective.

5. Inadequate Planning

Challenge : Projects often suffer from unrealistic timelines and scope creep. 

Scrum Solution : Inadequate planning is adeptly mitigated in Scrum through its iterative planning process, beginning with Sprint Planning. This crucial event gathers the whole team to define deliverables for the upcoming Sprint and outline strategies for achieving them. By breaking the development initiative into manageable, time-boxed Sprints. Each Sprint is launched with a Sprint Goal and a plan, aligning team efforts with broader developmental goals.

As Dwight D. Eisenhower famously said, " Plans are nothing; planning is everything ." This ethos is embodied in Scrum's flexible approach to planning, which accommodates adjustments as needed. Daily Scrum meetings facilitate ongoing reviews of progress and emerging challenges, allowing for real-time planning adjustments. This continuous reevaluation helps teams avoid the common pitfalls of rigid planning, such as overcommitment or failure to deliver.

Thus, Scrum not only enhances initial planning but also ensures sustained alignment through dynamic adaptation to the development landscape. This structured planning framework ensures that each Sprint makes a significant, goal-oriented contribution to the development initiative, embodying both the spirit and strategic intent of Eisenhower's insight.

6. Low Product Quality

Challenge : Products fail to meet customer expectations or need frequent revisions. 

Scrum Solution : Low product quality is directly tackled in Scrum through collective responsibility and adherence to the Definition of Done. This crucial standard defines what it means for work to be complete, ensuring all increments meet high-quality benchmarks before they are considered usable. This is not just the duty of a single team member but a shared commitment across the team to uphold standards of professionalism and quality in every Sprint.

Scrum facilitates this through its inherent iterative processes, particularly during the frequent Sprint Reviews. These reviews serve as regular checkpoints where the product increment is evaluated against the Definition of Done by the team and stakeholders. This collaborative scrutiny helps to catch and rectify quality issues early, preventing them from compounding over time.

Moreover, Scrum's cyclical nature fosters a culture of continuous improvement. Each Sprint ends with a Retrospective, which is an opportunity to reflect on the processes and outcomes, identifying areas for improvement in both product quality and team practices. This ongoing commitment to enhancing efficiency and effectiveness ensures that quality improvements are integral to the team's workflow, promoting a sustainable increment in quality and a robust, professional product development environment.

Additionally, integrating professional practices into the Scrum framework can further enhance product quality, particularly in fields like software development where DevOps principles play a crucial role. Practices such as continuous integration, automated testing, and continuous delivery align seamlessly with Scrum’s cycles, reinforcing the Definition of Done and ensuring that each increment not only meets quality standards but is also ready for production at any time. This integration of DevOps practices encourages a proactive approach to quality control, minimizing risks and reducing the time to market. By marrying Scrum with these advanced development practices, teams can achieve a higher level of operational efficiency and product excellence, making the most of both to drive superior outcomes.

7. Productivity Issues

Challenge : Teams are not working efficiently or are consistently overburdened.

Scrum Solution : Productivity issues within teams are effectively addressed through Scrum’s structured approach. Organizing work into Sprints provides clear short-term goals and deadlines, enhancing focus and driving team efforts towards efficient value delivery. The iterative nature of Sprints allows for ongoing progress assessment and adjustment, maintaining a steady pace and preventing burnout or underutilization.

The Daily Scrum is a key planning event for developers. It serves to synchronize team activities, clarify daily objectives, and swiftly address any impediments to progress. This essential gathering ensures that all team members are aligned, can collaborate effectively, and make the most productive use of their time.

Scrum also fosters a culture of self-management, empowering teams to own their workflows and processes. This empowerment boosts motivation and engagement, key drivers of productivity. Teams that feel accountable for their outcomes are more inclined to optimize their work processes and innovate solutions to efficiency challenges.

Moreover, Scrum’s focus on continuous improvement through Sprint Retrospectives ensures that productivity enhancements are systematically identified and implemented. Teams regularly reflect on their methods and dynamics, learning from each Sprint to refine their approaches. This cycle not only helps resolve immediate productivity issues but also develops strategies that enhance long-term efficiency and effectiveness.

8. Customer Satisfaction

Challenge : Products do not fully meet the needs or expectations of customers. 

Scrum Solution : Scrum significantly enhances customer satisfaction by fostering close collaboration between developers and stakeholders throughout the product development lifecycle. While Sprint Reviews are a formal opportunity for stakeholders to view progress and provide feedback on the product increments, collaboration is not restricted to these events alone. Stakeholders are encouraged to engage with the Scrum team at any point, which ensures that the product continuously aligns with customer needs and expectations.

The Sprint Review is also a critical time to inspect changes in the Product Backlog and to strategize on how to maximize value in upcoming Sprints. This not only involves assessing what has been accomplished but also planning future efforts based on stakeholder feedback and market developments. This ongoing interaction and flexibility in incorporating feedback ensure that products not only meet but often exceed customer expectations, fostering strong relationships and enhancing customer satisfaction.

Additionally, the iterative delivery of value builds trust and transparency between customers and the team, further boosting customer confidence in the team’s ability to deliver high-quality solutions promptly.

Challenge : Potential risks are not identified early enough to mitigate them effectively. Scrum Solution : The iterative nature of Scrum allows teams to identify and address risks early and often, enhancing proactive risk management.

9. Risk Management

Challenge : Potential risks are not identified early enough to mitigate them effectively. 

Scrum Solution : Scrum provides a robust framework for managing various types of risks that impact development initiatives, such as business, technological, and operational risks:

Business Risks : The Product Owner mitigates business risks by continuously updating the Product Backlog with the latest information, managing stakeholder expectations, and conducting small business experiments to test hypotheses. This proactive management ensures alignment with market and business needs.

• Visibility and Transparency : Gathering the right metrics such as Time To Market, Ability to Innovate, Current Value, and Unrealized Value is critical (learn more about Evidence-Based Management ). By measuring these aspects, teams can better understand and improve the actual value delivered, rather than just focusing on velocity.

Technological Risks : Developers address technological risks by adopting emergent architecture principles, which advocate for delaying difficult-to-reverse decisions to keep options open as long as responsibly possible. This approach is supported by implementing solid development practices like SOLID principles, design patterns, and Test Driven Development.

• Visibility and Transparency : Keeping technical debt visible in the Product Backlog and using techniques such as pair programming, mob programming, and code reviews ensure ongoing awareness and management of technical issues, fostering a culture of quality and continuous improvement.

Operational Risks : The Scrum Master oversees the collaboration structures, ensuring efficient coordination within and across teams and maintaining a relentless focus on quality. They also work closely with the Product Owner to keep empiricism at the core of the initiative, fostering an environment where continuous improvement is standard.

• Visibility and Transparency : Implementing tools like cross-team refinement boards and shared Sprint Backlogs that highlight dependencies enhances visibility across operations. These tools help teams identify and address potential bottlenecks or conflicts early, ensuring smoother workflows and better risk management.

By integrating these strategies, Scrum ensures that all potential risks are systematically addressed. This empowerment allows teams to deliver high-quality products consistently and efficiently, effectively mitigating risks and fostering a resilient development environment, nurturing trust all around. 

10. Overworked Teams

Challenge : Teams are frequently burnt out, impacting morale and output. 

Scrum Solution : Scrum addresses the issue of overworked teams by promoting self-management and shared responsibilities. In Scrum, the concept of self-management means that Developers organize their own work and make decisions collaboratively within the framework set by the Sprint Goals and Definition of Done. This autonomy allows the team to adjust their workload dynamically, ensuring that work is balanced and sustainable over the course of each Sprint. By fostering a sense of ownership and accountability, Scrum encourages all team members to contribute equally, which not only enhances productivity but also improves job satisfaction and morale.

The Daily Scrum plays a crucial role in addressing and preventing overwork within the team. This daily meeting serves as a platform for Developers to synchronize their efforts, discuss the day’s objectives, and highlight any potential roadblocks or areas of overload. By openly sharing their progress and challenges, team members can identify who might be overburdened and plan they day accordingly. This proactive approach allows the team to adjust their workload on a daily basis, ensuring that no one member is consistently overworked. The Daily Scrum thus acts not only as a planning tool but also as a preventive measure against burnout, fostering a supportive team environment where workload is managed collectively.

Moreover, Scrum’s regular Sprint Retrospectives provide a structured opportunity for teams to discuss their work process, identify any issues of overwork, and collectively find solutions to improve their workflow. This continuous improvement process helps to maintain a healthy work pace and prevent burnout, creating a more resilient and adaptive team environment. This shared responsibility ensures that quality and workload management are maintained collaboratively, reinforcing the team’s ability to deliver consistently without undue stress.

Scrum is straightforward in its framework but challenging in its discipline and commitment to professionalism. It requires a steadfast dedication to continuous improvement and a shift away from traditional command-and-control management styles. This dedication to evolving team dynamics and outcomes can significantly alter how teams meet challenges and deliver value.

For managers looking to deepen their understanding of Scrum or see real-world examples of its application, visiting Scrum Case Studies and exploring the Scrum Guides can provide valuable insights and guidance.

Remember, adopting Scrum isn't just about following a set of rules; it's about fostering a culture of adaptability and excellence that can truly transform your management approach and navigate the uncertainties with simplicity.

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The “case” for case studies: why we need high-quality examples of global implementation research

Blythe beecroft.

1 Fogarty International Center, US National Institutes of Health, Bethesda, USA

Rachel Sturke

2 National Cancer Institute, US National Institutes of Health, Bethesda, USA

Rohit Ramaswamy

3 Cincinnati Children’s Hospital Medical Center, Cincinnati, USA

Associated Data

Not applicable.

Rigorous and systematic documented examples of implementation research in global contexts can be a valuable resource and help build research capacity. In the context of low- and middle-income countries (LMICs), there is a need for practical examples of how to conduct implementation studies. To address this gap, Fogarty’s Center for Global Health Studies in collaboration with the Cincinnati Children's Hospital Medical Center and the National Cancer Institute is commissioning a collection of implementation science case studies in LMICs that describe key components of conducting implementation research, including how to select, adapt, and apply implementation science models, theories, and frameworks to these settings; develop and test implementation strategies; and evaluate implementation processes and outcomes. The case studies describe implementation research in various disease areas in LMICs around the world. This commentary highlights the value of case study methods commonly used in law and business schools as a source of “thick” (i.e., context-rich) description and a teaching tool for global implementation researchers. It addresses the independent merit of case studies as an evaluation approach for disseminating high-quality research in a format that is useful to a broad range of stakeholders. This commentary finally describes an approach for developing high-quality case studies of global implementation research, in order to be of value to a broad audience of researchers and practitioners.

Contributions to the literature

• Reinforcing the need for “thick” (i.e., context-rich) descriptions of implementation studies
• Highlighting the utility of case studies as a dissemination strategy for researchers, practitioners, and policymakers
• Articulating the value of detailed case studies as a teaching tool for global implementation researchers
• Describing a method for developing high-quality case studies of global implementation research

Research capacity for implementation science remains limited in low- and middle-income countries (LMICs). Various stakeholders, including NIH-funded implementation researchers and practitioners, often inquire about how to apply implementation science methods and have requested additional resources and training to support implementation capacity building. This is in part due to a dearth of practical examples for both researchers and practitioners of how to select, adapt, and apply implementation science models, theories, and frameworks to these settings; how to evaluate implementation processes and outcomes; and how to develop and test implementation strategies. The need for detailed documentation of implementation research in all settings has been well established, and guidelines for documentation of implementation research studies have been created [ 1 , 2 ]. But the mere availability of checklists and guidelines in and of themselves does not result in comprehensive documentation that is useful for learning, as has been pointed out by many systematic reviews of implementation science and quality improvement studies ([ 3 , 4 ]). It has also been observed that documentation alone is not enough, and there is a need for mentors to translate abstract theories into context-appropriate research designs and practice approaches [ 5 ]. Because of the especially acute shortage of mentors and coaches in LMIC settings, we propose that documentation with “thick” descriptions that go beyond checklists and guidelines are needed to make the field more useful to emerging professionals [ 6 ]. We suggest that the case study method intended to “explore the space between the world of theory and the experience of practice” [ 7 ] that has been used successfully for over a century by law and business schools as a teaching aid can be of value to develop detailed narratives of implementation research projects. In this definition, we are not referring to the case study as a qualitative research method [ 8 ], but as a rich and detailed method of retrospective documentation to aid teaching, practice, and research. In this context, our case studies are akin to “single-institution or single-patient descriptions” [ 9 ] called “case reports” or “case examples” in other fields. As these terms are rarely used in global health, we have used the words “case studies” in this paper but reiterate that they do not refer to case study research designs.

Fogarty’s Center for Global Health Studies (CGHS) in collaboration with the Cincinnati Children's Hospital Medical Center and the National Cancer Institute (NCI) is commissioning a collection of implementation science case studies that describe implementation research focusing on various disease areas in different (LMIC) contexts around the world. These case study descriptions will provide guidance on the process of conducting implementation science studies and will highlight the impact these studies have had on practice and policy in global health contexts. This brief note makes a case for using case studies to document and disseminate implementation research, describes the CGHS approach to case study development and poses evaluation questions that need to be answered to better understand the utility of case studies. This effort is intended to develop a set of useful examples for LMIC researchers, practitioners, and policymakers, but also to assess and improve the use of case studies as a tested documentation methodology in implementation research.

The “case” for case studies

A preliminary landscape analysis of the field conducted by CGHS found that there are not many descriptions of global implementation science projects in a case study format in the peer-reviewed or gray literature, and those that exist are embedded in the content of academic teaching materials. There is not a cohesive collection, especially relating to health, that illustrates how implementation research has been conducted in varied organizations, countries, or disease areas. This new collection will add value in three different ways: as a dissemination strategy, as a tool for capacity building, and as a vehicle for stimulating better research.

Case studies as a dissemination strategy

Case studies have independent merit as an evaluation approach for disseminating high-quality research in a format that is useful to a broad range of stakeholders. The Medical Research Council (MRC) has recommended process evaluation as a useful approach to examine complex implementation, mechanisms of impact, and context [ 10 ]. Guidelines on documentation of implementation recommend that researchers should provide “detailed descriptions of interventions (and implementation strategies) in published papers, clarify assumed change processes and design principles, provide access to manuals and protocols that provide information about the clinical interventions or implementation strategies, and give detailed descriptions of active control conditions” [ 1 ]. Case studies can be thought of as a form of post hoc process evaluation, to disseminate how the delivery of an intervention is achieved, the mechanisms by which implementation strategies produce change, or how context impacts implementation and related outcomes.

Case studies as a capacity building tool

In addition, case studies can address the universal recognition of the need for more capacity building in Implementation Science , especially in LMIC settings. Case studies have been shown to address common pedagogical challenges in helping students learn by allowing students to dissect and explore limitations, adaptations, and utilization of theories, thereby creating a bridge between theories presented in a classroom and their application in the field [ 11 ]. A recent learning needs assessment for implementation researchers, practitioners, and policymakers in LMICs conducted by Turner et al. [ 12 ] reflected a universal consensus on the need for context-specific knowledge about how to apply implementation science in practice, delivered in an interactive format supported by mentorship. A collection of case studies is a valuable and scalable resource to meet this need.

Using case studies to strengthen implementation research

Descriptions of research using studies can illustrate not just whether implementation research had an impact on practice and policy, but how, why, under what circumstances, and to whom, which is the ultimate goal of generating generalizable knowledge about how to implement. Using diverse cases to demonstrate how a variety of research designs have been used to answer complex implementation questions provides researchers with a palette of design options and examples of their use. A framework developed by Minary et al. [ 13 ] illustrates the wide variety of research designs that are useful for complex interventions, depending on whether the emphasis is on internal and external validity or whether knowledge about content and process or about outcomes is more important. A collection of case studies would be invaluable to researchers seeking to develop appropriate designs for their work. In addition, the detailed documentation provided through these case descriptions will hopefully motivate researchers to document their own studies better using the guidelines described earlier.

Developing and testing the case study creation process: the CGHS approach

Writing case studies that satisfy the objectives described above is an implementation science undertaking in itself that requires the engagement of a variety of stakeholders and planned implementation strategies. The CGHS team responsible for commissioning the case studies began this process in 2017 and followed the approach detailed below to test the process of case study development.

• Conducted 25+ consultations with various implementation science experts on gaps in the field and the relevance of global case studies
• Convened a 15-member Steering Committee 1 of implementation scientists with diverse expertise, from various academic institutions and NIH institutes to serve as technical experts and to help guide the development and execution of the project
• Developed a case study protocol in partnership with the Steering Committee to guide the inclusion of key elements in the case studies
• Commissioned two pilot cases 2 to assess the feasibility and utility of the case study protocol and elicited feedback on the writing experience and how it could be improved as the collection expands
• Led an iterative pilot writing process where each case study writing team developed several drafts, which were reviewed by CGHS staff and a designated member of the Steering Committee
• Truncated and adjusted the protocol in response to input from the pilot case study authors teams
• Developed a comprehensive grid with the Steering Committee, outlining the key dimensions of implementation science that are significant and would be important areas of focus for future case studies. The grid will be used to evaluate potential case applicants and is intended to help foster diversity of focus and content, in addition to geography

Implementing the process: the call for case studies

In March of 2021, CGHS issued a closed call for case studies to solicit applications from a pool of researchers. Potential applicants completed the comprehensive grid in addition to a case study proposal. Applicants will go through a three-tier screening and review process. CGHS will initially screen the applications for completeness to ensure all required elements are present. Each case study application will then be reviewed by two Steering Committee members for content and scientific rigor and given a numerical score based on the selection criteria. Finally, the CGHS team will screen the applications to ensure diversity of implementation elements, geography, and disease area. Approximately 10 case studies will be selected for development in an iterative process. Each case team will present their case drafts to the Steering Committee, which will collectively workshop the drafts in multiple sittings, drawing on the committee’s implementation science expertise. Once case study manuscripts are accepted by the Steering Committee, they will be submitted to Implementation Science Communications for independent review by the journal. CGHS intends for the case studies to be published collectively, but on a rolling basis as they are accepted for publication.

Future research: evaluating the effectiveness of the case study approach

This commentary has put forth arguments for the potential value of case studies for documenting implementation research for researchers, practitioners, and policymakers. Case studies not only provide a way to underscore how implementation science can advance practice and policy in LMICs, but also offer guidance on how to conduct implementation research tailored to global contexts. However, there is little empirical evidence about the validity of these arguments. The creation of this body of case studies will allow us to study why, how, how often, and by whom these case studies are used. This is a valuable opportunity to learn and use that information to better inform future use of this approach as a capacity-building or dissemination strategy.

Conclusions

Similar to their use in law and business, case study descriptions of implementation research could be an important mechanism to counteract the paucity of training programs and mentors to meet the demands of global health researchers. If the evaluation results indicate that the case study creation process produces useful products that enhance learning to improve future implementation research, a mechanism needs to be put in place to create more case studies than the small set that can be generated through this initiative. There will be a need to create a set of documentation guidelines that complement those that currently exist and a mechanism to solicit, review, publish, and disseminate case studies from a wide variety of researchers and practitioners. Journals such as Implementation Science or Implementation Science Communications can facilitate this effort by either creating a new article type or by considering a new journal with a focus on rigorous and systematic case study descriptions of implementation research and practice. An example that could serve as a guide is BMJ Open Quality , which is a peer-reviewed, open-access journal focused on healthcare improvement. In addition to original research and systematic reviews, the journal publishes two article types: Quality Improvement Report and Quality Education Report to document healthcare quality improvement programs and training. The journal offers resources for authors to document their work rigorously. Recently, a new journal titled BMJ Open Quality South Asia has been released to disseminate regional research. We hope that our efforts in sponsoring and publishing these cases, and in setting up a process to support their creation, will make an important contribution to the field and become a mechanism for sharing knowledge that accelerates the growth of implementation science in LMIC settings.

Acknowledgements

The findings and conclusions in this manuscript are those of the authors and do not necessarily represent any official position or policy of the US National Institutes of Health or the US Department of Health and Human Services or any other institutions with which authors are affiliated.

Abbreviations

Authors’ contributions.

BB, RS, and GN contributed to the conceptualization of the manuscript with leadership from RR. BB and RS drafted the main text. RR and GN reviewed and contributed additional content to further develop the text. All authors have read and agreed to the contents of the final draft of the manuscript.

Availability of data and materials

Declarations.

The authors declare that they have no competing interests.

1 Rohit Ramaswamy, CCHMC, Gila Neta, NCI NIH, Theresa Betancourt, BC, Ross Brownson, WASU, David Chambers, NCI NIH, Sharon Straus, University of Toronto, Greg Aarons, UCSD, Bryan Weiner, UW, Sonia Lee, NICHD NIH, Andrea Horvath Marques, NIMH NIH, Susannah Allison, NIMH NIH, Suzy Pollard, NIMH NIH, Chris Gordon, NIMH NIH, Kenny Sherr, UW, Usman Hamdani, HDR Foundation Pakistan, Linda Kupfer, FIC NIH

2 The first pilot case was led by the Human Development Research Foundation (HDRF) in Pakistan and examines scaling up evidenced-based care for children with developmental disorders in rural Pakistan. The second pilot was led by Boston College and investigates alternate delivery platforms and implementation models for bringing evidence-based behavioral Interventions to scale for youth facing adversity in Sierra Leone to close the mental health treatment gap.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Uniform Civil Code in 2023 - Challenges, Case Studies and Prospects

04 Jul 2023  · 21 mins read

The Uniform Civil Code (UCC) in India is a proposal to replace the personal laws, which are based on the scriptures and customs of each major religious community in the country, with a common set of laws governing every citizen. These laws are distinguished from public law and cover marriage, divorce, inheritance, adoption, and maintenance. The UCC is intended to promote national unity and solidarity by ensuring equality, fairness, and justice in the legal system, irrespective of religion. In todays in depth post we will learn about following topics: the

Introduction Historical Background of UCC Understanding the UCC Case Studies: Goa’s Civil Code and Other Countries The UCC and Gender Justice Controversies and Debates Surrounding UCC Legal and Constitutional Challenges in Implementing UCC Public Opinion and the UCC The Future of UCC: Possibilities and Predictions Conclusion FAQs

Introduction

The Uniform Civil Code (UCC) is a term that has stirred the socio-political landscape of India for decades. At its core, the UCC proposes to replace the personal laws, based on the scriptures and customs of each major religious community in the country, with a common set of laws governing every citizen. These laws pertain to personal matters such as marriage, divorce, inheritance, adoption, and maintenance.

The concept of UCC is enshrined in Article 44 of the Indian Constitution, which states that “The State shall endeavor to secure for the citizens a Uniform Civil Code throughout the territory of India.” However, it is important to note that this directive principle is not enforceable by any court, and the responsibility of its implementation rests solely on the shoulders of the government.

In the current socio-political context, the UCC has gained significant attention. With India’s increasing emphasis on secularism and gender justice, the UCC is seen by many as a tool to ensure equality and justice for all, irrespective of religion or gender. However, it is also a topic of heated debate, with concerns about the potential infringement on religious freedom and the homogenization of diverse cultural practices.

This article aims to delve into the complexities of the UCC, exploring its historical background, implications, controversies, and potential future. It seeks to provide a balanced perspective, shedding light on the various facets of this critical issue that holds the potential to reshape India’s legal and social fabric.

Historical Background of UCC

The concept of a Uniform Civil Code has its roots in colonial India. The British government, in an attempt to streamline the administration of justice, had introduced a uniform criminal code. However, they allowed religious communities to retain their personal laws in matters of marriage, divorce, inheritance, and other personal affairs, primarily to avoid any potential socio-religious unrest.

The idea of a Uniform Civil Code was first introduced to the Indian public discourse during the drafting of the Indian Constitution in the late 1940s. The Constituent Assembly debates saw a division of opinions on this issue. While some members advocated for a UCC to ensure gender justice and national unity, others expressed concerns about the potential infringement on religious freedom and the need to respect India’s cultural diversity.

Article 44 of the Indian Constitution, under the Directive Principles of State Policy, states, “The State shall endeavour to secure for the citizens a Uniform Civil Code throughout the territory of India.” However, these principles are guidelines rather than enforceable laws, leaving the implementation of a UCC to the discretion of the government.

Over the years, there have been several attempts to bring about a UCC. The most notable among these was during the tenure of the first Prime Minister of India, Jawaharlal Nehru. However, due to strong opposition, only Hindu personal laws were codified into a uniform code, known as the Hindu Code Bill, which applies to Hindus, Buddhists, Jains, and Sikhs.

The issue of UCC has been raised multiple times in the subsequent years, but it has always been met with resistance. The primary reasons for these failures have been the socio-political sensitivities associated with personal laws and the fear of backlash from religious communities, particularly the minorities. Despite these challenges, the debate around the UCC continues, reflecting the ongoing struggle between tradition and modernity in India’s socio-legal landscape.

Understanding the UCC

The Uniform Civil Code (UCC) is a proposal to replace the personal laws based on the scriptures and customs of each major religious community in India with a common set of laws governing every citizen. These laws would cover personal matters such as marriage, divorce, inheritance, adoption, and maintenance. The aim of the UCC is to ensure that all citizens of India are treated equally, regardless of their religion or gender.

In contrast, the existing personal laws in India are religion-specific. For instance, Hindus, Buddhists, Jains, and Sikhs are governed by the Hindu Code Bill, Muslims by the Shariat law, and Christians by the Indian Christian Marriage Act and the Indian Divorce Act. These laws have their roots in religious scriptures and traditions, and they vary significantly in their provisions, leading to disparities in the rights and protections afforded to individuals of different communities.

One of the primary benefits of the UCC is the promotion of gender justice. Many of the existing personal laws have been criticized for their patriarchal biases and discriminatory practices, particularly against women. The UCC could potentially rectify these biases by providing equal rights to men and women in all personal matters.

Another significant advantage of the UCC is the promotion of national unity. By ensuring that all citizens, irrespective of their religious affiliations, are governed by the same set of laws, the UCC could foster a sense of unity and solidarity among the diverse communities of India.

However, the UCC also has potential drawbacks. One of the main concerns is the potential infringement on religious freedom. Many argue that personal laws are an integral part of religious identity and that a UCC would violate the constitutional guarantee of freedom of religion.

Another concern is the potential homogenization of diverse cultural practices. India is a country of immense cultural diversity, with each community having its unique customs and traditions. A UCC could potentially lead to the erosion of this cultural diversity by imposing a uniform set of laws on all communities.

Furthermore, there are concerns about the practicality and feasibility of implementing a UCC in a country as diverse as India. The process of drafting a code that is acceptable to all communities is a daunting task, and the enforcement of such a code could potentially lead to social unrest.

In conclusion, while the UCC has the potential to promote gender justice and national unity, it also raises concerns about religious freedom and cultural diversity. The challenge lies in finding a balance between these competing interests.

Case Studies: Goa’s Civil Code and Other Countries

Goa, a small state on the western coast of India, provides a unique example of a form of Uniform Civil Code in action. The Goa Civil Code, also known as the Goa Family Law, is the set of civil laws that governs all Goans, irrespective of religious affiliation. This code is a remnant of the Portuguese Civil Procedure Code that was set up during the Portuguese rule and has remained in effect even after Goa’s integration into India in 1961.

The Goa Civil Code is uniform in its application and governs matters of marriage, divorce, and succession. It allows equal division of income and property between husband and wife and also between parents and children, irrespective of the child’s gender. This aspect of the law is seen as progressive and gender-just, setting an example for the rest of the country.

On the global front, many Western countries have implemented a form of Uniform Civil Code. For instance, France has a Civil Code, often referred to as the Napoleonic Code, which serves as the foundation of private law in France. It covers areas such as property, family, and contract law. Similarly, Germany has the Bürgerliches Gesetzbuch, a civil code that governs personal and family law and regulates property rights.

These Western civil codes, like the proposed UCC in India, aim to provide a uniform legal framework that applies to all citizens, regardless of their religious or cultural affiliations. However, it’s important to note that these countries have significantly less religious and cultural diversity compared to India, which makes the implementation of a UCC a more complex issue in the Indian context.

In conclusion, while the Goa Civil Code provides a working example of a UCC within India, and Western countries offer international examples, the implementation of a UCC in India would need to account for the country’s unique socio-cultural diversity and religious sensitivities.

The UCC and Gender Justice

The Uniform Civil Code (UCC) holds significant potential for advancing gender justice in India. By replacing the existing personal laws, which often contain patriarchal biases and discriminatory practices, with a uniform set of laws applicable to all citizens, the UCC could play a pivotal role in ensuring equal rights for men and women in personal matters.

Existing personal laws in India are often criticized for their gender biases. For instance, the Muslim personal law allows men to have up to four wives and to divorce their wives unilaterally through the practice of ‘triple talaq’, although the latter has been recently outlawed. Similarly, the Hindu personal law traditionally favored male heirs in matters of inheritance, although reforms have been made to grant equal inheritance rights to daughters. Christian personal laws, on the other hand, have different grounds for divorce for men and women, with the bar set higher for women.

These gender biases in personal laws not only perpetuate gender inequality but also lead to legal complexities and inconsistencies. For example, a woman’s right to maintenance after divorce can vary significantly depending on her religious affiliation.

The UCC could rectify these biases by providing a uniform set of laws that ensure equal rights and protections for men and women. For instance, it could mandate equal grounds for divorce for both genders, ensure equal inheritance rights, and provide equal rights in matters of adoption and child custody.

However, it’s important to note that the implementation of a UCC alone may not be sufficient to achieve gender justice. It needs to be accompanied by broader societal changes, including changes in patriarchal mindsets and practices. Furthermore, care must be taken to ensure that the UCC does not inadvertently perpetuate gender biases under the guise of uniformity.

In conclusion, while the UCC holds significant potential for advancing gender justice, its successful implementation would require careful drafting to ensure gender equality, as well as broader societal changes to support its objectives.

Controversies and Debates Surrounding UCC

The proposal of a Uniform Civil Code (UCC) in India has been a source of intense debate and controversy. The main points of contention revolve around political, religious, and cultural aspects, and the concerns of minority communities.

From a political perspective, the UCC has often been used as a tool for political mobilization. Some political parties support the UCC as a means to promote national unity and gender justice, while others oppose it, viewing it as an infringement on the rights of religious and cultural groups. The UCC has thus become a polarizing issue, often leading to a divide along political lines.

Religious debates form a significant part of the controversy surrounding the UCC. Many religious groups view the personal laws as an integral part of their religious identity and practices. They argue that a UCC would infringe upon their constitutionally guaranteed right to religious freedom. This is particularly the case with minority religious communities, who fear that a UCC could lead to the imposition of majority religious practices.

Cultural debates also play a crucial role in the UCC discourse. India is a country of immense cultural diversity, with each community having its unique customs and traditions. Critics argue that a UCC could lead to the homogenization of these diverse cultural practices, thereby eroding the rich cultural fabric of the country.

The concerns of minority communities are particularly significant in the UCC debate. Minority groups fear that a UCC could be used to impose the cultural and religious practices of the majority community. They argue for the preservation of their personal laws as a means to protect their cultural and religious identity.

In conclusion, the debate surrounding the UCC is complex and multifaceted, involving political, religious, and cultural dimensions. While the UCC has the potential to promote gender justice and national unity, it also raises concerns about religious freedom, cultural diversity, and the rights of minority communities. The challenge lies in finding a balance between these competing interests, and in ensuring that the UCC, if implemented, is inclusive, equitable, and respectful of India’s diverse cultural and religious landscape.

Legal and Constitutional Challenges in Implementing UCC

Implementing a Uniform Civil Code (UCC) in India presents a host of legal and constitutional challenges. These challenges stem from the complex interplay of personal laws, constitutional provisions, and the role of the judiciary.

One of the key legal hurdles in implementing the UCC is the task of reconciling the diverse personal laws of various religious communities into a single, uniform code. Each of these laws has evolved over centuries and is deeply rooted in the religious and cultural practices of the respective communities. Modifying these laws to create a uniform code is a complex task that requires careful consideration of the religious sentiments and cultural practices of each community.

From a constitutional perspective, the implementation of a UCC must navigate the delicate balance between the right to equality (Article 14) and the right to religious freedom (Article 25). While the UCC aims to promote equality by ensuring that all citizens are governed by the same set of laws, it must also ensure that it does not infringe upon the constitutional guarantee of freedom of religion.

The judiciary plays a crucial role in the UCC debate. Over the years, the Supreme Court of India has made several observations in favor of a UCC. In the Shah Bano case, the court observed that a common civil code would help the cause of national integration by removing disparate loyalties to laws. However, the judiciary cannot enforce the implementation of a UCC as it is a directive principle of state policy (Article 44) and not an enforceable part of the Constitution.

In conclusion, the implementation of a UCC in India is fraught with legal and constitutional challenges. It requires a careful balancing act between promoting equality and respecting religious freedom, and it involves navigating the complex terrain of diverse personal laws and constitutional provisions. The role of the judiciary, while significant, is limited by the constitutional framework, making the implementation of a UCC primarily a task for the legislature.

Public Opinion and the UCC

Public opinion on the Uniform Civil Code (UCC) in India is as diverse as the country itself. Based on various surveys and studies, it’s clear that the UCC elicits a range of responses, often influenced by factors such as religious affiliation, socio-economic status, education level, and political beliefs.

Several surveys indicate a divided public opinion on the UCC. While a significant proportion of the population supports the implementation of a UCC as a step towards gender justice and national unity, there is also a substantial segment that opposes it, viewing it as an infringement on religious freedom and cultural diversity. This division is often along religious lines, with minority communities expressing more resistance towards the UCC compared to the majority community.

The role of media in shaping public opinion on the UCC cannot be overstated. Media outlets play a crucial role in disseminating information about the UCC, highlighting its potential benefits and drawbacks, and providing a platform for debates and discussions. However, the portrayal of the UCC in the media is often influenced by the political leanings of the media outlets, which can lead to a polarized representation of the issue.

Social media has also emerged as a significant player in shaping public opinion on the UCC. It provides a platform for individuals to express their views, share information, and engage in debates. However, it also carries the risk of spreading misinformation and fueling polarization.

In conclusion, public opinion on the UCC in India is divided and influenced by a range of factors. The media plays a crucial role in shaping this opinion, highlighting the need for accurate, balanced, and comprehensive coverage of the issue. As the debate on the UCC continues, it’s essential to engage in constructive dialogues that take into account the diverse perspectives and concerns of the Indian populace.

The Future of UCC: Possibilities and Predictions

The future of the Uniform Civil Code (UCC) in India is largely dependent on the political will of the government, legal developments, and social trends. Given the sensitive nature of the issue, the implementation of the UCC requires a strong political commitment, which has been a challenge in the past due to the fear of backlash from religious and cultural groups.

The current political climate in India suggests a renewed interest in the UCC. The ruling party has expressed its support for the UCC in its election manifestos, indicating a potential push towards its implementation. However, the political will to implement the UCC must be balanced with the need to respect religious freedom and cultural diversity, and to ensure that the rights of minority communities are protected.

Legal developments also play a crucial role in shaping the future of the UCC. The judiciary has been increasingly vocal about the need for a UCC, and there have been several landmark judgments that have called for the implementation of a UCC. These developments suggest a growing legal momentum towards the UCC.

Social trends, particularly the increasing emphasis on gender justice and equality, also influence the future of the UCC. As societal attitudes evolve, there is a growing recognition of the need for laws that ensure equal rights for all citizens, regardless of their gender or religious affiliation. This could potentially increase public support for the UCC.

In conclusion, while predicting the future of the UCC is challenging given the complexities involved, current political, legal, and social trends suggest a gradual movement towards the UCC. However, the successful implementation of the UCC will require a careful balancing of the need for uniformity with the respect for India’s diverse religious and cultural landscape.

The Uniform Civil Code (UCC) is a topic of significant importance in India’s socio-political landscape. This article has delved into the complexities of the UCC, exploring its historical background, implications, controversies, and potential future. The UCC, with its promise of a common set of laws governing all citizens, holds the potential to promote gender justice and national unity. However, it also raises concerns about religious freedom, cultural diversity, and the rights of minority communities.

The debate surrounding the UCC is multifaceted, involving political, religious, and cultural dimensions. The implementation of a UCC in India is fraught with legal and constitutional challenges and requires a careful balancing act between promoting equality and respecting religious freedom. The role of the judiciary, while significant, is limited by the constitutional framework, making the implementation of a UCC primarily a task for the legislature.

As we look towards the future, the successful implementation of the UCC will require not just political will and legal reforms, but also a broader societal change that embraces the principles of equality and justice while respecting the rich diversity of India’s cultural and religious landscape.

In conclusion, the UCC is not just a legal issue, but a reflection of the larger socio-cultural dynamics of Indian society. It calls for further research and dialogue, involving a wide range of stakeholders, to ensure that any move towards a UCC is inclusive, equitable, and respectful of India’s diverse cultural and religious fabric.

Frequently Asked Questions

• What is the Uniform Civil Code (UCC)? The Uniform Civil Code is a proposal to replace the personal laws based on the scriptures and customs of each major religious community in India with a common set of laws governing every citizen.
• Why is the UCC important? The UCC is seen as a tool to ensure equality, fairness, and justice for all citizens, irrespective of their religion or gender. It can promote national unity and gender justice.
• What is the current status of the UCC in India? As of now, the UCC has not been implemented in India, except in the state of Goa. The implementation of the UCC is a directive principle of state policy as per the Indian Constitution, which means it is a goal that the state should strive to achieve.
• What are the main controversies surrounding the UCC? The main controversies surrounding the UCC involve concerns about potential infringement on religious freedom, homogenization of diverse cultural practices, and the rights of minority communities.
• What is the role of the judiciary in the UCC debate? The judiciary plays a crucial role in the UCC debate. It has made several observations in favor of a UCC. However, the judiciary cannot enforce the implementation of a UCC as it is a directive principle of state policy and not an enforceable part of the Constitution.
• How does the UCC relate to gender justice? Many of the existing personal laws have been criticized for their patriarchal biases and discriminatory practices, particularly against women. The UCC could potentially rectify these biases by providing equal rights to men and women in all personal matters.
• What is the public opinion on the UCC? Public opinion on the UCC is divided. While a significant proportion of the population supports the implementation of a UCC, there is also a substantial segment that opposes it, viewing it as an infringement on religious freedom and cultural diversity.
• What is the future of the UCC? The future of the UCC depends on various factors, including the political will of the government, legal developments, and social trends. While current trends suggest a gradual movement towards the UCC, its successful implementation would require a careful balancing of the need for uniformity with the respect for India’s diverse religious and cultural landscape.

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• Targeted and Inclusive Approaches to Tackling Energy Poverty in a Crisis Context: Case Study from Moldova pdf (0.6 MB)

Targeted and Inclusive Approaches to Tackling Energy Poverty in a Crisis Context: Case Study from Moldova

April 15, 2024.

According to UNDP estimates from the early days of the energy crisis in Moldova, 71 percent of households were in the most vulnerable energy category, spending 90 percent or more of their available income—after the minimum expenditure—on energy and heating during the cold period. Highly dependent on energy imports, the country risked tripling its population living in poverty from 11 to 35 percent. In the context of a compounded crisis and the war in Ukraine, the Moldovan Government, in close collaboration with the United Nations Development Programme (UNDP), developed an innovative and targeted on-bill energy compensation mechanism, the first of its kind in Moldova, the Energy Vulnerability Reduction Fund (EVRF). 

The aim of EVRF is to create an inclusive solution that minimizes the negative impacts of the sharp increase in energy prices on energy-vulnerable and income-poor households, therefore safeguarding social cohesion. At the same time, in the longer term, the EVRF aims to incentivize the transition towards sustainable energy sources and to achieve higher levels of energy efficiency in the residential sector. 

This paper presents the main outcomes of the UNDP support for the establishment and implementation of a robust EVRF, along with an impact assessment and lessons learned that are applicable to other country contexts.  

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How tackling a tech challenge helped the Pro Football Hall of Fame score

The Hall needed to digitize its annual voting process — so leaders called in the pros at EY.

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When the game is on the line, can technology tackle the challenge?

The Pro Football Hall of Fame needed a digital play that would infuse speed and security into its annual voting process.

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The Pro Football Hall of Fame is where football legends are enshrined. The Hall’s mission is to honor the greatest of the game, preserve its history, promote its values and celebrate excellence together. Enshrinement is the ambition of every player, coach and contributor and pays lasting tribute to the talents, triumphs and integrity of pro football’s greatest icons.

Each year the Hall inducts a new class of football heroes, comprising up to five modern era players plus candidates from the coach, contributor and senior player categories. They are chosen by a 49-person Selection Committee made up primarily of news media representatives and current Hall of Famers. Traditionally, the Hall’s voting process involves multiple rounds of manual ballots and spans several months. It starts with 100-plus nominees, who are announced in September. Those 100 nominees are pared to 25 by November, and then further reduced to 15 in December. The final cuts leave five or fewer modern-era nominees, who receive a yes/no vote from the Selection Committee. The Hall’s 15-to-five process has traditionally taken place in person over the course of a full day on the Saturday before the Super Bowl.

Until recently, the voting process has been entirely manual; ballots were mailed or emailed, and all Selection Committee members had to convene in the Super Bowl host city to deliberate in person to cast their final ballots. This meant each phase had to be manually tabulated, a process that evolved to the tabulation and verification via the digital ballot and Ernst & Young LLP (EY) serving as the Pro Football Hall of Fame’s partner of choice.

“With the importance of the vote going off without a flag and the element of security and time being a factor, we needed a team we could trust and reached out to EY because of their history of proven success and bench of strong, diversified players,” said Pat Lindesmith, Executive Vice President of Sponsorships & Partnerships.

In 2020 amid the COVID-19 pandemic, the Hall recognized the traditional in-person meeting of all Selection Committee members would need to be canceled due to health, safety and travel concerns. The game was changing and the Hall needed an answer that would maintain its standards for integrity, confidentiality and security.

With the clock ticking down to Super Bowl LV, the Hall and EY needed to work together to roll out a new user-friendly digital platform that streamlined the voting process, had the technical functionality to count and verify votes, and maintained the security and secretive nature of the nominees and votes with record-setting accuracy and speed.

The better the answer

A digital ballot solution that changed the game

The Hall knew EY could quarterback the big play by taking voting online with a customized process that drives sustainable success.

EY has been the official vote counter of the Hall for three years. So when the Hall needed to change its process on a dime but still maintain its operational quality, voter integrity and ballot security, leaders turned to the pros at EY to discuss leveraging a technology solution initially developed by an EY wavespace™ team for annual consumer confirmation audit processes and customized to help a global financial institution elect a new bank president.

Huddling up and hitting the field

The EY team huddled up and pulled in professionals from across the firm including Mike Risk from our EY Consulting team and Dilip K. Balan from our EY Assurance practice to meet the Pro Football Hall of Fame. The EY team listened to the needs of the Hall and set out to customize a digital ballot solution in just two weeks.

“Our goal was to improve the efficiency and help ensure the integrity of the Pro Football Hall of Fame Class of 2021 selection process, and we were able to accomplish that using a customized technology solution that digitized the voting process,” said Joe Lukac, Partner, Ernst & Young LLP. “We are proud to work with the Hall and assist the Selection Committee in continuing the legacy of the legends of the game.”

The EY team made the pregame adjustments, transforming paper ballots into digital ballots that leveraged unique codes for each voter to eliminate security concerns and preserve privacy. To further minimize risk, all assets were housed on a secured EY cloud platform. The team at the EY Innovation Lab built the digital ballot solution on the EY Client Technology Platform, which was reviewed and tested by our EY Infosec and Cybersecurity teams so that everything was “game ready.” Customer experience testing was then conducted via five pilot test rounds to validate user intuitiveness of the digital ballots, followed by workflow tuning for a seamless people-centered voting process capable of accommodating a digitally diverse Selection Committee.

When the voting process kicked off in October, the Hall hit the field with its new digital solution powered by EY. Additionally, EY professionals were at the ready to provide 24/7 tech support and training throughout the process. The vote happened without a single glitch, with vote tabulations going from hours to just minutes.

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EY delivers what football is all about: speed, accuracy, teamwork

For the Hall, the voters have their voice, the players have their glory and the fans have their football legends.

The pros at EY implemented a new solution and built a tool that modernized the voting process by improving and streamlining it in just two weeks. This digital solution also increased the integrity and security of the process. Voters now have a user-friendly app that can be accessed securely on a phone, tablet or laptop, allowing EY auditors to view and validate the voting results instantaneously via live pivot tables in Excel as opposed to a manual tabulation process.

“We appreciate EY providing the Hall with a digital platform that made selecting the Class of 2021 safe, secure and efficient,” said Jim Porter, President of the Pro Football Hall of Fame. “This tech-driven process provides immediate results as votes are taken, shortening a long day for our Selectors and increasing the integrity of the voting process.”

This digital solution delivered many benefits for the Hall, including:

“Voting is a great responsibility, and it’s an honor for our EY teams to help ensure it’s done securely, efficiently and with integrity,” said Lukac. “We are excited to be part of the process that gives the best of the best their rightful place in football history.”

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