Which countries invest most in TB research?

By Marcus Low, Spotlight

Investment in TB research can be measured in many ways. The most obvious way is simply to look at who gives the most money for TB research. The country that gives the most, by far, is the United States – which gives more money than all other countries combined.

Of the $726 million invested in TB research and development (R&D) in 2016, 66% was invested by governments, 20% by philanthropic organisations, 11% by industry, and 3% by multilateral entities. Together, the United States National Institutes for Health (NIH) and the Gates Foundation contributed half of global investment in TB R&D. Many pharmaceutical companies do not invest in TB at all; and the few that do, invest relatively small amounts.

The top 10 countries in terms of absolute investment in TB R&D were:

  1. United States $316 471 566
  2. United Kingdom $27 575 390
  3. European Union $23 575 253
  4. Canada $16 898 180
  5. Germany $14 820 938
  6. India $14 768 283
  7. South Korea $12 359 135
  8. The Netherlands $9 858 859
  9. Australia $9 489 424
  10. South Africa $6 465 746

While a new BRICS TB Research Network was announced recently, of the five BRICS countries, only India and South Africa are in the top 10 in terms of absolute investment in TB R&D. Large developing economies such as China, Russia, Indonesia and Brazil make only very modest investments in TB R&D. Among wealthy countries, the very low investment made by France, Japan, Italy and Spain is notable.

SA top on two important measures

In the latest TAG R&D report, South Africa is ranked number one on two important measures of investment in TB R&D: percentage of GDP and percentage of GERD (explained below). In terms of the absolute investment in TB R&D, South Africa ranked 10th, with $6.5 million (around R90 million) invested in 2016. Whichever measure you use, South Africa invests more than most other countries with high TB burdens.

Yet, even with South Africa’s relatively high levels of investment in TB R&D, many of our researchers are still dependent on funding from the United States government to do their research. The United States invests almost 50 times as much as South Africa in TB R&D.

“South Africa ranks first when its spending on TB R&D is judged relative to its GDP and GERD; however, this is largely a function of South Africa’s lower GDP and R&D expenditures, compared to other countries that report data. The absolute amount of money South Africa gives to TB research is still low – only $6.5 million last year – and most goes to a handful of universities and academic medical centres.

“Given the burden of TB in South Africa, its significant clinical trials capacity, and the depth of its scientific talent, there is ample room for South Africa to increase its contributions to TB research. In addition to supporting domestic researchers through grant funding, South Africa should explore innovative ways to finance and incentivise TB research, including co-financing for regional and global initiatives such as The Life Prize or the BRICS TB Research Network.” – Mike Frick, author of the TAG TB R&D Report

Percentage of GDP

Because countries have different-sized economies and different levels of development, simply looking at who gives the most money is not always a fair comparison. One alternative is to see what percentage of a country’s GDP is spent on TB R&D. GDP, or Gross Domestic Product, is the total value of everything produced by all the people and companies in a country.

The top 10 countries in terms of percentage of GDP invested in TB R&D are:

CountryTB R&D Funding 2016GDP 2016 (USD Millions)TB R&D Expenditure as % of GDP Rank Order
South Africa$6 465 746$294 8411
United States$316 471 566$18 569 1002
Norway$5 503 497$370 5573
The Netherlands$9 858 859$770 8454
Canada$16 898 180$1 529 7605
United Kingdom$27 575 390$2 618 8866
Switzerland$5 938 196$659 8277
South Korea$12 359 135$1 411 2468
Australia$9 489 424$1 204 6169
India$14 768 283$2 263 52310

Percentage of GERD

Another option is to look at what percentage of all the money invested in R&D in a country is invested specifically in TB R&D. This total investment in R&D in a country is called GERD, or Gross Domestic Expenditure on R&D.

The top 10 countries in terms of percentage of GERD invested in TB R&D are:

CountryTB R&D Funding 2016Average Annual GERD 2010–2015GERD calculationTB R&D Expenditure as Percentage of GERD Rank Order
South Africa
$6 465 746
$4 718 475 774
0,14%
1
Norway$5 503 497$5 441 716 1000,10%2
United States$316 471 566$452 804 833 3330,07%3
United Kingdom$27 575 390$41 157 956 4650,07%4
Canada$16 898 180
$25 773 702 491
0,07%
5
The Netherlands$9 858 859$15 342 022 2200,06%6
Australia$9 489 424$21 554 008 7150,04%7
Switzerland$5 938 196$13 669 878 7100,04%8
The Philippines$302 178$762 079 5320,04%9
New Zealand$679 649$1 811 948 5690,04%10

TAG calculated that in order to meet the WHO End TB Plan’s target of $2 billion per year for TB R&D, all high-burden and G20 countries must invest 0.1% of GERD in TB R&D. Currently, the only two countries to meet this target are South Africa and Norway.

 

  • The figures in this article are taken from the Treatment Action Group report ‘The Ascent Begins: Tuberculosis Research Funding Trends, 2005-2016’, published in November 2017. Find the full report at TreatmentActionGroup.org/TB

Moment of truth for global TB response

On Thursday 16 November 2017, Russian president Vladimir Putin told a hall full of health ministers in Moscow that TB is a “serious problem”, and said, “I am confident that the only way we can stand up against this truly global threat is if we join forces.” Over the next day and a half, the meeting at which President Putin was speaking – the first World Health Organisation (WHO) Global Ministerial Conference: Ending Tuberculosis in the Sustainable Development Era – positively resonated with such talk of the “urgency” of the TB crisis, and calls to “work together”.

Yet one of the lessons one learns when working on TB is that whether it concerns financing, health-system reform or political will, the difference between what is said and what is done is often depressingly stark. Even as President Putin was reading his speech, many people in his own country still do not have access to a state-of-the-art diagnostic test that most experts agree should be a critical part of any country’s TB response.

This gap between what is said on the international stage and what is done back home will have to close if meetings such as these are to have any impact on the actual treatment and care received by people with TB. The somewhat toothless declaration coming out of this week’s meeting may generally say the right kind of things, but governments steered clear of making any firm and binding commitments. And without firm and binding commitments, it is hard to see how such declarations can have any real impact in a world of shrinking health budgets and many competing priorities.

Even so, the process heading into the Ministerial Meeting and onward to the September 2018 United Nations (UN) High-Level Meeting (HLM) on TB presents a rare moment of political opportunity to improve the often mediocre global response to TB. There is a kind of weary optimism among people working on TB – weary because of an underlying fatalism that seems to permeate much of the TB world; optimism because at last there is a reason to hope for substantially more political will, together with all the resources that entails.

How will the BRICS fund their plans?

Together with Putin’s appearance, the establishment of a BRICS Research Network is probably the most concrete piece of good news from the meeting. Research cooperation between the BRICS (who together have around 40% of the world’s TB cases) suggests that these governments may be willing to start shouldering more responsibility and investing in domestic research capacity. It is also indirect evidence of the failure of such research cooperation processes that have come through the WHO – where wealthy countries such as the United States have managed to scupper good ideas such as a binding R&D treaty. That the BRICS nations are taking the initiative is great news.

One concern is that the deliberations behind the BRICS TB Research Network to date have been relatively insular. As a next step, the negotiators – now involving the foreign ministries of each country – should reach out to civil society, and make the work of the network as transparent as possible. One of the network’s priorities will be to “develop innovative mechanisms for R&D”, guided by “principles of affordability, efficiency, equity, and effectiveness”. Given the potential influence of industry lobbies, civil-society input may be needed to ensure these values are not lost along the way.

As with R&D more broadly, the true test of this network will be whether or not governments will put up the money. An unfunded network will offer only marginal benefits, and not the major innovations we need for TB. Extracting money from already stretched austerity budgets will be difficult, which means it will probably have to be found elsewhere. The idea of approaching the BRICS Bank was mentioned – other possibilities include sin taxes, or even financial-transaction taxes.

TB research grossly underfunded

That money for TB research is a problem is borne out by a recent report showing that total global investment in TB research was only around $726 million in 2016. The report, published by the Treatment Action Group (TAG), showed an increase over 2015 levels, but emphasised that it is still only around a third of the annual $2bn in total global investment that the WHO’s End TB Plan estimates is needed per year. For some context, the United States military budget alone is set to rise by $54 billion in 2018, to around $600 billion.

The power of TB R&D as a critical indicator, when compared to the long laundry list of issues cited in the Moscow Declaration, is that it can be measured precisely. As such, it provides probably the clearest test we have of political will. If all the world’s governments cannot even scrape together $2bn per year for a disease that kills around 1.7 million people a year, then the idealistic language of the ministerial declaration, and the declaration that will come out of next year’s UN HLM on TB, will clearly be empty rhetoric – and perhaps worse than empty rhetoric; a kind of rhetoric that loudly proclaims to help the poor, but when the time comes, does nothing.

How much should countries contribute?

While the WHO’s estimate that we need around $2bn per year for TB research is a good starting point, there are obvious differences regarding who should contribute how much. As with cutting greenhouse gas emissions, countries will differ on who is responsible for what, and on what is fair. It seems likely that a system perceived to be fair will be required if countries are to buy in or to sign up to binding funding commitments.

This problem has now been satisfactorily solved – at least in my view – by a new set of country-specific targets published by TAG. TAG suggests that each of the high-TB-burden countries and the G20 should invest 0.1% of their Gross Domestic Expenditure on R&D (GERD) in TB research. This means, by definition, that less is asked of countries that invest less in R&D, and more of countries that invest more – something that builds a degree of fairness and realism into the targets.

As with any targets, these are imperfect. It may or may not be a good idea to ask more of high-burden countries than is indicated in these targets. Perhaps there should be greater focus on increasing overall R&D spending, rather than shifting existing R&D funds to TB. When one looks at the actual targets, though, most of these criticisms fall away. Most countries will be asked to invest more (currently, only South Africa and Norway meet the targets) – but in almost all cases, the asks are realistic, given the threat and seriousness of TB. The 0.1% of GERD target also has the benefit of being simple. More complicated formulas taking into account TB burden, GDP, and GERD could be developed – but adding such complexity would make the targets more opaque.

Kicking it upstairs

In a rousing speech at the opening of the meeting, South Africa’s Minister of Health, Dr Aaron Motsoaledi, said: “We must come up with innovative research and development models, such as The Life Prize – formerly known as the ‘3P’ project – which delinks the cost of R&D from the final cost of medicines.” It was disappointing that, apart from strong interventions by Motsoaledi and South Africa’s Director General of Health, Precious Matsoso, The Life Prize and delinkage did not get more traction at the conference – given that The Life Prize (in its specificity) and delinkage (with its intellectual framework) are some of the best responses we have to the partial market failure of TB medicines and diagnostics, where patent protection has proven insufficient incentive to drive innovation. In his understanding of how increased R&D can best play out in the real world, Motsoaledi was a step ahead of most other speakers.

He was also clearer than most about the politics of the process, heading toward the UN HLM. He was unequivocal that heads of states must now take responsibility, and give ministers their “marching orders” in the fight against TB. He is correct.

At the opening of the ministerial meeting, President Putin said: “Another important success factor is to step up scientific tuberculosis research and develop effective diagnostic tools, vaccines and medicines, including those aimed at treating resistant forms of tuberculosis. In this regard, I believe that the initiative of the BRICS countries to create a network to study tuberculosis is very important.”

No doubt many similar things will be said by other world leaders in the next 10 months, and at the 2018 UN HLM on TB. Yet, behind the words, hard cash and hard indicators such as investment in R&D will tell us whether our world leaders mean what they say; whether President Putin is serious about TB; whether the emperor is wearing any clothes.

Note: Low is a member of the Life Prize steering committee. The Life Prize is mentioned in this article. Low’s views are his own.

Note: This is an early online access article from the upcoming print edition of Spotlight to be launched on 1 December 2017.

Less money for TB research

By Mike Frick

Treatment Action Group

The world spent less on tuberculosis (TB) research in 2015 than it did in 2009. This decrease in spending does not track a similar decline in TB incidence or mortality.

The World Health Organisation (WHO) recently announced that the TB epidemic is larger than previously estimated, a grim truth uncovered by improved surveillance data from India. More than 10 million people fell ill with TB in 2015 and 1.8 million died from the disease, making TB the leading cause of death from a single infectious agent globally. Yet research by the Treatment Action Group (TAG) shows that funding for research to develop the diagnostic tests, preventive interventions, and combination drug treatments needed to eliminate TB fell for the second year in a row, landing at US$620,600,596 – the lowest level of funding since 2008.

The TAG’s 2016 Report on Tuberculosis Research Funding Trends: No Time to Lose is the 11th in a series of reports that track annual spending on TB research and measure actual spending against the targeted funding called for by the Stop TB Partnership’s Global Plan to Stop TB, 2011-2015.

Only one third of needed investment

The Stop TB Partnership estimated that the world needed to spend $9.84 billion on TB R&D between 2011 and 2015 to end TB as a public health threat. Instead, actual funding for TB R&D amounted to $3.29 billion, just one-third of this target. Most alarming, funding for TB R&D fell in three of the last five years – by $36.5 million in 2012, $12.3 million in 2014, and $53.4 million in 2015. This downward trend belies the upward revisions to the extent of the TB epidemic over the same time period and points to an acute anemia of political will to address TB. The fact that spending on TB research is falling as estimates of TB mortality rise is a damning illustration of how governments have failed to mobilise against TB.

All sectors – including the pharmaceutical industry – have an obligation to fight TB by investing in the science required to end this epidemic, but the heavy lift will need to come from governments. (In 2015, the private sector spent $86.8 million on TB R&D, 40 percent less than the $145 million industry invested in 2011.) Over 60 percent of TB research funding comes from the public sector, and over half of all public money for TB R&D from 2011 to 2015 came from a single country: the United States. This degree of concentration has produced a precarious reliance on the political commitment of a single country.

BRICS: Half of TB, 4.3 percent of TB R&D

Countries that shoulder the heaviest burdens of TB are conspicuously absent from the list of leading TB R&D funders. Together, the BRICS countries (Brazil, Russia, India, China, and South Africa) accounted for nearly half of all TB cases and deaths in 2015, but only contributed 4.3 percent of public financing for TB R&D. In absolute terms, India led the BRICS countries with $11.1 million, followed by South Africa with $3.9 million and Brazil with $1.9 million. (Despite repeated requests, the governments of China and Russia did not return TAG’s survey.)

South African universities – which conduct some of the world’s most cutting-edge TB research – received more funding from the US National Institutes of Health (NIH) and the Bill & Melinda Gates Foundation (Gates Foundation) than from the South African Medical Research Council or other domestic agencies.

In 2015, the South African Medical Research Council disbursed $3.1 million in support of TB research (some of these funds came from budgetary allocations by the Department of Science and Technology and the Department of Health). By comparison, the Gates Foundation gave $17.5 million to South African research organisations, and the NIH gave $3.9 million.

A crisis of political will

The growing recognition that the deficit of TB R&D funding is a crisis of political will owes a lot to the unflinching analysis of South African TB and HIV activists. After reviewing TAG’s 2015 TB R&D funding data, Lynette Mabote of the AIDS and Rights Alliance of Southern Africa offered this frank diagnosis: ‛There can be no end to TB without an end to political indifference in this R&D agenda.’

Mabote’s words echoed a point Anele Yawa, General Secretary of the Treatment Action Campaign, made in his closing speech at the 46th Union World Conference on Lung Health in Cape Town: ‛The lack of investment in TB is a political problem. It is political, because at its essence it is about governments not being held accountable for failing to respond to TB. We are not going to change it if we accept business as usual. We can’t win this battle if we don’t make it a political battle.’

Key UN processes

The tools, frameworks, and platforms for making TB R&D a political battle are starting to coalesce. In particular, two UN-led processes that culminated in September 2016 have created unprecedented opportunities for TB research activists to engage political leaders on the global stage.

The first is the final report of the UN Secretary-General’s High-Level Panel on Access to Medicines, which issued a formidable set of recommendations to address the market failures that have resulted in meager research funding for diseases like TB.

The second is a political declaration adopted at the first-ever UN High-Level Meeting on Antimicrobial Resistance in which UN member states expressed a broad intention to tackle the threat of antimicrobial resistance through joint action, including fixing the ‛lack of investment in research and development’.

The TB field should not let this flurry of ‛high-level’ activity dislodge its grounding in the organising and mobilisation work that must take place at the country level and in the communities hit hardest by TB. In the words of Mabote, there is a need for ‛actionable strategies which support R&D resource mobilisation’, both within countries and regionally.

Previous attempts to harness more support from the BRICS countries for TB R&D – for example, the 2012 Delhi Communiqué of the 4th BRICS Ministers of Health Summit – have resulted in mellifluous statements about the need to collaborate without any actual commitments of funding. Future statements of intent must come with all the ingredients of accountability – clear targets, action plans, and timelines – that have previously been missing, and empowered civil societies in the BRICS countries and elsewhere must ensure that promises to support TB research are followed by a real increase in funding.