Catalysing multimorbidity research in Low and Middle Income Countries through a "community of practice" approach: An India-Brazil-UK Initiative

This international network between India Brazil and UK aims to foster global south-south collaboration to research on multimorbidity across Low and Middle Income Countries by creating "community of practice" as an enabling platform to address the challenges of multimorbidity in respective countries through shared learning, capacity building and collaborative research. We envisage that this mutually enriching coalition between India and Brazil, with the overarching support of UK, a leader in primary care multimorbidity, will not only catalyse multimorbidity research in individual countries, but further lead to a larger trans-continental (South Asia- South America-UK) collaboration and pave path for the LMIC Network on multimorbidity.
Principal objectives of this project are to:
1. Set up systems and bring synergy within public health care environment to develop a "community of practice" on multimorbidity using the existing networks and institutions through a mix of strategies comprising coalition building, advocacy and multidisciplinary capacity building. This community of practice will be a self-driven cohesive platform and would sustain the research momentum in the region and design locally relevant for mitigating the care challenges of patients living with multimorbidity.

2. To come up with a simple yet useful capacity building framework/ training program for general practitioners, public health researchers, academicians, and health service managers to appreciate the multiple challenges of multimorbidity on health care and patients and identify the immediate research priorities to respond to this challenge as a team.

3. We believe that this in turn would improve better assessment and management of multimorbidity in primary care leading to improved patient outcomes through provision of continuous, coordinated and tailor-made care based on evidence and consultatively develop, design or contribute to contextualized care protocols.

4. To provide an adaptable template for building multimorbidity research capacity in low and middle income country settings by sharing with both policy and scientific community.
5. To collaboratively work with our "community of practice" and apply for large grant to develop, implement and evaluate a patient focused integrated system of care based in primary care practice for people with multimorbidity.
The International and national network created would spearhead advocacy and engage with policy makers, health planners and health care managers in respective countries and across LMIC for considering multimorbidity while reorienting the health services to strengthen primary care under the ambit of universal health coverage. With the help of the project findings, wet would also continue dialogues with the National research agencies to include multimorbidity as a new research priority and provide grant opportunities for further research.
We additionally plan to disseminate our findings with diverse audience through national workshops, publications in international journals, stakeholder reports and bulletins, guidelines and linkages with government and non-government stakeholders. Through these channels we will deepen the evidence base, further the research agenda of multimorbidity and ultimately influence health and social policy and practice. Our work will have applicability nationally and internationally especially in the low and middle income countries strengthened by our collaboration with researchers from and thus contribute significantly to the social and economic development.

Multimorbidity, the co-existence of two or more chronic conditions in an individual, leads to substantial health care resources use, inferior quality of life and increased premature mortality thus posing enormous challenge for health systems and populations. Despite the unprecedented rise in Non-Communicable diseases in low and middle income countries (LMIC), the domain is sparsely explored in these settings excepting few reports from India, Brazil and South Africa. One of the factors could be the multimorbidity research capability asymmetry and the research-policy-practice ecosystem in LMIC is yet to be cognizant of this burgeoning health care challenge. Our study in India has revealed that one-third of primary care patients have multimorbidity where the challenges are ''horizontal'', integrating not only at the level of the clinical encounter, but also in the co-ordination of services to support patients with multiple problems.
We therefore aim to build a South-South Collaboration between India and Brazil with the expert support of UK faculty to develop a "community of practice" on multimorbidity by linking university research hospital, specialists, primary care, public health researchers and health services managers. We plan to adopt a complimentary strategy encompassing: network formation, coalition building within network partners, capacity building of members, and evidence-informed advocacy with key stakeholders for government buy-in. We would develop a contextualized curricular framework for multidisciplinary capacity building in multimorbidity and stimulate the community of practice to collaboratively identify the prioritised research to improve patient outcomes in multimorbidity. We believe that, each country's community of practice established through the project would catalyse multimorbidity research within respective countries and pave path for larger South Asian- South American Network and be a demonstration template for other LMIC to adopt and adapt.

Multimorbidity is the greatest health care challenge in the 21st century with its profound effect on patients, populations and health care systems. Patients with multimorbidity register higher mortality, incur greater health care utilization and expenditure and experience poorer quality of life thus putting an enormous burden on a country's' economic and social development. Currently there is paucity of research capacity among the health care practice, policy and the academic community in Low and Middle Income Countries (LMIC) addressing this issue. Through this grant we aim to establish a shared learning and mutually enriching collaboration between India and Brazil with guidance from UK to strengthen the research capacity of these key stakeholders. To achieve this, we would adopt a "community of practice" approach by linking Medical Colleges Faculty, Specialists, Primary Care Practice Team and the Public health Programme Managers and build their capacity on various aspects of multimorbidity.
This will create a cohort of multimorbidity researchers who would work together as "a community of practice" and facilitate high quality research, and support the diverse care needs of people living with multimorbidity. We envisage there will be improved functional amalgamation between health services, realigning of current health policy and team-based care delivery for patients by both inter-professional communication and inter-disciplinary linkages.
Patients and Population groups: Elderly populations, those with chronic immunodeficiency conditions, disabled, patients living in geographically difficult terrains, urban poor, socially deprived population having multimorbidity will have early diagnosis, appropriate care delivery, and improved referrals. A holistic-patient-centred health care will improve their quality of life and health outcomes thus contributing to social development.

Primary care practitioners: Practitioners working in rural, remote areas will be empowered with knowledge and skills to better manage multimorbidity patients. Their practice experiences will contribute to research, facilitating design of appropriate care protocols. for geriatric or high-risk patients.

Informal Networks: Community health workers, traditional care providers, and non-government organisations working with aged populations can assist government agencies in multimorbidity care. Informal social networks like patient support groups, or self-help groups will be multimorbidity literate and advocate policy changes.

Peoples representatives and health activists from remote, rural, or deprived areas will be in a better position to oversight the delivery of services. They can champion the health care needs of multimorbidity and enable appropriate policy interventions.

Academicians of university teaching hospitals: Those from general medicine, community medicine, geriatric and other specialities treating patients with multimorbidity, young faculty and researchers associated with them will benefit by improvised training programmes and research to focus on multimorbidity. There will be better inter-disciplinary communications, improved primary-secondary care interface and coordinated continuity of care for multimorbidity.

Policy makers: Those from government bodies like the dept. of health, department of social security for geriatric and marginalised populations, can better understand the issues, make pragmatic decisions and facilitate quick and efficient policy changes.

LMIC countries: Eventually, the LMIC will benefit by a healthier population, reduced burden on healthcare system, reduced financial burden on individuals as well as on the national economy.

Research team: The international collaboration will create a multimorbidity focused platform to share ideas and experiences and identify challenges and solutions. As a spinoff from this project, replicability of this model in other regions which will be considered