The US is the largest funder of global health R&D; funding is primarily channelled through NIH
The US’ funding for research and development (R&D) on poverty-related and neglected diseases (PRNDs), referred to as ‘global health R&D’ in this profile, stood at US$1.5 billion in 2016, according to G-FINDER. The US is by far the largest public funder to global health R&D, contributing 73% of all government funding and nearly half (46%) of all funding across sectors (industry, philanthropic, and public). US global health R&D funding peaked in 2012 at US$1.7 billion and has declined since. However, between 2015 and 2016, funding increased again from US$1.4 billion to US$1.5 billion. According to the Global Health Technologies Coalition (GHTC), 89% of the US’ global health R&D budget was invested domestically in 2015.
In 2016, US global health R&D funding focused primarily on HIV/AIDS (US$793 million), representing 53% of total US global health R&D. Other focus areas included tuberculosis (TB; US$226 million, 15%) and malaria (US$207 million, 14%), followed by dengue fever (US$58 million, 4%), kinetoplastids (US$44 million, 3%), and diarrhoeal diseases (US$44 million, 3%).
The US allocated its funding in 2016 to preventative vaccines (US$640 million, 43%), basic research (US$464 million, 31%), drugs (US$173 million, 12%), and microbicides (US$106 million, 7%). The focus on preventative vaccines and basic research has been stable since 2007.
Currently, the US does not have an overarching strategy for global health R&D. Funding comes from, and is implemented through, a variety of programs across several agencies. The main ones are (in order of the amount of funding provided in 2016):
National Institutes of Health (NIH), an agency comprising 27 institutes under the Department of Health and Human Services (HHS) (see question three: ‘Who are the main actors in the US’ development cooperation?’), is the biggest funder of global health R&D in the world. It is also the leading US agency for medical research and provided 89%, or US$1.3 billion, of total US investment for global health R&D in 2016. Global health research has been identified as one of five opportunities for the tenure of Dr. Francis Collins, the current NIH director. Within NIH, the National Institute for Allergy and Infectious Diseases (NIAID) leads on research for infectious diseases such as HIV/AIDS, Ebola, and Zika.
Department of Defense (DOD) is also a main actor in US global heath R&D efforts, mostly to address infectious diseases and other neglected health conditions that US service members may encounter while stationed overseas. One of every four vaccines approved by the US Food and Drug Administration (FDA) in the last century has been developed with the participation of DOD. The department provided US$79 million, or 5%, of US global health R&D funding in 2016.
US Agency for International Development (USAID), the US’ lead development agency, provided US$72 million, or 5%, of the US’ global health R&D funding, led by its Bureau for Global Health. USAID focuses all funding on HIV/AIDS, malaria, and TB, in line with its role as an implementer of the President’s Emergency Plan for AIDS Relief (PEPFAR) and the President’s Malaria Initiative (PMI). The largest share by far was spent on HIV/ AIDS R&D in 2016 (US$476 million). Product development partnerships (PDPs) are strongly prioritized. In 2016, 60% of USAID funding went to the International AIDS Vaccine Initiative (IAVI; of which USAID is the largest funder). Other PDP recipients include the TB Alliance and Contraceptive Research and Development (CONRAD). The agency houses the Malaria Vaccine Development Program.
Centers for Disease Control and Prevention (CDC) make up the largest government agency worldwide working in disease surveillance, control, and prevention. CDC operates under HHS. In 2016, CDC channeled US$4.4 billion in global health R&D funding. In 2010, the CDC established the Center for Global Health, which oversees all of CDC’s global health operations, and focuses on topics such as women’s health, HIV/AIDS, malaria, refugee health, and health systems strengthening. CDC leads the TB Trials Consortium and is an implementing partner of the PMI, the USAID’s Neglected Tropical Diseases program, and PEPFAR.
In addition, while not a main funder of global health R&D in the US, the Food and Drug Administration, also under HHS, oversees the safety and efficacy of pharmaceutical and biological products, and works with partner governments on improving regulatory capacity. The agency has expanded its global health engagement in recent years, helping to reduce challenges that hamper regulatory review and access to health technologies in developing countries.
President Donald Trump’s budget request for FY2018, released in May 2017, called for major cuts to US global health and research funding across most of the agencies listed above. Congress pushed back on these strongly in its FY2018 omnibus bill and has retained – if not increased – funding to global health R&D. Congress has funded NIH at US$37 billion, which is US$3 billion more than FY2017, this includes US$3.5 million more for the Fogarty International Center (FIC) at NIH, totaling US$76 million; the administration proposed to eliminate FIC in the president’s FY2018 request. FIC facilitates partnerships and trains researchers globally. Total funding to the CDC also increased, including US$54 million more for global health funding than FY2017 levels, at US$489 million. Further, USAID funding for HIV/AIDS research is held at US$330 million, the same as the previous year. This account funds R&D for microbicides and HIV vaccines. US funding to NTD and TB also goes to research, including to TB drug facility- and multidrug-resistant financing; the FY2018 omnibus bill keeps NTD funding at US$100 million, while it increases TB funding from US$241 million to US$261 million.
Despite Congress’ opposition to cuts, President Trump proposed similar cuts to the US global health budget in his FY2019 budget request, which would have significant implications for US global health R&D. These include a proposal to eliminate USAID’s HIV/AIDS account and reduce support for global TB and NTD programs, as well as for malaria and maternal and child health. It also proposes a US$2 million cut to NIH’s FIC and would slash CDC’s total budget by 12% relative to FY2017 levels, to US$5.6 billion. The request would also only fund the Global Health Security Agenda at US$59 million, a dramatic cut from the US$600 million provided over five years (2014-2019), meaning that CDC would have to cut programs currently active in global health and global health security. Further, the president’s budget request also includes cuts to biomedical research through the Labor, Health and Human Services (LHHS) appropriations bill, which could significantly impact US global health R&D.
It is unclear how the FY2019 budget will develop through Congress’ budget and appropriations process, but if FY2018 is any indication, the cuts will not be included the future FY2019 budget bill. Policy aspects that may influence the levels and delivery of the US’ global health R&D funding in the future include the reauthorization of the Pandemic and All-Hazards Preparedness Act (PAHPA), which authorizes the US Biomedical Advanced Research and Development Authority (BARDA), in 2018. Since the Ebola outbreak, BARDA has played an increasingly important role in global health R&D for emerging infectious diseases and antimicrobial resistance. Also part of HHS, it focuses on medical countermeasures for public health medical emergencies. BARDA carried out US$1.4 million in global health R&D funding in 2016. The US Department of Agriculture is another key actor, and carried out research programs worth US$3.5 million in global health R&D funding in 2016.