The Real Challenges of Global Clinical Research

flowchart TD
 A[Protocol finalized] --> B[Country startup begins]
 B --> C[Local requirements surface]
 C --> D[Docs and contracts reworked]
 D --> E[Site activation delayed]
 E --> F[Enrollment plan slips]
 F --> G[Resourcing and budget reset]

flowchart LR
 A[Core dossier ready] --> B1[Country A: authority + ethics in parallel]
 A --> B2[Country B: authority first]
 B1 --> C1[Site activation prep]
 B2 --> C2[Ethics submission after authority feedback]
 C1 --> D[First patient in]
 C2 --> D

flowchart TD
 A[Add procedure or endpoint] --> B[Longer visits and more training]
 B --> C[Site workflow strain]
 C --> D[Patient burden increases]
 D --> E[Deviations and missed windows]
 E --> F[Queries, amendments, dropout]

flowchart TD
 A[Country prevalence] --> B[Diagnosed patients]
 B --> C[Referred to study-capable centers]
 C --> D[Meet eligibility]
 D --> E[Consent and logistics work]
 E --> F[Randomized patients]

flowchart TD
 A[Feasibility questionnaire] --> B[Optimistic capacity estimate]
 B --> C[Startup and training begin]
 C --> D[Competing studies and turnover surface]
 D --> E[Coordinator workload spikes]
 E --> F[Enrollment slows and data lags]

flowchart TD
 A[Local practice or tool mismatch] --> B[Delayed or incomplete source flow]
 B --> C[Late EDC entry or inconsistency]
 C --> D[Query volume rises]
 D --> E[Site time diverted to cleanup]
 E --> F[Further lag and frustration]

flowchart LR
 A[Name key assumption] --> B[Test with local evidence]
 B --> C[Assign owner and threshold]
 C --> D[Monitor early signal]
 D --> E{Signal holds?}
 E -->|Yes| F[Proceed]
 E -->|No| G[Adapt plan or scope]