Table 1.

A theory of change model to increase data generation and contextual research in low- to middle- income countries.

Impact: Improved evidence generation and contextual research for optimal CHD care N (%): Increase in available health outcome metric datasets, increase in number of papers on data from LMIC authored by investigators from Global south.
Intermediate Outcome: Improved resources, representation, and publications N (%): 1. Increase in the number of resources: Amount in $ funding toward health outcome research in LMIC and number of high quality LMIC researchers and other supporting staff (e.g., statisticians, data scientist etc) 2. Increase diversity in global health advisory, editorial and conference representation 3. Increase in the number of publications and citations from LMICs lead investigators.
Pre-conditions	Interventions	Indicator/Metrics
1. Improved Funding
1.1 Value creation around contextual evidence and research among local stakeholders	• Involving key stakeholders (patients, physicians, insurance companies, pharmaceuticals/device companies, government health ministries). • Demonstrating value in investing in data especially health outcome metrics at a micro (individual- physician or patient or institutional- hospital, academic medical centers) or a macro-level (government- health ministries)	– Number of disease specific health outcome registries or collaboratives created nationally. – Number of block chain start-ups managing health outcome data emerging locally. – Number of national conferences or meeting around contextual data generation and health outcome research including all stakeholders.
1.2 Increased local funding	• Creating holistic impact outcomes for healthcare workers and institutions thus tying in health outcome data and research to improved human capacity and productivity i.e., a healthy individual will have less working days lost and less expenditure on a healthy workforce for company with health insurance benefits. • Demonstrating benefits of value-based health care to pharmaceuticals/device industry, insurance companies. • Incentive for government health authorities to invest in data generation and research around health outcomes thus helping them objectively and effectively allocate health budget. • Educate stakeholders (industry, insurances, government, philanthropist etc) about better return of their investment through data and research driven improved quality of care.	– Number of health care providing entities collecting and providing health outcome data. – Number of corporate health care entities (device companies, pharmaceuticals) with dedicated health outcome funding budgets.
1.3 Contextually relevant external funding	• Increased transparency of external grants by ensuring allocation of external grants alignment with the national health care needs and in consultation with the community. • Prevent centralization of resources by funding research in all geographic areas regardless of economy status	– Amount (in $) of research funds allocated by health care philanthropic organizations, government and insurance companies – Reports by large funding agencies of N(%) of local stakeholders involved in grant evaluation. – Amount of (in $) external funds allocated to the disease areas causing the highest morbidity and mortality. – Geographic mapping of percentage of funding by large funding agencies – Amount (in $) amount allocated to health care facilities clearly demonstrating holistic impact outcomes.
2. Improved research culture
2.1 Value creation around institutions promoting contextual research and capacity building	• Preferential health budget support of federal funds to institutions demonstrating robust research activities, improvement in healthcare based on contextual data generation and research capacity building. • National academic institutional collaborations amongst various schools–health, humanities, business, engineering, information and technology–to promote a culture of innovation and entrepreneurship to tackle healthcare challenges using a multi-disciplinary approach. Technology transfer and opportunity to create health care startups and revenue generating opportunities. • Acknowledging institution which has employee appraisal based on their contextual research productivity. Encourage institutions to value impact on health outcome vs. journal impact factors or number of publications.	– N (%) of clinicians and researchers at government and private health institutes involved in conducting research – Number of scalable technologies and startups created yearly from graduates of such academic institutions. – $ funding to institution fulfilling the criteria of a “research” valuing center.
2.2 Increased participation in international database and collaboratives.	• Mandate (at a national level) benchmarking of outcomes and quality improvement sciences. Highlight programs with improved outcomes as determined by a third-party auditor (i.e., IQIC) • Encourage local stakeholders within multiple LMICs to collaboratively propose optimal and cost-effective solutions to prevalent problems by sharing their experiences and promote the practice of evidence-based medicine.	– Number of health care delivery entities benchmarking their health outcomes by being on national or international registries.
2.3 Increased transparency around funded research outputs and health outcome data	• Encourage focus on knowledge translation and innovative projects pertaining to local solutions • Develop feedback systems to monitor alignment of resource allocation and outcome improvement. Monitor newly introduced modified policies to ensure sustainability.	– Number of nationally funded projects leading to contextual clinical practice guidelines – Number of nationally funded research projects demonstrating improvement in health outcomes.
3. Adequate capacity to do conduct research activities
3.1 Improved training via northern exchange programs and mentorship	• Online and in person certificate training programs and workshops of conventional research courses to target larger masses. Sponsored master's and doctorate degrees, postdoctoral research positions to LMIC grantees and trainees. • Teaching translational and implementational science to encourage innovation and contextually relevant research that may improve practice and policy • Assign mentors to these trainees that can give detailed feedback and offer continued assistance throughout their journey promoting research career development. Sustained mentorship should be lauded, supported and programs demonstrating it prioritized in receiving global health funds. • Increased expectations and accountability from exchange program awardees to build research developmental programs at home institutes and achieve long term scientific independence.	– Number (%) of exchange programs awardees from LMICs every year at HIC global health institutes. – Number (%) conference presentations and manuscripts led by LMICs mentees – Number (%) of research programs developed by LMICs mentees in their setups
3.2 Training provided by academic institutions within LMICs	• Institutional level journal clubs and seminars encouraging lower resourced health care setups to participate, voice and formulate research agendas. • Collaborative platforms by federal bodies to address problems and suggest sustainable solutions through modified interventions. Modified care practices need to be documented initially at a local level via publications in local journals with a larger goal of establishing national database and guidelines to support these claims. • At a national level, encourage local health care workers with limited resources and large patient loads to exchange ideas and information at health conferences as participants, panelists, speakers, and advocates to bring neglected local health problems to the table. Promote large scale evidence-based medicine practices by defining clear outcomes and objectives of such forums.	– Number (%) of research related activities conducted every year at leading academic health institutes. – Number (%) local specialized journal publications and their quality of work. – Number (%) of national health conferences and participants diversity across the country.
3.3 Incentives and fair growth opportunities	• Competitive salaries and benefits for health care workers conducting research in the communities at government and private institutional levels. • Providing technological expertise and tools for improved data acquisition and health information exchange. • Health research award programs need to acknowledge high quality research work aimed at reporting large data, quality improvement initiatives, creating contextual guidelines and demonstrating improved health outcomes.	– Number (%) of national awards given to researchers to recognize their efforts in improving health outcomes. – % increment in salaries of researchers based on their contribution toward improving health outcomes nationally.
4. Increase representation in global health journal, conferences, and governance bodies.
4.1 Regional journals to target relevant audience.	• Encourage separate local or regional branches of global health journals which may publish more relevant and applicable data from local researchers. • Encourage utilization of publication and the importance of quality of work over journal impact-factor.	– Number of leading global health journals having subsets of regional journals.
4.2 Diversity amongst journal editorial boards and conferences.	• Increase diversity of representation amongst all journals and conference stakeholders. This may apply to editor-in-chiefs, editors, first authors of published articles for top global health journals. This may also extend to speakers and participants at global health conferences.	– A diversity score similar to the Composite Editorial Board Diversity (CEBD) score reported by [Bhaumik and Jagnoor (44)] can assess geographic, ethnic, and country income-level diversity.
4.3 Inclusion amongst global health bodies	• Systematic reporting system to keep track inclusion in global health advocacy bodies • Liaisons with researchers active in eliminating disparity of representation.	– Yearly audits of number (%) of LMIC representation in advisory bodies and editorial boards.