Tuberculosis Research
Funding Trends
2005-2017

ACKNOWLEDGMENTS
Treatment Action Group is grateful to all of the participating TB R&D funders thatmake this report possible and to the Stop TB Partnership for supporting the writingof this report. TAG would like to thank the TB scientists, funders, and activists who
agreed to be interviewed and Derek Ambrosino for conducting the interviews.

ABOUT TAG
Treatment Action Group (TAG) is an independent, activist, and community-based
research and policy think tank fighting for better treatment and prevention, a vaccine, and a cure for HIV, tuberculosis (TB), and hepatitis C virus (HCV).
TAG works to ensure that all people with HIV, TB, or HCV receive lifesaving treatment, care, and information. We are science-based treatment activists working to
expand and accelerate vital research and effective community engagement withresearch and policy institutions. TAG catalyzes open collective action by all affected communities, scientists, and policy makers to end HIV, TB, and HCV.

TB PROJECT
TAG’s TB project works to create a policy, funding, and advocacy environment thatis conducive to TB research, the uptake of evidence-based interventions, and thepromotion of human rights of people affected by TB.

CONTACT TAG
Treatment Action Group90 Broad Street, Suite 2503
New York, NY 10004 USA
Tel 1.212.253.7922
Fax 1.212.253.7923
tag@treatmentactiongroup.org
www.treatmentactiongroup.org
ISBN 978-0-9983966-7-5© 2018 by Treatment Action GroupMay be copied with attribution for noncommercial use.
Cover illustration by Jingru Chen.
Design and layout by Hollander Snow Studio, Inc.

Tuberculosis Research Funding Trends,
2005–2017

DECEMBER 2018
TREATMENT ACTION GROUPWRITTEN BY MARCUS LOWEDITED BY MIKE FRICK AND ERICA LESSEM

DEDICATION

We dedicate this report to apolicymaker, a physician-researcher,and a patient advocate.
The policymaker: We dedicate this publication to Dr. Aaron Motsoaledi, South Africa’s minister of healthand chair of the Stop TB Partnership. Motsoaledi has been a driving force behind the renewed political will
we’ve seen in the TB response in recent years. He has also made South Africa a world leader in introducing
new technologies such as the TB drug bedaquiline and the GeneXpert TB diagnostic test. Through theintroduction of new technologies, and by overseeing the large-scale rollout of antiretroviral therapy topeople in South Africa living with HIV, he has probably helped save hundreds of thousands of lives that would
not have been saved with less-courageous leadership. In South Africa he has also taken a brave stance against
corruption, something that impacts healthcare services as much as all other spheres of society. At a time
when calls for political will in the TB response outnumber actual political actions and solutions, Motsoaledi
embodies the decisive leadership the world needs to end TB.
The physician-researcher: We dedicate this report in memory of Dr. Fred Gordin, chief of the infectious
diseases section at the Veterans Administration Medical Center in Washington, D.C. Fred was a visionary
HIV and TB clinician and researcher and was instrumental in establishing the Community Programs forClinical Research on AIDS (CPCRA), a clinical trials network that conducted research on HIV treatment andthe prevention and treatment of its comorbidities, including TB, and was notable for carrying out researchwithin local communities. The CPCRA provided a model for several of the clinical trial networks that playa leading role in TB research today, including the U.S. Centers for Disease Control and Prevention (CDC)
Tuberculosis Trials Consortium, which Fred helped to found. We will remember him as a steadfast friend of
the activist community and as a scientist who championed the meaningful involvement of people affected by
HIV and TB in all aspects of clinical research.
The patient advocate: We dedicate this report in memory of Shreya Tripathi, the brave young woman withextensively drug-resistant TB (XDR-TB) who successfully sued a public Indian hospital for access to new
drugs to treat her disease. Last year, we dedicated this report to Shreya under the pseudonym Siya Trivedi.
At that time, Shreya had recently won a case before the Delhi High Court, which ruled in January 2017 thatthe government could not deny her access to bedaquiline based on her legal domicile being located outside one of the six sites at which the drug was initially available through the government-run clinical accessprogram. After winning her case before the court, Shreya sought care at Mumbai’s esteemed Hinduja
Hospital, where she received bedaquiline as well as a second new drug, delamanid, under compassionate
use. Shreya passed away in early October 2018. Although her XDR-TB was cured, the delays in accessing
bedaquiline and delamanid left her with overwhelming damage to her lungs that cost Shreya her life.
We will remember Shreya for her courage, for the hope her legal battle gave to a great many people, and forthe undeniable truth at the core of her determination to overcome TB: access to medicines is a human right.

Table of Contents
Executive Summary

1

Introduction

3

Results

7

The big picture

7

Trends in public-sector funding

7

Trends in philanthropic funding

8

Trends in private-sector funding

9

Trends in multilateral funding

9

What Is a Country’s Fair Share of TB R&D Funding?

12

TB research investment as a percentage of GERD

12

Burden-investment index

14

Funding by Research Area

16

Basic Science18

Diagnostics

20

Drugs

23

Vaccines

26

Operational Research

29

Pediatric TB Research

32

Discussion

36

Endnotes

39

Appendix 1: Methodology

42

Limitations to the Data

43

Appendix 2: TB R&D Funders by Rank, 2017

44

Appendix 3: TB Experts Interviewed by TAG

52

Executive Summary
Treatment Action Group (TAG) has been tracking global investment in tuberculosis (TB) research and development (R&D) since 2005. In this report, we present data on TB research funding trends from 2005 to 2017.
In 2017, global investment in TB research reached a new high of USD $772 million. This represents a$46 million (6%) increase on the previous high of $726 million set in 2016.
After a nominal increase of 29% from 2008 to 2009, funding was relatively stable from 2010 to 2015,
increasing again substantially in 2016 and 2017. However, after adjusting for inflation, the 2017 figure
is worth only $552 million in 2005 constant dollars, only marginally above the 2009 figure of $544 million.
In real terms, there has been no substantial increase in funding for TB research in the last decade.
Total global investment in TB research over the 13 years from 2005 to 2017 adds up to $7.8 billion. In order
to meet the Stop TB Partnership’s Global Plan to End TB (Global Plan) target of investing $9 billion from 2016
to 2020, the world will now have to invest almost as much ($7.5 billion) in the three years from 2018 to 2020,
since investments in 2016 and 2017 only amounted to $1.5 billion combined. Strictly speaking, meeting the
Global Plan target now requires investment of $2.5 billion per year, rather than the widely quoted $2 billion.
Sixty-six percent ($510 million) of global TB funding in 2017 came from public sources, 19% ($145 million)
from philanthropies, 11% ($85 million) from private industry, and 4% ($32 million) from multilateral entities.
Public funding showed the greatest growth over 2016 levels, with an increase of $27 million.
The U.S. government remains by far the largest funder of TB research, having invested $312 million in2017 through eight different agencies. This accounts for 40% of global TB R&D funding and 62% of all
public funding—more than all other governments added together. The European Union invested $37 million,
the United Kingdom $36 million, Germany and Canada $19 million each, India $17 million, and South Korea$15 million. No other countries reported spending more than $10 million in 2017.
Spending on TB research relative to the capacity of states to invest in R&D is also low. Only three countries
reported investing more than 0.1% of gross domestic expenditure on research and development (GERD) on
TB research in 2017. South Africa topped the list on this metric, exceeding its target by 83%. The Philippines
surpassed its target by 61% and New Zealand by 14%. Among countries that did not meet the 0.1% target,
the United Kingdom came closest, investing 89% of its target, followed by Canada with 73% and the UnitedStates with 70%. The 0.1% of GERD target has gained traction over the last year as a means to calculate acountry’s fair share of global TB R&D funding.
The Bill and Melinda Gates Foundation (Gates Foundation) was the second largest funder of TB researchin 2017, with an investment of $128 million. This is multiple times more than the contribution from any
government except for the United States, is more than all private sector investments combined, and makes
up 17% of total TB research funding. Together, the U.S. government and the Gates Foundation contributed
57% of TB R&D funding in 2017. Philanthropic funding for TB research has, however, been relatively flat inrecent years and has never climbed far beyond the $154 million reported in 2008.
The next largest funder after the U.S. government and the Gates Foundation was Unitaid, with an investment of $29 million. With U.S. government funding split across various funding entities, Unitaid ranks fifthon the list of top funders. Unitaid funding in 2017 nearly doubled from $15 million in 2016. That Unitaid,
an organization whose core mission is to take innovations to scale by supporting implementation, now counts
among the largest funders of research says just as much about the absence of traditional R&D funders fromthe TB field as it does about Unitaid’s commendable commitment.
With an investment of $23 million in 2017, the pharmaceutical company Otsuka ranks sixth overall and was
the top private-sector investor in TB R&D. It is one of four pharmaceutical companies in the top 20 funders.
Together, these four companies contributed $66 million of the total $85 million reported by private-sector
groups in 2017.

1

“I think 2018 has been an extraordinary year for TB research. In the lastyear, we’ve had these extraordinary
announcements. We had the NIXTB trial, and it’s looking like we’remaking real progress in MDR-TB
treatment. We had, from the diagnostic perspective, the results of
the STAMP trial and TB urine LAM
looking like it’s making a real difference for hospitalized HIV patientsand mortality. And then we had
BCG revaccination looking reallyexciting and now a subunit vaccine
looking exciting. I almost feel like
I’ve just stepped into some kind ofparallel TB research universe. A
year ago, it was a really difficult
place, and suddenly there’s justlots of potential and excitement.”
Helen Fletcher, Professor of Immunology,
TB Centre at the London School ofHygiene and Tropical Medicine

Total private-sector investment in TB research was above $100
million from 2010 to 2013 and has been under this threshold eversince. Although a few companies, most notably Otsuka, Johnson& Johnson (Janssen), and GlaxoSmithKline (GSK) remain active inthis area, a number of major pharmaceutical companies are notinvesting in TB R&D. These include Pfizer, AstraZeneca, Gilead,
Bristol Myers Squibb, Merck, and Abbott, among others.
EvaluatePharma has estimated that total pharmaceutical industry
investment in R&D in 2017 was $97.2 billion; the $85 million thatindustry invested in TB research in 2017 is less than 0.1% of thisfigure. Attempts to incentivize greater private-sector participation
in TB research through prize funds (e.g., the Life Prize) have so
far been unsuccessful—mainly because governments have not yet
funded any such prizes.
In 2017, 41% of total global TB R&D funding went to TB drug
research, 19% to TB basic science, 13% to TB vaccine research,
12% to operational research, 10% to TB diagnostics research, and
5% to infrastructure/unspecified projects.
All areas except for basic science and infrastructure/unspecified
showed increases over 2016 levels. The largest year-on-year increase
was in drug research, where spending rose by $58 million from $257
million to $315 million. Over a third of this increase can be attributed
to the Gates Foundation, whose funding for drug research rose from
$40 million in 2016 to $63 million in 2017. The year 2017 marked
the third consecutive year in which funding for operational researchincreased. In contrast to recent increases in operational and drug
research, investment in basic science has been relatively flat from2014 to 2017.
Funding for pediatric TB research nearly doubled between 2016
and 2017, jumping from $29 million to $56 million. The European andDeveloping Countries Clinical Trials Partnership (EDCTP) was thelargest funder in this area with $10.6 million, followed by the U.S.
Agency for International Development (USAID) with $9.5 million.
In all years from 2005 to 2017, TB drug R&D has been the researcharea with the highest level of annual investment. In all years except
for 2008, basic research ranked second. Vaccines ranked third in all
years except for 2008, when it ranked second.
Of the total $7.8 billion invested in TB R&D from 2005 to 2017, 37%
was invested in drug research, 21% in basic science research, 15% in
vaccine research, 10% in operational research, and 9% in diagnostic
research.

2

Introduction“It’s now or never! If we cannot really move things after a Ministerial
Conference and having TB for the first time on the agenda of theUnited Nations General Assembly, why would we be able to moveit ahead next year or in three years?”
Kitty van Weezenbeek, Executive Director, KNCV Tuberculosis Foundation

In September 2018, the global TB movement had arguably the most important political moment in its history,
when over 15 heads of state addressed the first-ever United Nations High-Level Meeting (HLM) on TB in New
York.1 The meeting was a critical moment for TB more broadly, but also for TB research in particular—with
the need for greater investment in TB R&D standing out as one of the most prominent themes at the meeting.
“Investing in research and development is critical if we are to develop new diagnostics, vaccines andmedicines—and find innovative ways to deal with the social determinants of tuberculosis and its
transmission,” South African president Cyril Ramaphosa told the meeting. “It is only with new tools that
we can achieve the dramatic reduction in the incidence of TB needed to ensure total elimination of thisdisease by 2030 or earlier.”2
Although governments made relatively few concrete and specific commitments in the political declaration
endorsed at the HLM, the declaration nevertheless reflected wide agreement about the need for muchgreater investment in TB R&D.3 UN member states committed “to mobilize sufficient and sustainablefinancing, with the aim of increasing overall global investments to US$2 billion, in order to close the estimated
US$1.3 billion gap in funding annually for tuberculosis research.” The broad intent is thus present, but
unfortunately the $2 billion per year is an “aim” rather than a concrete commitment.
If the declaration had made a concrete commitment of $2 billion per year for TB research, the question
would have arisen as to what amount each country would be responsible for contributing. To the extent
that this problem is implicit in the text, UN member states committed to “ensuring all countries
contribute appropriately to research and development.” In this report, we provide some data that can be
useful in determining which countries are contributing “appropriately” and which ones are not.
A few months after the TB cause’s big moment in New York, several important questions remain unanswered. Where will we find the $2 billion per year that is needed for TB research? How will we get countries
to contribute their fair share? How will governments be held accountable for closing the funding gap?
Where will we find the political will and money to trial new delinkage-based innovation models for TB
drug and diagnostic development?
Of course, the HLM was never going to provide the answers to all of these questions. Rather than an end in
itself, the meeting is best understood as just another stop on the long walk toward eliminating TB—be it in
15 or in 50 years. What the HLM has provided, however, is unprecedented political visibility. This politicalattention may or may not be leveraged into real momentum toward finding the money we need for TB
research. Part of the function of this report, as well as future reports, is to track how well this political
momentum is being converted into concrete increases in TB research funding.
In this report, we present data on TB research funding trends for the 13 years from 2005 to 2017. Although
there have been spurts of notable growth, particularly in 2009 and again in 2016 and 2017, funding for
TB research has lagged far behind internationally agreed-upon targets and has remained dependent on a
few large funders. This extreme reliance on a handful of major funders makes the progress we have seen overthe last decade precarious. In addition, when adjusted for inflation, funding for TB research has not increased
from where it was a decade ago.

3

FIGURE 1

Total TB R&D Funding, 2005–2017$800,000,000$700,000,000$600,000,000$500,000,000$400,000,000$300,000,000$200,000,000$100,000,000
$0

2005

2006

2007

2008

2009

2010

2011

2012

2013

Funding adjusted for inflation (2005 constant dollars)

2014

2015

2016

2017

Nominal funding (current dollars)Year

Nominal funding(current dollars)Year

Nominal funding(current dollars)

2005$358,119,753

2012$638,783,272

2006$418,928,300

2013$686,303,295

2007$478,343,421

2014$674,036,492

2008$494,168,892

2015$620,600,596

2009$636,979,349

2016$726,080,643

2010$643,360,390

2017$772,001,759

2011$675,328,887

TAG collected the investment data presented here through a global survey of TB research funders(see Appendix 1 for a detailed description of the methodology). Not all funders of TB research reported
to us, but the vast majority did. Our survey also does not fully capture indirect funding through salaries,
overhead, or infrastructure that is not TB specific. In addition to documenting TB research expenditures,
we spoke to scientists, activists, TB program managers, policy makers, and other experts in the field togather their opinions on TB research and funding for it in the context of the HLM. Interviewees had each seena preliminary summary of this year’s data, which TAG published the week of the HLM.4 Overall, interviewees
spoke of gaps—gaps in funding, in implementation, in access to information and new technologies, in politicalwill, and in human rights and accountability. We quote from these rich interviews throughout the report toput the numbers and financial analyses into their bigger context.
In absolute terms, global funding for TB research reached a new high of $772 million in 2017. This amount ismore than $1.2 billion behind the $2 billion target mentioned in the HLM Political Declaration. Although that
$2 billion target was set based on a target in the Global Plan,5 it did not take into account what we now know

4

“We should never confuse these [high-level] meetings with success.
They are really just catalysts, and the proof is in what we do coming out of
those meetings. I hope people don’t get too stuck on the declaration but rather
get stuck [on]: What are the targets for the next three years? How are we goingto measure it? How are we going to hold people accountable, and how are wegoing to ensure that actions happen?”
Mitchell Warren, Executive Director, AVAC

has been two years of dramatic underspending against the Global Plan target. The Global Plan estimates thata total of $9 billion should be invested in TB R&D from 2016 to 2020. This amounts to $1.8 billion per year.
Given that the 2016 and 2017 figures are well below this target, annual investment for the period 2018 to2020 must average $2.5 billion to reach the target. This is more than triple the current funding and would
require spending in three years an amount that is almost equal to the total $7.8 billion invested in TB researchin the 13 years from 2005 to 2017.
Whether or not these funding targets are met may have serious implications for the future of the
global TB epidemic. As succinctly stated in the 2018 World Health Organization (WHO) Global TB Report:“The SDG [Sustainable Development Goal] and End TB Strategy targets set for 2030 cannot be met without
intensified research and development.”6 This assertion is based on epidemiological modeling that suggests
current tests and treatments will not bring TB rates down quickly enough and that, accordingly, the worldmust develop breakthrough new tests, treatments, and vaccines by 2025. Triangulating from the End TB
Strategy, the latest Global TB Report, and the figures we report here, it seems clear that a major scale-up in
funding over current levels is required if we are to have any chance of ending TB in the next decade. As yet, wecannot report any such major scale-ups. At best, we can describe recent data as incremental growth. As statedin the 2018 Global TB Report, “the development pipelines are progressing, but slowly.”
There are, however, a number of reasons for optimism.
First, with the unprecedented political momentum created by the HLM and the substantial focus on TB
research in its resulting political declaration, the potential is now there for substantial funding increases
in 2018 and 2019. New investments announced by the governments of the United States and the United
Kingdom during the HLM are the first concrete sign of this increased commitment. From the U.K. side, theU.K. Department for International Development (DFID) announced a new award of £7.5 million to the TB
Alliance, a product development partnership (PDP), to develop shorter, simpler TB treatments.7 DFID was theseventh largest funder of TB research in 2017, with contributions totaling $20.6 million. The U.S. commitment
followed the release of a new strategic plan for TB research by the National Institute of Allergy and Infectious
Diseases (NIAID) at the U.S. National Institutes of Health (NIH), the largest funder of TB research globally.8
At a side event to the HLM, an official from the NIH shared the agency’s intention to increase annual funding
for TB research to $440 million per year, in line with the TAG-derived target for the U.S. government’s “fairshare” of the global TB R&D funding need (for more on country-specific targets, keep reading).
Second, as we saw with the large increase in TB research funding in 2009, it is possible to increase funding
substantially and then maintain it at those higher levels. In 2009, funding for TB research increased by 29%
from 2008’s $494 million to $637 million. As illustrated in figure 1, those gains have been maintained in
the years since. Most of this increase came from the U.S. government as part of an $800 billion stimulus
package released in response to the 2008 economic crisis. That funding for TB research did not drop
back down to pre-stimulus levels after the economic spending package ended is largely owed to the strong
bipartisan support for the NIH, which has enjoyed several years of increasing appropriations. (Other U.S.
government agencies active in TB research have seen some budget increases since 2009, but not at the levelor with the consistency seen at the NIH.)

5

FIGURE 2

Progress toward Global Plan 5-Year TB Research Funding Targets
Global Plan 5-year target

2016 + 2017 funding$5,000,000,000$4,155,000,000$3,750,000,000$3,431,000,000$2,500,000,000$1,250,000,000$1,250,000,000$571,605,166$303,063,926$160,681,196$195,733,081$176,172,736

Vaccines

Operational
Research$85,529,584$0Basic Science

Diagnostics

Drugs

Pediatrics

The Global Plan to End TB did not set funding targets for TB basic science, operational research, or pediatric TB R&D.

Third, the establishment of the BRICS TB Research Network, in addition to various national TB research
networks in countries from Thailand to Ethiopia, signals that more high-burden countries are prioritizing
TB research. (BRICS stands for Brazil, Russia, India, China, and South Africa, a group of emergent economic powers that together account for nearly half of the world’s new TB cases each year.9) In addition, newevidence published this year shows that the BRICS countries have substantially increased their TB research
outputs over the decade from 2007 to 2016 (measured as number of publications),10 something that indicatesboth increased research activity and greater capacity. Many of these countries have relatively large economies and as such have the ability to invest much more given sufficient political will. As pointed out by Afrânio
Kritski, a founding member of the Brazilian TB Research Network: “To achieve the End TB Strategy, we needto have BRICS on board. If we cannot combat TB properly in BRICS, we will never achieve the targets set by
End TB or the Sustainable Development Goals.”
Ultimately, the amount of money governments are willing to invest in TB research provides one of themost concrete and objective measures of their commitment to the fight against TB. As this report shows,
all countries, even leading donor nations like the United States and the United Kingdom, can do a lot better.

6

Results“I would like to see a year-on-year increase in TB R&D funding,rather than targets being set for five or 10 years’ time without any
interim analysis of how we are on course to achieve those targets.”
Grania Brigden, Deputy Director, TB and HIV Department,International Union Against TB and Lung Disease (The Union)

The big picture
In 2017 annual global investment in TB research reached a new high, totaling $772 million. This represents
a $46 million (6%) increase from the previous high of $726 million set in 2016. This upward movement was
primarily driven by a $27 million increase in public funding and a $12 million increase in multilateral funding.
In terms of research areas, this increase is mostly accounted for by the $58 million year-on-year increasein funding for TB drug R&D.
After an increase in global investment in TB R&D of 29% from 2008 to 2009, funding was relatively stablefrom 2010 to 2015, increasing again substantially in 2016 and 2017. However, after adjusting for inflation,
the 2017 figure of $552 million (in 2005 constant dollars) is only marginally above the 2009 figure of $544
million. In real terms, there has thus been no substantial increase in funding for TB research in the last decade.
Total global expenditures on TB research over the 13 years from 2005 to 2017 add up to $7.8 billion. In order
to meet the End TB target of investing $9 billion from 2016 to 2020, the world will now have to invest almost
as much ($7.5 billion) in the three years from 2018 to 2020—with only $1.5 billion having been invested in2016 and 2017 combined. Strictly speaking, meeting the End TB target now requires investing $2.5 billion
per year, rather than the widely quoted $2 billion.
In 2017, investment in TB research continued to be dominated by the U.S. government and the Gates
Foundation. This long-running dependence on two large funders represents a critical vulnerability of the
global TB research infrastructure.

Trends in public-sector funding
In 2017, the U.S. government remained by far the largest funder of TB research, investing $312
million through eight different agencies. This accounts for 40% of global TB research funding and 62% of
all public funding and thus exceeds spending by all other governments combined. This investment is slightly
down from 2016’s $316 million but is nevertheless part of a positive trend given that from 2009 to2015 annual U.S. government spending remained relatively stable in the band between $247 million and$268 million.
The European Union invested $37 million in TB research in 2017, the United Kingdom $36 million, Germany
and Canada $19 million each, India $17 million, and South Korea $15 million. No other countries reported
spending more than $10 million in 2017. India, a country with 27% of the global TB burden, invested only
$85 million in TB R&D over the entire period from 2009 to 2017—just over a quarter of what the UnitedStates invested just in 2017.
Total public funding for TB research increased from $482 million in 2016 to a new high of $510 million
in 2017.This $28 million increase was primarily driven by year-on-year increases in the European Union ($13.5
million), United Kingdom ($8.5 million), and Germany ($4 million). Although the increase is relatively modest,
it is notable that funding did not drop back down to the relatively narrow $389–$419 million band where
it was every year between 2009 and 2015. However, it is clear that there has not been a large spike from2016 to 2017, as some may have expected ahead of the HLM.

7

FIGURE 3

Total TB R&D Funding by Funder Category, 2005–2017 (in Millions)PublicPrivatePhilanthropic

Multilateral

$525

510
482

$450
413

405

389

390

399

419

393

$375

$300
277
248

236

268

$225
170

155

$150
132

123
116

$75

53

$0

1.6

1.5

2005

2006

124

124

100

78
43

145

124

69

113

112

2008

2009

6

1.7

2010

2011

145

145

87

78

85

124
99

72

0.5

2007

149

128

8.1

8.2

17

20

33

6

2012

2013

2014

2015

2016

2017

Out of 17 countries for which TAG has sufficient data and whichhave invested more than $10 million over the last nine years,
only seven reached new annual investment highs in 2017. It is encouraging that these seven countries include three of the BRICS:
Brazil, India and South Africa. (Neither China nor Russia provided
data in time for this report.) Of the wealthier countries, Canada,
Germany, and HLM co-facilitator Japan also achieved new highs
in 2017. U.S. investment dropped only very slightly, and as yet
there are no major cuts to report as some feared would be thecase under the Trump administration.

Trends in philanthropic funding“We can’t always rely on the Gates
Foundation. We need many otherfoundations to contribute to TB and
TB research and development.”
Albert Makone, Global Health Advocate

Total philanthropic spending on TB research in 2017 was $145
million—about a million less than in 2016. This constituted 19%
of total investment in TB research and was 69% more than total
private-sector investment over the same period. The 2017 figure
was lower than the $170 million reported in 2013, the highest
number reported by philanthropic organizations since TAG started tracking in 2005. There has thus been no real growth in philanthropic funding in recent years.

8Much as public funding for TB research is dominated by theUnited States, philanthropic funding is dominated by the Gates
Foundation, whose $128 million investment in 2017 constituted 89% of total philanthropic funding in that year. The Gates
Foundation was also the second largest funder of TB researchoverall. Its spending is multiple times more than any government’s
except for the United States, exceeds all private-sector investments combined, and makes up 17% of total TB research funding.
Together, the U.S. government and the Gates Foundation contributed 57% of TB R&D funding in 2017.

Trends in private-sector funding
With an investment of $23 million in 2017, the pharmaceuticalcompany Otsuka was the sixth largest funder overall and the top
private-sector investor in TB research in 2017. Four pharmaceutical companies rank among the top 20 funders. Together, thesefour companies contributed $66 million of the $85 million spentby private industry in 2017.
The $85 million invested by the private sector in 2017 is a
$7 million increase on the $78 million reported in 2016. Althoughprivate-sector spending was above $100 million from 2010
to 2013, it has been below the $100 million mark in all otheryears since 2005.
While a few companies, most notably Otsuka Pharmaceuticals,Johnson & Johnson (Janssen), and GSK remain active in this area,
a number of major pharmaceutical companies are not investing anything in TB research. These include Pfizer, AstraZeneca,
Gilead, Bristol Myers Squibb, Merck, and Abbott, among others.
EvaluatePharma has estimated that total pharmaceutical industry investment in research and development in 2017 was $97.2
billion; the $85 million industry investment in TB research in2017 is less than 0.1% of this figure. Attempts to attract greater private-sector participation in TB research through prize
funds (e.g., the Life Prize) have so far been unsuccessful—mainly
because governments have not yet funded any such prizes.

Trends in multilateral funding
With $32 million in multilateral funding for TB research, this
sector achieved new relevance in 2017. After resting below the$10 million mark from 2005 to 2014, multilateral funding has
now broken above this level in each of the last three years.
The significant increase in multilateral funding can primarily
be attributed to increased investment from Unitaid. In 2017,
Unitaid’s investment of $29 million (up from $15 million in 2016)
made it the fifth largest funder of TB research overall. Beyond
research-specific spending, Unitaid’s overall funding for TB
projects jumped from $127 million in 2016 to $215 million
in 2018 and is on track to hit $300 million in 2020.11
Not traditionally thought of as an R&D funder, Unitaid has become an increasingly large player in a field short on resources.
Unitaid describes its work as supporting projects that “harness
innovation to improve preventive treatment, diagnostics andbetter, faster-acting treatments, setting them up for wide-scale
introduction by funding partners.”129“We can’t just keep repeating the
problems of the past in terms of sweetening the deal for the private sector to
get involved without any recognitionof the need to have affordability andaccess provisions built in [to publicfunding agreements].”
Sharonann Lynch, HIV and TB Policy Advisor,
Médecins Sans Frontières Access Campaign“In addition to Big Pharma, we also
have biotech industries. [The problem]
there is: how are we going to ensurethat they get the capital to be able
to take their compounds forward? Weneed to think about, in addition to incentivizing big pharmaceutical companies, how do we ensure that biotech
companies, [which] may not have thesame financial structure, are able tohave adequate investment to advancetheir TB compounds?”
Grania Brigden, Deputy Director,
TB and HIV Department, The UnionFIGURE 4

Total TB R&D Funding by Funder Category, 2017
Total: $772,001,759
Public$509,642,802(66%)

Philanthropic$144,532,177(19%)

Multilateral$32,489,122(4%)
Private$85,337,659(11%)

The second largest multilateral funder is the Japan-based Global Health Innovative Technology Fund (GHIT), a partnership between the Japanese government, 16 Japanese pharmaceuticalcompanies, the United Nations Development Program (UNDP),
and two charitable organizations (the Wellcome Trust and
the Gates Foundation). The Global Fund to Fight AIDS, TB and
Malaria (Global Fund) may, in actuality, be the largest multilateral
funder of TB research. The Global Fund reports spending $166.7
million on TB operational research since its creation in 2002;
however, it cannot disaggregate this total figure by year, making
it difficult to evaluate its funding for TB research over time.13

10“As wealth and resources to support
research are increasingly concentrated
in middle- and high-income countries,
and TB burden is highest in low- andmiddle-income countries, the commitments have to come from the former.”Paul Farmer, Co-Founder, Partners in Health11$2,098,544$958,927$176,652

IrelandFranceDenmark

Not Reported$2,644,386

SwedenItaly$3,424,657

NorwayNot Reported$5,292,685

Switzerland

Spain$5,558,751$18,901,110

Germany

The Netherlands$36,065,970

Peru
Not Reported

Colombia$194,000

United Kingdom

Europe by Country

MexicoNot Reported

Canada$18,573,136

United States$311,939,843

Brazil$2,116,380

Nigeria
Not Reported

European Union$36,983,994

South Africa$8,402,370

Not Reported

Vietnam$1,128,864
Not Reported

Philippines
China$127,300$1,323,230
Hong Kong$5,508,140
Taiwan$15,100,698

Indonesia
Not Reported

Singapore$1,814,213

Japan

South Korea

East Asia by Country

India$16,842,455

Thailand$902,147

Russian Federation
Data Forthcoming

Australia$9,578,906

New Zealand$2,055,977

FIGURE 5Country Contributions to TB R&D, 2017

What Is a Country’s Fair Shareof TB R&D Funding?
“The lack of middle-income countries as top public funders[is surprising] because there’s all this research showing
the huge return on investment to TB control.”Kathryn Snow, doctoral candidate, University of Melbourne

In the HLM political declaration, governments committed to “mobilize sufficient and sustainable financing,with the aim of increasing overall global investments to US$2 billion, in order to close the estimated US$1.3
billion gap in funding annually for tuberculosis research.” Governments also committed to ensure that“all countries contribute appropriately to research and development,” although without defining what wasmeant by “contribut[ing] appropriately.”
Apart from absolute investment in TB research (shown in figure 5), we provide two additional measuresthat may be of use in calculating a country’s appropriate share of global TB R&D investment. The first is TB
research funding as a percentage of what a country spends on all forms and types of R&D (GERD); we callthese the 0.1% fair-share targets. The second is a new measure we call the burden-investment index (BII).

TB research investment as a percentage of GERD
“Even though it was not included explicitly in the final political declaration of the HLM, the 0.1% fair-sharetarget has gained traction over the last year as a means to calculate a country’s fair share of global TB funding.
GERD is a measure of how much a country spends on all forms of R&D (including but not limited to health).
The world could reach the $2 billion annual target if all high-TB-burden countries and a list of wealthy countries devoted 0.1% of their overall R&D spending to TB research. The 0.1% fair-share target asks countries toreprioritize within existing funding envelopes and as such is theoretically achievable in most countries given
sufficient political will. It also has a solidarity element built in because it does not distinguish according to TB
burden and it asks proportionally more of wealthier countries. The HLM political declaration affirmed theimportance of solidarity and committed member states to advancing research and innovation through global
collaboration.
Only three countries met their 0.1% fair-share targets in 2017. South Africa topped the list on this metric,
exceeding its target by 83%. The Philippines surpassed its target by 61% and New Zealand by 14%.
Of countries that did not meet the 0.1% target, the United Kingdom came closest, satisfying 89% of its target,
followed by Canada with 73% and the United States with 70%. Some wealthy countries, such as Japan andSouth Korea, have substantial R&D capacity but dedicate relatively little of this capacity to TB research.
Japan, co-facilitator of the UN HLM, met only 4% of its $154.9 million fair-share target.

12

TABLE 1

Majority of Countries Have Not Met TB R&D Fair Share Funding Targets
COUNTRY

2017 FUNDING

ANNUAL FAIRSHARE TARGETPERCENTOF TARGETMET IN 2017

1

United States$311,939,843$444,500,00070%2European Union$36,983,994$202,400,000

18%3United Kingdom$36,065,970$40,400,000

89%

4Germany$18,901,110$99,700,000

19%5Canada$18,573,136$25,300,000

73%

6

India

$16,842,455$46,500,000

36%7South Korea$15,100,698$64,000,000

24%8Australia$9,578,906$21,200,000

45%9South Africa$8,402,370$4,600,000

183%

10

The Netherlands$5,558,751$15,100,000

37%

11

Japan

$5,508,140$154,900,000

4%

12

Switzerland$5,292,685$13,400,000

39%

13

Norway$3,424,657$5,300,000

65%

14

Sweden$2,644,386$13,700,000

19%

15

Brazil$2,116,380$35,000,000

6%16

Ireland$2,098,544$3,300,000

64%

17

New Zealand$2,055,977$1,800,000

114%

18

Singapore$1,814,213$8,400,000

22%

19

Taiwan$1,323,230$4,369,762

30%

20

The Philippines$1,128,864$700,000161%

21France$958,927$55,400,000

2%

22Thailand$902,147$4,900,000

18%

23

Colombia$194,000$1,748,730

11%

24

Denmark$176,652$7, 5 00,000

2%

25Hong Kong$127, 300

$9,900,000

1%

26

Russian Federation

Data forthcoming$36,500,000

---

27

China

Not reported$305,600,000

---

28

Italy

Not reported$27, 5 00,000

---

29

MexicoNot reported$10,300,000

---

30

Nigeria

Not reported$7,000,000

---

31

Indonesia

Not reported$2,100,000

---

32

Vietnam

Not reported$1,300,000

---

RANK

Table includes countries that reported more than $100,000 in TB R&D funding to TAG and select other high-income or high-TB-burden countries.
Countries that met the target of spending 0.1% of overall R&D expenditures on TB research are shaded.

13

“To achieve the End TB Strategy, weneed to have BRICS on board. If wecannot combat TB properly in BRICS,
we will never achieve the targets set by
End TB or the SDGs.”
Afrânio Kritski, Founding President,
Brazilian TB Research Network“Even though the burden is mostly in
middle-income countries, it is a handful of high-income countries that are
predominantly funding TB. And thatneeds to be addressed.”
Tenu Avafia, Team Leader, Human Rights,
Law, and Treatment Access, HIV, Health andDevelopment Group, UNDP

Burden-investment index
The BII is a measure of a country’s investment in TB research relative to its TB burden. It is calculated by subtracting a country’s
share of the global TB burden (expressed as a percentage) fromthe country’s share of the total investment in TB research of all
countries (also expressed as a percentage). Positive BII scores indicate that a country’s share of global TB research investment isgreater than its TB burden. Negative scores indicate that a country’s share of investment is lower than its TB burden. BII scores
do not account for wealth and therefore do not reflect the expectation that wealthier countries should contribute more thanpoorer countries. Even so, the BII is a useful metric since it helps
identify outliers and provides some indication as to whether
high-burden countries are contributing sufficiently.
The United States, home to around 0.1% of the world’s TBburden but the source of 62% of public investment in TB
research, has the best BII score by far (0.62). By comparison to
the United States, investments from elsewhere in the developed
world, particularly Europe and Japan, are woefully low.
At the other end of the scale, India has 27% of the global TB burden but contributes only 3% of public funding for TB research,giving it a BII score of –0.24. The BRICS countries together have
41% of the global TB burden but contribute only around 6% of
public funding for TB research. Given that the BRICS countries
all have relatively large economies, it should be possible to close
this ratio if governments prioritize TB research.
As pointed out by TB researcher Madhukar Pai in an editorial
for the journal PLoS Medicine: “The world cannot depend on a
few wealthy countries with very low TB incidence to support all
the research that is required to tackle TB. High-burden,
middle-income countries with high TB rates must step up.
They have the potential to transform the global TB research
agenda through increased domestic funding, collaborative
networks, and transnational research partnerships.”1414TABLE 2

Burden-Investment Index: Country Funding for TB R&D in Relation to Disease Burden
Burden-Investment Index (BII) is a measure of a country’s investment in TB research relative to its TB burden. BII is calculated by subtracting a country’s share of the
global TB burden (expressed as a percentage) from its share of total public investments in TB R&D (also expressed as a percentage).
BII > 0: A country’s share of global TB R&D funding is greater than its TB burden; BII < 0: A country’s share of global TB R&D funding is less than its TB burden

RANK

COUNTRYSHARE OFGLOBAL TB
BURDENSHARE OFGLOBAL PUBLICINVESTMENTS
IN TB R&D

BII SCORE

1

United States

0.10%

61.72%

0.61622

European Union

0.57%

7.32%

0.0675

3

United Kingdom

0.06%

7.14%

0.0708

4

Germany

0.06%

3.74%

0.03685

Canada

0.02%

3.67%

0.0365

6

South Korea

0.36%

2.99%

0.0263

7

Australia

0.02%

1.90%

0.0188

8The Netherlands

0.01%

1.10%

0.0109

9

Switzerland

0.01%

1.05%

0.0104

10

Japan

0.19%

1.09%

0.009011

Norway

0.00%

0.68%

0.0067

12

Sweden

0.01%

0.52%

0.0052

13

Ireland

0.00%

0.42%

0.0041

14

New Zealand

0.00%

0.41%

0.004015

Singapore

0.03%

0.36%

0.003316

Taiwan

0.10%

0.26%

0.0016

17

France

0.05%

0.19%

0.001418

Denmark

0.00%

0.03%

0.000319

Hong Kong

0.05%

0.03%

-0.000220

Colombia

0.16%

0.04%

-0.0012

21

Brazil

0.91%

0.42%

-0.0049

22

Thailand

1.08%

0.18%

-0.009023

South Africa

3.21%

1.66%

-0.0154

24

The Philippines

5.78%

0.22%

-0.055625

India

27.28%

3.33%-0.2395

26

China

8.85%

Unknown

Unknown

27

Indonesia

8.38%

Unknown

Unknown

28

Italy

0.04%

Unknown

Unknown29

Mexico0.28%

Unknown

Unknown

30

Nigeria

4.16%

Unknown

Unknown

31

Russian Federation

0.86%

Unknown

Unknown

32

Vietnam

1.23%

Unknown

Unknown

Table includes countries that reported more than $100,000 in TB R&D funding to TAG and select other high-income or
high-TB-burden countries.

15

Funding By Research Area
FIGURE 6

Total TB R&D Funding by Research Area, 2005–2017 (in Millions)
Diagnostics

Basic Science

Infrastructure/
Unspecified

Operational
Research

Vaccines

Drugs

315

$300

268
263

257

$250
240

232

243
232

$200

200

173

176

172

156

$150

150
145

147
138
140
130

129

111

122
115

$100

113

92

116

99

99

92
88

82

81

74

63

68

41

95

92

87

83
77

$50

81

109

57

43

43

32

41

30

35

2006

2007

32

50

52

77

80

54

54
45

46

90
81

72
68

58

100

49

65

63

53

61

51

44

52

39

39

35
25

20

$0
2005

2008

2009

2010

2011

16

2012

2013

2014

2015

2016

2017

FIGURE 7

Total TB R&D Funding by Research Area, 2017
Total: $772,001,759
Drugs$315,051,622(41%)

Operational
Research$89,672,465(12%)

Basic Science$147,439,441(19%)
Vaccines$100,338,945(13%)

In 2017, 41% of total global funding for TB research was invested in TB drug research, 19% in basic science, 13% in TB vaccine
research, 12% in operational research, 10% in TB diagnostics
research, and 5% in infrastructure/unspecified projects.
All areas except for basic science and infrastructure/unspecified
showed increases over 2016 levels in 2017. The largest year-onyear increase was in drug research, where funding jumped by$58 million from $257 million to $315 million. The year 2017
marks the third consecutive year in which funding for operational research increased. By contrast, funding for basic sciencehas been relatively flat from 2014 to 2017.
In all years from 2005 to 2017, drug research has been the
research area with the highest level of annual investment. Basicscience ranked second in all years except for 2008. TB vaccine
R&D ranked third in all years except for 2008, when it ranked
second.
Of the total $7.8 billion invested in TB research from 2005 to
2017, 37% has been invested in drug research, 21% in basic
science, 15% in vaccine research, 10% in operational research,
9% in diagnostic research, and 8% in infrastructure/unspecified
projects.
According to the 2018 WHO Global TB Report, TB research
priorities include “a vaccine to lower the risk of infection,a vaccine or new drug treatment to cut the risk of TB diseasein the 1.7 billion people already latently infected, rapid
diagnostics for use at the point of care, and simpler, shorter
drug regimens for treating TB disease.” The comparatively
low level of investment in TB diagnostics seems at odds with
the WHO’s emphasis on the importance of this research area.
Other trends in funding by research area are discussed in thesections that follow.
17

Infrastructure/
Unspecified$38,589,352(5%)
Diagnostics$80,909,934(10%)“At the end of the day, product development doesn’t have a lot of certainty, but there is one certainty, and thatis if we don’t fund it at all, we will
not get better drugs, we will not getbetter vaccines, we will not get better
diagnostics.”
Mitchell Warren, Executive Director, AVAC
“In addition to more funding, one of
the things that we need if we want tokeep talented people in TB is to provide them with job security—and that[means] creating longer-term funding that creates a clear career path.
Longer-term funding and funding
with more flexibility to support people
through research is really important.”
Kathryn Snow, doctoral candidate,
University of Melbourne

Basic Science
FIGURE 8

Basic Science: $147,439,441
Funders under 2%$23,722,983 (16%)
U.K. MRC$2,588,633 (2%)
U.S. NSF$2,602,993 (2%)
Australian NHMRC$2,670,008 (2%)
NIAID*$82,846,672 (56%)

European Commission$2,940,086 (2%)
BMBF
$3,182,141 (2%)
SNSF
$3,254,864 (2%)
Wellcome Trust$6,092,268 (4%)

NIH Other ICs$17,538,793 (12%)

Funders with investments under 2%
Marsden Fund

$2,055,977

Thailand National Science and Technology Development Agency

Institut Pasteur$2,036,863

Korean Ministry of Education$254,487

Swedish Research Council$1,924,179

Singapore Agency for Science, Technology and Research (A*STAR)$217,788

Canadian Institutes of Health Research$1,790,029

University of the Philippines Manila—National Institutes of Health$207,399

South African Medical Research Council (SAMRC)$1,475,643

Norwegian Ministry of Health and Care Services$204,787

South African Department of Science and Technology (DST)$1,440,709

Australian Research Council$194,068

Max Planck Institute for Infection Biology$1,211,000

Indian Council of Medical Research (ICMR)$179,677

Japan Agency for Medical Research and Development (AMED)$1,141,760

BioFabri$170,292

Swiss Federal Institute of Technology in Lausanne (EPFL)$1,044,240

Else Kröner Fresenius Foundation$156,000

Taiwan Centers for Disease Control$1,037,594

Thailand Ministry of Public Health$151,645Bill & Melinda Gates Foundation$1,018,473

Japan BCG Laboratory$125,871

Korean Ministry of Science, ICT and Future Planning$805,840

Howard Hughes Medical Institute$100,000

National Research Foundation of South Africa$760,417

Singapore National University Health System$92,994

Norwegian Agency for Development Cooperation (NORAD)$692,053

CRDF Global$76,963

Indian Ministry of Science and Technology$525,364

Hong Kong Health and Medical Research Fund

$75,637

U.S. Department of Veterans Affairs$500,000

Public Health England$67,349

Norwegian Ministry of Education and Research$451,781

Taiwan Ministry of Science and Technology$60,000

Korean Ministry of Health and Welfare$426,666

Other funders with investments less than $50,000$315,648

Natural Sciences and Engineering Research Council of Canada$388,956* All acronyms and abbreviations of organization names are defined in Appendix 2.

18$344,833

“In the basic science space . . . we’ve seen a lot of progress over the last
five years, through big cohort studies [advancing] basic understandings ofthe immune mechanisms and pathways associated with risk of TB disease.
More recently, there’s been some indication of correlates of protection orparameters which might be associated with lower risk. We’ve also, as a field,
been spending a lot of time looking at the animal models we use for TB.”
Helen Fletcher, Professor of Immunology, TB Centre at the London School of Hygiene and Tropical Medicine

Of the $147 million spent on TB basic science research in 2017, $100 million (68%) came from the NIH($83 million from NIAID and $17 million from other NIH institutes and centers). If investments from the
U.S. National Science Foundation and U.S. Department of Veterans Affairs are added, U.S. government
contributions make up more than 70% of total global expenditure on TB basic science.
Though paling in comparison to the United States, Germany ($4.4 million), Switzerland ($4.3 million),
South Africa ($3.7 million), Australia ($2.8 million), the United Kingdom ($2.7 million), and New Zealand($2.1 million) all invested more than $2 million in TB basic science. Apart from South Africa, no other high-TBburden country invested more than $1 million in TB basic science in 2017. The $3.7 million investment madeup 44% of South Africa’s total $8.4 million investment in TB R&D in 2017—more than the country spent inany other research area. The $2.1 million New Zealand gave to TB basic science made up the entirety of thiscountry’s investment in TB research.
With spending of $6 million in 2017, the Wellcome Trust (a charity) is the third largest funder in this area andinvests more in TB basic science than any government apart from the United States.
Annual funding for TB basic science has been relatively flat in the last five years, staying within the band
between $137 and $156 million and decreasing by $8 million from 2016 to 2017. This band is well below thehigh of $172 million set in 2009 when the NIH received a one-time 34% budget increase of $10.4 billion instimulus money released by the U.S. government in response to the 2008 economic crisis.15 With 19% of total
TB research funding in 2017, TB basic science ranks second among the research areas tracked by TAG.
Helen Fletcher, professor of immunology at the TB Centre at the London School of Hygiene and Tropical
Medicine, sees a connection between limited funding for TB R&D generally and the reticence of some funders
to invest in basic science, an area of research that inherently contains more uncertainties. “The reason why
funders have had to be so brutal in their decisions about funding one research area over another is because,
if there hasn’t been enough money invested in research, then they can’t take the high-risk approaches. Basicscience is high risk. TB vaccines—they’re high risk. It’s a lot of money. It’s going to take maybe five to ten years
before you know whether that investment paid off or not.”The risk-taking and timelines required to support basic discovery call for a different definition of successthan product development. Mitchell Warren, executive director of AVAC, a nongovernmental organizationthat advocates for HIV prevention, pointed out that although the five-to-ten year arc of product development may be long, it is no longer than other public goods that governments invest in, such as development
assistance aimed at improving education, health systems, or the material conditions of life. “Funding research
is different than funding development, and funding product development is even different than funding someareas of what is basic research. This is hard stuff. It’s about a different mindset, it’s about a different set ofdeliverables, a different set of success metrics, and we have to orient people that way.”
In Warren’s view, sustained, predictable funding may be just as important as increased funding when it comesto supporting basic science, which in some respects is the engine of product development: “The only thingworse than having declines [in funding] is having fluctuations that are unpredictable.”

19

Diagnostics
FIGURE 9

Diagnostics: $80,909,934

Funders under 4%$19,910,544 (25%)

NIAID$17,410,414 (22%)

BMBF$3,163,256 (4%)

Gates Foundation$10,753,483 (13%)

Unitaid$3,585,000 (4%)
EDCTP
$3,748,979 (4%)

CDC
$5,135,297 (6%)

DFID
$3,959,018 (5%)
Korean Ministry of
Health and Welfare$4,212,800 (5%)

NIH Other ICs$4,481,143 (6%)

Company Y$4,550,000 (6%)

Funders with investments under 4%
Australian Department of Foreign Affairs and Trade (DFAT)$2,561,833

South African Department of Science and Technology (DST)$276,434

U.K. Medical Research Council (U.K. MRC)

$1,954,934

Carlos III Health Institute$275,287

Molbio Diagnostics$1,851,600

Japan Agency for Medical Research and Development (AMED)$251,544

European Commission$1,805,289

Taiwan Centers for Disease Control$195,636

Indian Council of Medical Research (ICMR)$1,620,653

Canadian Institutes of Health Research$190,458

Korean Ministry of Science, ICT and Future Planning$1,200,333

Swedish Research Council$183,334

Australian National Health and Medical Research Council (NHMRC)$1,167,233

Wellcome Trust$179,903

Korean Ministry of SMEs and Startups$1,015,500

Thrasher Research Fund

$150,868

U.S. National Science Foundation$778,555

CRDF Global$120,994

U.S. Department of Defense Medical Research and Development Program (DMRDP)$606,368

Korean Ministry of Trade, Industry and Energy$110,000

University of the Philippines Manila—National Institutes of Health$577,710

Thailand Ministry of Public Health$103,082

Japan International Cooperation Agency (JICA)$503,819

Damien Foundation Belgium$91,181South African Technology Innovation Agency$458,647

French National Agency for AIDS Research (ANRS)$83,478

Genedrive$457,660

Hong Kong Health and Medical Research Fund

$51,663

Norwegian Agency for Development Cooperation (NORAD)$346,006

Korean Ministry of Education$51,035

South African Medical Research Council (SAMRC)$309,448

Other funders with investments less than $50,000$380,059

20

“It’s one thing to develop a new innovation, but if they’re not being
used where they should be, then it’s a waste of resources. For example,
if we look at GeneXpert—it should be a point-of-care test,
but it really isn’t, the way we are utilizing it.”
Welile Sikhondze, Technical Advisor and Research Coordinator, eSwatini National TB Control Program

As in most areas, the U.S. government is the largest investor in TB diagnostics research by some distance.
Of the $81 million invested globally in TB diagnostics R&D in 2017, $21.9 million (27%) came from the
NIH ($17.4 million from NIAID and $4.5 million other NIH institutes and centers). With an additional $5.1
million from the CDC plus smaller contributions from the U.S. National Science Foundation and the U.S.
Department of Defense, total U.S. government investment in TB diagnostics R&D adds up to $28 million,
or 35% of the global total.
With an investment of $10.8 million in 2017, the Gates Foundation ranks second among all fundersof diagnostics research. An unnamed pharmaceutical company (Company Y) ranks fourth with $4.6 million.
The Gates Foundation invested more in TB diagnostics R&D in 2017 than any country apart from the UnitedStates.
Aside from the United States, governments that invested more than $2 million in TB diagnostics research in2017 include South Korea, the United Kingdom, Germany, and Australia. Of the high-TB-burden countries,
India stands out with 2017 spending of $1.7 million. South Africa is the only other high-burden country tohave invested over $1 million in TB diagnostics R&D in 2017.
After hovering around $60 million between 2013 and 2015, annual funding for TB diagnostics researchjumped to $80 million in 2016, where it remained virtually unchanged in 2017. Given the widespread consensus on the need for new and improved TB diagnostics, it is puzzling that investment in this area remains so low
in comparison to other areas—2017 investment in diagnostics R&D was only 26% of that invested in TB drug
research and only 10% of total TB R&D funding.
Global health advocate Albert Makone summarized the situation this way: “Progress has been moving
at a slow pace. If you look at diagnostics R&D, the funding increase between 2016 and 2017 is less than
$2 million. Yet we are missing a lot of [TB] cases each year. So for me, both the donors and the countries,
especially high-burden countries, haven’t been coming to the table to do their parts.”
In some ways, the fitful, slow pace of progress in diagnostics development mirrors the uneven scale-up of newtechnologies that have emerged from the pipeline in recent years. Makone pointed to the pitiful scale-up of
TB LAM, a simple, inexpensive, urine-based dipstick test for detecting TB in people with advanced HIV who
are at highest risk of death. In 2018, the STAMP trial—funded by the U.K. Medical Research Council, DFID,
and the Wellcome Trust—published results showing that using TB LAM to systematically screen hospitalized
people with HIV increased TB diagnosis and treatment initiation and reduced mortality in three most-atrisk patient populations (people with low CD4 count, severe anemia, or clinically suspected TB), even in thepresence of high HIV treatment coverage.16 Uptake of the test has been dismal, despite positive findings
from the STAMP trial and other evidence indicating that TB LAM testing reduces TB mortality. By March
2018, Abbott, the manufacturer of TB LAM, reported it only receives 100,000 orders of TB LAM tests fromcountries per quarter, when the estimated number of people in need of LAM testing per WHO guidance is725,000 per quarter.17
Despite disappointing uptake, research on urine LAM testing continues to show promise. Shortly before the
HLM, the diagnostics PDP FIND announced what it called a “technological breakthrough in point-of-care
testing using urine samples.”18 The test in question, Fujifilm SILVAMP TB LAM, may offer improvements insensitivity over the currently available LAM test. The FIND press release announcing promising preliminary
data from evaluations of Fujifilm SILVAMP TB LAM is a testament to the collaboration required to advance21

“GeneXpert has been brought out to many countries, but still anotherquestion comes: the issue of utilization. Yes, many countries have managed
to buy GeneXpert, but we are failing to utilize it to the optimal level. . . .
Or the TB LAM test—how can a country like Zimbabwe, being a TB/HIV
high-burden country, only order 20 LAM test kits within a year?”
Albert Makone, global health advocate

TB diagnostics R&D. The release notes that early work on this test was supported by the governments of
the Netherlands, Australia, and the United Kingdom and by the Gates Foundation. Clinical trials to generate
further evidence are being funded by GHIT and Germany’s Federal Ministry of Education and Research.19
Collaboration among funders must extend beyond cost-sharing and co-financing to include the coordinationof research itself. Taking GeneXpert as an example, Kitty van Weezenbeek, KNCV Tuberculosis Foundation
executive director, commented: “What we really need is simultaneous R&D. We knew that Xpert would becoming in 2007. And we didn’t have the MDR-TB regimens, the tools to take advantage of the test. . . . What
happened was predicted by many—we diagnosed many more people, but the R&D in drugs was not at thesame level.” In van Weezenbeek’s view, research priority setting should aim to construct a “comprehensive
package of R&D.” That is, development efforts in one area should anticipate and respond to progress in another. This may be especially important for TB diagnostics research. Diagnostic technologies touch every part ofTB care—from treatment initiation to drug-resistance testing to side-effect monitoring to adherence support.
Just as “treatment is blind without good diagnostics,” efforts to prevent TB will also depend on developing
better diagnostics.20 For example, new TB vaccines may require accompanying new TB diagnostics to identify people who are priority candidates for vaccination, which, depending on the vaccine, could include thoseindividuals most likely to progress from infection with Mycobacterium tuberculosis (MTB) to active TB diseaseor those not yet infected with MTB.

22

DrugsFIGURE 10

Drugs: $315,051,622
Gates Foundation$62,592,423 (20%)
Funders under 4%$93,516,602 (30%)

NIAID$60,792,339 (19%)

Company V$13,604,436 (4%)

USAID
$19,250,000 (6%)
Company X$20,550,920 (7%)

Unitaid$21,971,016 (7%)

Otsuka Pharmaceuticals$22,773,887 (7%)

Funders with investments under 4%
U.K. Department for International Development (DFID)$10,401,360

Irish Aid

European and Developing Countries Clinical Trials Partnership (EDCTP)$9,934,061

Singapore Ministry of Health, National Medical Research Council$1,049,705

U.S. Centers for Disease Control and Prevention (CDC)$7,399,574

U.S. Food and Drug Administration (FDA)$1,017,990

German Federal Ministry of Education and Research (BMBF)$5,933,768

French National Agency for AIDS Research (ANRS)$875,448

U.K. Medical Research Council (U.K. MRC)

$5,303,483

Swiss Federal Institute of Technology in Lausanne (EPFL)$710,083

U.S. National Institutes of Health, Other Institutes and Centers (NIH Other ICs)

$4,930,426

U.S. Department of Veterans Affairs$679,524

Dutch Ministry of Foreign Affairs (formerly listed as DGIS)$3,495,346

Japan Agency for Medical Research and Development (AMED)$624,400

U.S. Department of Defense Medical Research and Development Program (DMRDP)$3,320,851

Molbio Diagnostics$617,200

European Commission$3,298,128

Canadian Institutes of Health Research$600,036

LegoChem Biosciences$3,000,000

Public Health England$588,197

Australian Department of Foreign Affairs and Trade (DFAT)$2,561,834

Company R$472,041

Novartis Pharma AG$2,400,000

Swedish Research Council$454,077

Dutch National Postcode Lottery$2,273,117

Singapore Agency for Science, Technology and Research (A*STAR)$453,725

Qurient$2,175,000

Norwegian Ministry of Education and Research$423,418

Wellcome Trust$2,055,519

U.S. President’s Emergency Plan for AIDS Relief (PEPFAR)$381,205

Global Health Innovative Technology Fund (GHIT)$1,978,314

University of the Philippines Manila—National Institutes of Health$334,966

Korean Ministry of Science, ICT and Future Planning$1,952,764

Swiss National Science Foundation (SNSF)$283,498

South African Medical Research Council (SAMRC)$1,702,863

Ireland Health Research Board$271,157

Company N$1,500,000

Indian Council of Medical Research (ICMR)$267,500

Indonesian philanthropic donors to TB Alliance$1,500,000

South African Department of Science and Technology (DST)$209,414

Korean Ministry of Health and Welfare$1,437,069

Corporate donors to TB Alliance$200,646

Indian Council of Scientific and Industrial Research (CSIR)$1,387,157

Korean Ministry of Agriculture, Food and Rural Affairs$187,000

Sequella$1,356,000

Other funders with investments less than $100,000$376,469

23$1,142,270

“What I don’t want to happen is for good drugs or good regimens not to go totrials because of cost rather than science. We can’t let cost be a factor on whatgoes forward. We should be making sure the best science goes forward.”
Grania Brigden, Deputy Director, TB and HIV Department, The Union

The Gates Foundation was the single largest investor in TB drug research in 2017 with $63 million, or 20%of the $315 million global total. This was only slightly more than the $61 million given by NIAID. However,at $98 million, total U.S. government investment (including funding from eight different agencies) is greaterthan that of any other government, foundation, or pharmaceutical company, and it comprised 31% of total
funding for TB drug research in 2017.
Otsuka was the third largest investor in TB drug R&D in 2017 with $23 million. Two unnamed pharmaceutical companies—Company X and Company V—reported investments of $21 million and $14 million, respectively. Three of the top 10 and five of the top 20 funders of TB drug research in 2017 were pharmaceuticalcompanies. Eleven pharmaceutical companies reported spending a combined $68 million on TB drug R&D in2017. This is 80% of the $85 million contribution that private industry made to TB research overall and 22%of total expenditures on TB drug research. This concentration of pharmaceutical industry investment is an
important factor contributing to TB drug research receiving more investment than any other area of TB R&D.
After the United States, the United Kingdom stands out from other country governments, with an investmentof $16 million in TB drug research in 2017. Other countries above $3 million include Germany ($5.9 million),
the Netherlands ($3.5 million), and South Korea ($3.6 million). The European Union invested $13 million.
In addition to attracting greater investment than other areas of TB research, drug R&D also has the mostdiverse funding pool, with governments, philanthropies, and private industry all contributing meaningfully.
This stands in stark contrast to TB basic science, which is almost entirely dependent on government funding.
The total $315 million invested in TB drug research in 2017 represents a $58 million increase over the $257
million spent in 2016 and amounts to 41% of total funding for TB research in 2017. While this year-on-year
improvement is impressive, it is less so when one considers that annual investments had already reached$263 million by 2011. There was no great increase over the 2011 level until 2017.
The last 12 months have been unusually active for TB drug development. Among the major events, Otsuka
released results from its phase III trial of delamanid—the first phase III trial of a new anti-TB compound froma novel class in decades. (This achievement was clouded by the trial’s lack of a clinical primary endpoint anddifficult-to-interpret findings that have muddied normative guidance on how to best incorporate the drug
into drug-resistant TB [DR-TB] treatment.) Preliminary data from the TB Alliance’s Nix-TB trial continued tooffer hope that a three-drug regimen of bedaquiline, pretomanid, and linezolid (BPaL) can cure people withthe most drug-resistant forms of TB in six to nine months.21 Based on Nix-TB results to date, the TB Alliancelaunched the ZeNix study, looking at whether the BPaL regimen can be efficacious when linezolid is given atlower doses and/or for shorter durations designed to reduce the serious toxicities associated with that drug.22
In addition, the TB Alliance announced the launch of the SimpliciTB trial, which will test a four-month regimen
of bedaquiline, pretomanid, moxifloxacin, and pyrazinamide (BPaMZ) in people with drug-sensitive TB (DSTB; as well as a controversial uncontrolled evaluation of BPaMZ given for six months to people with DR-TB).23
The year’s biggest news in TB treatment came when the South African Department of Health announced that
bedaquiline would become part of the initial treatment regimen for all people with DR-TB.24 Notably, thisbold yet evidence-based move preceded WHO advice on the topic. South African officials felt compelled toact after reviewing the records of 19,617 people treated for DR-TB in South Africa between 2014 and 2016,
1016 of whom received bedaquiline. Those who received bedaquiline had a higher rate of treatment successand were significantly less likely to die during treatment.25 Shortly after South Africa’s decision, the WHO
convened a guidelines development group, which after reviewing the evidence issued a rapid communication recommending bedaquiline as a “core agent” for treating DR-TB.26 The same communication downgraded other drugs commonly used in DR-TB treatment—including five of the seven agents used in the so-called
shorter regimen studied in the STREAM trial.27 This seismic shift in DR-TB treatment is expected to improve24

treatment outcomes and end the hearing loss induced by previous regimens that incorporated injectable
drug agents (including the shorter regimen evaluated in STREAM). That said, the optimal treatment regimens
for drug-resistant forms of TB are not yet known, and guidelines are set to keep changing as findings fromongoing trials are reported in the coming years.
In the realm of TB preventive therapy, two phase III trials published results supporting the efficacy and safety of shorter alternatives to isoniazid preventive therapy (IPT). A study by the NIH-funded AIDS Clinical
Trials Group showed that a one-month regimen of isoniazid and rifapentine (1HP) is noninferior to six monthsof daily isoniazid, with fewer safety concerns and better adherence in people with HIV.28 Supported by the
Canadian Institutes of Health Research, investigators at McGill University showed that four months ofdaily rifampicin is noninferior to and safer than nine months of isoniazid in adults and children.29 And theInternational Maternal Pediatric Adolescent AIDS Clinical Trials Network (IMPAACT) completed a phase IV
study assessing the safety of IPT in pregnant and postpartum women—finally providing high-quality clinical
trial data on IPT use in this population decades after IPT was first used for TB prophylaxis.30
These achievements have incontrovertibly moved the field forward, but each came with its own caveats,and some illustrated structural vulnerabilities in the way TB drug development is conducted.31 Under the
status quo, new agents are more likely to be developed singly rather than in combination as part of new
regimens; for instance, only after approval were bedaquiline and delamanid combined together and withother drugs in trials seeking new, shorter regimens. Most of these efforts have relied on public funding.32
Moving forward, there is growing consensus that a different approach to funding innovation will be required
to develop wholly novel regimens backed by the high-quality data necessary to produce clinical guidelines
with minimal ambiguities, patient exclusions, and evidence gaps.
Grania Brigden, deputy director of the TB and HIV Department at the International Union Against TB
and Lung Disease (The Union), pointed to open data sharing as one necessary ingredient: “We need data
sharing for regimen development. That data sharing may have unexpected benefits that in five to ten years’ time
[will] completely change how we do TB regimen trials to make them easier or less expensive or to pushforward regimens in a quick way. So I think, from a funder perspective, everyone wins if we can make thewhole framework much more transparent.”
The call for data sharing is about several ideas—collaboration, for one, but also transparency and efficiency.
Tenu Avafia, human rights, law, and treatment access team leader at UNDP, elaborated: “There are sort oftwo elements to the calls for things like transparency and efficiency. There’s the element of being more accountable . . . but then there’s another aspect where working with funders to encourage researchers to work
[together] may unlock new efficiencies for the way researchers collaborate.” Sharonann Lynch of the MSF
Access Campaign offered a more blunt diagnosis: “Simply put, because of the way R&D is performed, theprofit-seeking nature is that there is not much incentive for companies to collaborate, to share molecules, toshare data. So that competitiveness stymies research, stymies . . . what could otherwise be a more efficient
process, and not just for regimen development but across the board.” The challenge will be to swing R&D for
TB drugs and other new tools from a market-driven system to one driven by human and public health need.

25

Vaccines
FIGURE 11

Vaccines: $100,338,945
Funders under 2%$9,897,555 (10%)
Brazilian Development Bank
$1,814,040 (2%)
U.S. DOD$2,134,915 (2%)
AMED
$2,313,848 (2%)
EDCTP
$3,794,913 (4%)

Gates Foundation$37,326,666 (37%)

BMBF$4,256,601 (4%)

European Commission$7,480,058 (7%)

GSK
$8,675,541 (9%)

NIAID
$22,644,809 (23%)

Funders with investments under 2%
Korean Ministry of Health and Welfare$1,483,800

Japan BCG Laboratory$446,604

Public Health England$1,115,546

U.S. National Institutes of Health, Other Institutes and Centers (NIH Other ICs)

$426,417

U.K. Department for International Development (DFID)$1,040,136

Wellcome Trust$385,885

Max Planck Institute for Infection Biology$807,000Brazilian Ministry of Health$302,340

Korean Ministry of Science, ICT and Future Planning$735,591

Industry donors to TBVI

$228,454

Canadian Institutes of Health Research$732,263

Danish Council for Independent Research$176,652

Ireland Health Research Board$685,118

U.K. Biotechnology and Biological Sciences Research Council$110,514

U.K. Medical Research Council (U.K. MRC)

$552,296

Other funders with investments less than $100,000$174,176

Norwegian Agency for Development Cooperation (NORAD)$494,764

26

“Data from recent clinical trials are changing the way we think
about TB vaccine development. The combination of scientific advances
and increased political attention suggests that this is a pivotal moment in
the decades-long quest to develop more widely effective TB vaccines.
We are no longer asking whether we can develop new TB vaccines,
but how we can expedite promising candidates and how we can use
new immunologic insights to design even better approaches.”
Mark Feinberg, President and CEO, International AIDS Vaccine Initiative (IAVI)

In 2017, the Gates Foundation invested $37 million in TB vaccine research. This is more than any otherphilanthropy, government, or pharmaceutical company, and 37% of the global total of just over $100
million. NIAID ranks second with $23 million, and total U.S. government investment in TB vaccine R&D in2017 stands well ahead of other governments at $25 million. Vaccine R&D is the only TB research area where
the U.S. government is not the top funder, trailing the Gates Foundation by $12 million.
At $8.7 million, GSK is the third largest funder of TB vaccine research. During the HLM, GSK and its
collaborator, Aeras, published promising phase IIb findings showing that two doses of GSK’s TB vaccine
candidate M72/AS01E conferred 54% protection against developing active TB in HIV-negative people with
MTB infection.33 At the time of this writing, it was not known whether the company would move the vaccine
into a phase III trial and how public and philanthropic funding would figure into such an endeavor. GSK is the
only major pharmaceutical company that reported major investments in this area. Earlier in the year, Sanofi
Pasteur ended its support for TB vaccine candidate H4:IC31 when a phase IIa trial showed that the vaccine
did not offer significant protection against MTB infection in South African adolescents (although a second
arm of that trial, evaluating revaccination with BCG, looked more promising).34,35
The European Union with $11 million, as well as the governments of Germany, Japan, South Korea, and theUnited Kingdom, all invested more than $2 million in TB vaccine research in 2017. High-TB-burden countries such as India and South Africa, which made substantial investments in other research areas, invested
only very small amounts in TB vaccine R&D (although South Africa hosts a significant share of the world’s TB
vaccine clinical trials). The government of India’s support for TB vaccine R&D is expected to increase incoming years as the Indian Council of Medical Research prepares to launch a massive efficacy trial of two
vaccine candidates (VPM1002 and MIP) with an anticipated enrollment of 19,000 participants.36,37
Even though investment in TB vaccine R&D has increased in each of the last two years, not much can beread into these increases given the lack of a discernible upward trend over the last decade. The $100 million
invested in TB vaccine research in 2017 is only the fourth highest annual investment since TAG started tracking in 2005, with higher annual totals reported in 2008, 2009, and 2014. With 13% of total investment in
TB research in 2017, vaccines rank third among research areas.
One explanation for the relatively low levels of government funding for vaccine research is that TB vaccine
development may be perceived as comparatively high risk. However, with higher risk comes the potential for
greater public health reward. The rapid reductions in TB incidence envisioned by the WHO End TB Strategy
2030 targets will only be possible with the advent and rapid introduction of new TB vaccines. Of course, thepotential public health impact of any new vaccine will depend on many factors—vaccine efficacy, whether thevaccine prevents MTB infection or blocks reactivation of established infection, and the age group it targets,to name a few. But nearly all of the epidemiological models agree that one (or more) new TB vaccines will be
required to end the TB epidemic.

27

“When funders put in money, they want
to be able to see impact for investment,
and research doesn’t always show
an immediate impact—especially when
we are talking about developing avaccine, it takes a long time.”
Welile Sikhondze, Technical Advisorand Research Coordinator, eSwatini National
TB Control Program“The reward in public funding is evengreater—eliminating a disease, ending
an epidemic, having people live longer
and higher-quality lives. Those are remarkable returns on investment, hardto quantify, and I think the hardest
thing is that they are hard to see in the
short term. So when I look at the last
15 years of funding [for vaccine R&D],
no one expected a quick win . . . I don’t
think people thought ‘Oh, this is a slamdunk.’ But I don’t know that anyone
thought 15 years later we wouldn’t haveanext-generation
vaccinefor TB or an HIV vaccine. . . . We’ve notseen as many great advances as we’dlike. That’s just the reality.”
Mitchell Warren,
Executive Director, AVAC

Although the long-term importance of TB vaccines is clear, inthe short term, where funding decisions are made in three- andfive-year cycles, investments in vaccination and other prevention tools may appear less urgent than the need for new drugs ordiagnostics. As eSwatini National TB Control Program technicaladvisor Welile Sikhondze explained: “Over the years, because
we’re in such an emergency mode, we were focused on improving treatment or improving how we care for those that we know
about. So we’ve done all we can do from the case management[perspective]. Let’s also try to find new innovations to help findthose we do not yet know about. We also need to look at those
who are not in the [risk] pool [for TB] but are at risk of falling into
the pool. So we also need to focus on prevention. . . . A lot more
focus needs to be put into prevention and vaccinology.”
Vaccine R&D will always be laden with risk, but governments
should put these uncertainties into their proper context: TB vaccine R&D is in the midst of its most productive and promising period maybe ever, at the very least since the field’s revitalization
at the turn of the century after decades of inactivity.38 By one
count, at the start of 2018, there were eight clinical trials withefficacy endpoints either soon to start or approaching completion.39 The biological samples generated from this body of work
will provide a trove of data on how different vaccine candidates
perform in humans, an invaluable resource for conducting thekind of basic immunology and biomarker discovery needed to
improve current candidates and sustain the pipeline with innovative strategies and novel vaccine constructs. The protective
effect observed in the M72/AS01E phase IIb trial—althougha relatively modest 54% and bookended by wide confidence
intervals—should put to rest any lingering doubts about
whether developing a vaccine that can improve on the body’s
adaptive immune response to TB is possible. We now know it
is possible, but bringing such a vaccine from discovery throughlicensure will require much more investment than what funders
have given over the past 12 years.

28

Operational Research
FIGURE 12

Operational Research: $89,672,465
SAMRC$1,469,942 (2%)

CIHR
$1,593,420 (2%)

Funders under 2%$7,4 85,239 (8%)

Gates Foundation$16,165,681 (18%)

Dutch Ministry of Foreign Affairs$2,063,405 (2%)
U.K. MRC$2,774,478 (3%)
Unitaid$3,000,000 (3%)
European Commission$3,079,102 (3%)

Global Affairs Canada$13,093,570 (15%)

DFID$5,242,120 (6%)

CDC
$5,721,329 (6%)

USAID
$7,363,976 (8%)

NIH Other ICs$8,356,118 (9%)

NIAID
$12,264,084 (14%)

Funders with investments under 2%
U.S. President’s Emergency Plan for AIDS Relief (PEPFAR)$1,213,130

Indian Council of Medical Research (ICMR)$204,120

World Health Organization$997,004

Australian National Health and Medical Research Council (NHMRC)$193,365

Global Health Innovative Technology Fund (GHIT)$907,513

ELMA Foundation$175,000

Norwegian Agency for Development Cooperation (NORAD)$594,560

Wellcome Trust$163,275

Médecins Sans Frontières$588,773

Colombia Administrative Department of Science, Technology and Innovation$100,000

German Federal Ministry of Education and Research (BMBF)$347,344

Korea Foundation For International Healthcare$93,786

Korean Ministry of Health and Welfare$306,790

Thrasher Research Fund

$86,428

Japan Agency for Medical Research and Development (AMED)$285,440

Indian Ministry of Science and Technology$83,091

Thailand Health Systems Research Institute$257,811

Swedish Research Council$82,796

Australian Department of Foreign Affairs and Trade (DFAT)$230,565

Indian Ministry of Health and Family Welfare (MOHFW)$56,715

European and Developing Countries Clinical Trials Partnership (EDCTP)$230,317

Other funders with investments less than $50,000$287,417

29

“We can rattle the world’s attention by introducing the next cool tool.
But it is difficult to get as enthusiastic about the cool tools thatmight emerge from the pipeline as long as we have such a standardof mediocrity in terms of scale-up. We can see this from all of the missed
opportunities to provide TB LAM today, in outpatient facilities andespecially hospitals where there is high TB-HIV coinfection.”
Sharonann Lynch, HIV and TB Policy Advisor, Médecins Sans Frontières Access Campaign

The largest single investor in TB operational research in 2017 was the Gates Foundation, with $16 million, or
18%, of the $90 million total. The highest-ranking U.S. government entity, NIAID, is ranked third highest, andtotal U.S. government investment in this area adds up to $35 million—nearly $20 million more than the Gates
Foundation.
Global Affairs Canada ranks second with $13 million, most of it channeled through the Stop TB Partnership’s
TB REACH program. This is the lion’s share of the Canadian government’s total TB R&D investment of $19
million. Other countries with TB operational research expenditures over $1 million are the United Kingdom($8 million), the Netherlands ($2 million), and South Africa ($1.5 million). The European Union spent $3.3
million through the European Commission and the EDCTP.
The $90 million reported in 2017 marks a new high and the third consecutive year of growth in this area.
These three good years follow directly on three consecutive years of falling investment in which fundingfor operational research dropped from $88 million in 2011 to $53 million in 2014. With 12% of the total TB
research investment in 2017, operational research ranks fourth among research areas.
Operational research is where the research conditions of the pipeline meet reality and where new technologies that worked well in the clinic may require additional tailoring to meet the practical demands of patientcare. Another way to understand this is to see operational research as the place where the biomedical R&D
system meets the health system. As the TB community has learned time and again, scale-up of new technologies and ideas cannot be taken for granted. Health systems must prepare for new tools, access barriers must
be overcome, new knowledge about TB must be translated into evidence-based policies and practices, andpatients and communities must be given information about new interventions.
In the words of Tenu Avafia of UNDP: “It’s one thing to talk about insufficient biomedical R&D. . . . That aside,
it’s also critical to invest in strengthening health systems so that when you have technologies available
they can be efficiently absorbed into the health system, and that includes [things like] new vaccines anddiagnostics for TB.” Avafia continued by saying that “once R&D is done, the value gap of when you havea product and when it reaches a patient requires strengthening capacity and making specific, deliberateinterventions in health systems to address bottlenecks where they occur.”
There has been an attempt over the last year to reframe operational research as “applied health research,” aterm that encompasses operational, implementation, and health systems research as distinct domains without paving over their nuanced but important distinctions.40 Broadly speaking, advocates of applied healthresearch in TB seek to improve equity in health access and outcomes, translate knowledge into practice, andgenerate knowledge that lends itself to policy and implementation in the first place.41 Signs that this broader concept is gaining traction can be found in the HLM political declaration, in which member states committed “to advance a new research and innovation environment” through, inter alia, supporting “operational,
qualitative and applied research, to advance effective tuberculosis prevention, diagnosis, treatment, and care
and actions on the economic and social determinants and impacts of the disease.”

30

What should this aspect of the HLM political declaration look
like in practice? Irene Ayakaka, senior research associate
at Makerere University Lung Institute, articulated a simple
but powerful operational research agenda: “There are many
unanswered questions about how to reach every person with
TB, and I think that’s an important one—to find the individuals
with TB that health systems don’t see. What quality can we giveto all people with TB we find, irrespective of who they are, where
they are from? We need to protect everyone from the catastrophic costs of access to care and management. . . . We need tosee that communities, healthcare workers—everyone—changes their attitudes about the stigma that comes from being an
individual with TB.”
To address these questions, TB operational research must adopt
a multidisciplinary outlook—something that is still lacking.
“There’s a huge amount of qualitative research that still needs
to be done in TB to identify good models of care. And that’s not
expensive compared to developing and manufacturing a vaccine,for example,” said Kathryn Snow, a University of Melbourne doctoral candidate. “Qualitative research is really cheap, but wedon’t seem to do very much of it in TB.” The qualitative dimensions of operational research also make it relevant for tackling many of the human-rights-related barriers to an effective
TB response. In the words of Albert Makone: “One thing thatis lacking in terms of TB is the issue of human rights. This applies
both to funders and to governments, especially in high-burdencountries. They need to focus more on patient-centered careand human-rights-based approaches to TB diagnosis and treatment. For example, in Zimbabwe, yes, the treatment is free.
But one challenge people face before diagnosis is that a chest
X-ray costs a minimum of $20. That in itself is a barrier . . . [one]that we need a human rights approach to address.”

31“In operational research, you can see
an increase in funding in the last five
years and various efforts to optimize
the use of new tools that we have orthat are emerging in the pipeline.
We are seeing a renewed call for patient-centered TB management that iscontext specific. We are seeing calls forpartnerships that enable access to all
key populations that we consider whentalking about TB . . . but there’s still alot of work to be done.”
Irene Ayakaka, Senior Research Associate,
Makerere University Lung Institute“For all the research to be beneficial,
we do need to look at how our healthsystems function and what countries
can already do without spending hugeamounts of money to really strengthen
and have robust health system infrastructures in place that can make theenvironment ready to receive a new
vaccine, a new test, a new drug, or
any other innovative technology thatis developed.”
Welile Sikhondze, Technical Advisorand Research Coordinator, eSwatini
National TB Control ProgramPediatric TB Research
FIGURE 13

Pediatric TB R&D Funding by Research Area, 2017
Total: $56,429,152
Basic Science$2,952,041 (5%)

Infrastructure/
Unspecified$497,004 (1%)

Vaccines$6,682,659 (12%)

Drugs$26,434,485 (47%)

Diagnostics$9,747,839 (17%)

Operational Research$10,115,125 (18%)

The EDCTP is the top single investor in pediatric TB research, having spent $10.6 million in 2017, almost 20%of the total $56 million put into this research area. The EDCTP is funded by the European Union and also
made multimillion-dollar investments in diagnostic, drug, and vaccine research in 2017. In 2017, the EDCTP
reported supporting pediatric-related research projects ranging from a phase II trial of the TB vaccine
candidate MTBVAC in South African neonates to a study of how TB affects respiratory infection risk in South
African children to an evaluation of a household-level TB/HIV intervention that is enrolling adolescents.
USAID ranks second in pediatric TB research with $9.5 million. Most USAID funding in this area went tosupport TB transmission studies that included children and adolescents alongside other age groups.
As in most research areas, total U.S. government expenditures are greater than that of any single investor at$22 million and double the EDCTP investment.
The only other countries with investments above $1 million in pediatric TB research in 2017 are the United
Kingdom with $4.5 million and South Africa with $1.1 million. Company X reported an investment of $5.7
million and Unitaid invested $6.6 million. Previous investments by Unitaid led to the development of appropriately dosed pediatric fixed-dose formulations of first-line TB drugs by the TB Alliance and generic drug
manufacturer Macleods. Current Unitaid funding for pediatric-related research is split between two projects.
One, led by the University of Bordeaux, is seeking to reduce childhood TB morbidity and mortality throughenhanced diagnosis.42 The second, led by the Elizabeth Glaser Pediatric AIDS Foundation, is trialing innovativemodels of TB care for children with the goal of improving the market for new, child-friendly TB medicines.43

32

TABLE 3

Pediatric TB R&D Funders by Rank, 2017
FUNDER
TYPE

2017 PEDIATRICTB R&DFUNDINGPERCENTAGE OFTOTAL PEDIATRICFUNDING

European and Developing Countries Clinical Trials Partnership(EDCTP)P$10,604,544

18.8%

2

U.S. Agency for International Development (USAID)

P$9,500,000

16.8%

3

U.S. National Institutes of Health, National Institute of Allergy
and Infectious Diseases (NIAID)

P$6,886,622

12.2%

4

UnitaidM$6,615,400

11.7%

5

Company X

C$5,700,000

10.1%

6

U.S. National Institutes of Health, Other Institutes and Centers(NIH Other ICs)

P

$5,562,805

9.9%

7

U.K. Medical Research Council (U.K. MRC)

P

$4,535,821

8.0%

8

Brazilian Development BankP

$1,814,040

3.2%

9

South African Medical Research Council (SAMRC)

P$1,083,446

1.9%

10

World Health OrganizationM$600,000

1.1%

11Norwegian Agency for Development Cooperation (NORAD)P$437,361

0.78%

12

Novartis Pharma AG

C$320,000

0.57%

13

Australian National Health and Medical Research Council

P$311,383

0.55%

14

Molbio Diagnostics

C$308,600

0.55%

15

Brazilian Ministry of HealthP$302,340

0.54%

16

Médecins Sans FrontièresF$261,742

0.46%

17

Japan Agency for Medical Research and Development (AMED)P$251,544

0.45%

18

Thrasher Research FundF

$237,296

0.42%

19

German Federal Ministry of Education and Research (BMBF)P$231,310

0.41%

20

ELMA Foundation

F$175,000

0.31%

21

Wellcome TrustF$171,040

0.30%

22

Swedish Research Council

P$141,936

0.25%

23

Company VC$114,227

0.20%

24

Canadian Institutes of Health ResearchP$65,823

0.12%

25

Thailand Ministry of Public HealthP$62,798

0.11%

26

Thailand Health Systems Research InstituteP$61,993

0.11%

27

Other public funders with investments less than $50,000

P$72,083

0.13%

2017
RANK

FUNDING ORGANIZATION

1

TOTAL

$56,429,152

C = Corporation/Private Sector; F = Foundation/Philanthropy; M = Multilateral; P = Public-Sector R&D Agency
Otsuka Pharmaceuticals, which is close to completing its pharmacokinetic and safety study of delamanid in children, notified TAG that it cannot disaggregate
pediatric expenditures from its overall investment and is therefore not listed in the table.

33

“We’re lacking some of the most critical tools necessary to effectively
address pediatric TB. From developing appropriate and accurate diagnostics
to defining the most efficient ways to deliver care, investment in R&D isrequired to accomplish the goal of ending childhood TB. Children havebeen waiting for decades for real advances that can address their uniqueneeds. Significantly increased investment is needed if we are to see
game-changing advancements that achieve measurable impacts.”
Jennifer Cohn, Senior Director of Innovation, Elizabeth Glaser Pediatric AIDS Foundation

After three years of relatively flat funding, global pediatric TB research expenditures nearly doubled from$29.1 million in 2016 to $56.4 million in 2017, a 93% increase. Much of this can be attributed to Unitaid,
which doubled its investment, as well as to the EDCTP, which went from spending nothing on pediatricresearch in 2016 to being the largest funder in this area in 2017. This latter move indicates the extent
to which pediatric TB research funding may depend on grant cycles and the inclusion of children in large,
periodic funding calls. TAG only started tracking investments in pediatric TB research in 2010 and, accordingly, does not have the same historic (2005–2017) data series as for the other research areas (see Appendix 1
for a note on the methodology TAG used to collect pediatric TB R&D funding data).
One of the best pieces of news in the pediatric TB research community came when the Division of
AIDS at NIAID announced that it would re-fund the IMPAACT network for another seven years.
IMPAACT is jointly funded by NIAID and the NIH Eunice Kennedy Shriver National Institute of Child
Health and Human Development and is the largest sponsor of clinical trials that include children withand at risk of TB, as well as pregnant and postpartum women. Work by IMPAACT and its associatedinvestigators has been critical to filling pediatric pharmacokinetic (PK) and safety data gaps for TB drugs.
IMPAACT reported spending $2.6 million on TB research in 2017, about a third less than what it spent in
2016, but a figure that will likely rise as its new seven-year funding cycle gets underway.
A review of the pediatric TB treatment pipeline by Lindsay McKenna, TAG TB Project co-director, notes:“PK and safety studies in children continue . . . to produce a steady flow of data, yet the translation of
R&D gains into policy and access for children with TB remains pitifully slow.”44 Aside from progress in safety/
PK work and implementation concerns, several efficacy studies underway or planned will evaluate whether
it is possible to shorten DS- or DR-TB treatment in children. TB disease presentation in children is highlyvariable. Young children with disseminated or less severe forms of disease may achieve good treatment
outcomes with shorter, simplified regimens. On the other side of the spectrum, children with more severe
disease require safer, optimized regimens, with studies of TB meningitis in children being one of themost pressing—but difficult—areas of work. In the field of diagnostics, McKenna calls for “scale-up ofpediatric-specific discovery, validation, and implementation research efforts to develop novel assays thatcan detect TB . . . in children.”45
These research priorities and others are described in Research Priorities for Pediatric Tuberculosis, a brief
released at the HLM in conjunction with a new edition of the Roadmap towards Ending TB in Children andAdolescents.46,47 The first edition of the Roadmap, published in 2013, drew global attention to the near-total
neglect of childhood TB in global health priority setting. The new edition includes a clearer focus on adolescentsand argues that pediatric populations merit a dedicated, focused research agenda, one that goes beyond themere adaptation of products first studied in adults for use in kids: “Pediatric TB R&D efforts have largely focusedon generating evidence to inform the use of existing technologies and treatments, which are designed for andproven in adults, for children. Yet children affected by TB have specific needs that merit a pediatric-focusedresearch agenda.”48

34

Advocacy for such an agenda received a boost in the HLM
political declaration, which calls on UN member states toadvance “global collaboration to ensure accelerated development of accessible and affordable diagnostic tools, and shorter and more effective oral regimens, including those that meetthe unique needs of children.” The political declaration also
singled out children when it articulated TB research commitments, asking states to “deliver, as soon as possible, new, safe,
effective, equitable, affordable, available vaccines, point-ofcare and child-friendly diagnostics, drug susceptibility tests andsafer and more effective drugs and shorter treatment regimens
for adults, adolescents and children for all forms of tuberculosis and infection.” The prominent inclusion of children within the
HLM political declaration is a sign that advocates have finallybroken through the longstanding silence on pediatric TB. Futureversions of this report will assess whether this critical attention
translates into concrete funding for the research and implementation required to end unnecessary suffering and death due
to TB among children and young people.

35“Pediatric TB R&D efforts have largely
focused on generating evidence to inform the use of existing technologies
and treatments, which are designed forand proven in adults, for children. Yet
children affected by TB have specificneeds that merit a pediatric-focusedresearch agenda.”
Research Priorities for
Pediatric Tuberculosis53

Discussion“The highest known standard of care should be delivered to all patients sufferingfrom all forms of TB in the world. There shouldn’t be distinct rich-world and poorworld standards.”
Paul Farmer, Co-Founder, Partners in HealthWith around 1.6 million TB deaths and 10 million people falling ill with TB in 2017, it seems clear that
TB should be a global research priority. Either through their own investments, or through creating an enabling
environment, it should be the role of governments to ensure that sufficient funds are invested and the rightincentives and legal and regulatory frameworks are put in place. Even so, the global TB research effort has
until now been relatively haphazard—and haphazardly funded.
At least one long-standing problem, however, that we are now well on our way to solving, is determining how
much we can reasonably expect governments to invest in TB R&D. Until recently, the TB research community
has had no real benchmarks by which to judge whether an extra $10 million from the Indian government, oran extra $100 million from the United States, are major steps forward or simply what these countries shouldhave been spending anyway.
In 2018, UN member states signed the HLM political declaration and collectively agreed to “aim” toincrease annual global investment in TB research to $2 billion. Even though a binding commitment to the$2 billion would have been a preferable outcome, this “aim” nevertheless helps solidify a shared global
target. The $2 billion is derived from an earlier Global Plan target that aimed for $9 billion from 2016 to 2020—
a target the world has already fallen far behind. Either way, to have agreement among UN member states on
the $2 billion annual target sets an important marker.
But how do we translate a global target into country-specific targets? By design, the 0.1% fair-share targets
devised by TAG and partners add up neatly to this $2 billion target. If all high-burden countries and a listof the world’s wealthiest countries all contributed 0.1% of their total annual research spending to TB, then
the world would hit this $2 billion target. The 0.1% target has gained significant traction this year and has thebenefit of tailoring a country’s target to its existing levels of research spending.
What all this means is that we now have agreement on a $2 billion annual target and we know the fair-shareamount that each country should be contributing (Table 1).

Doing research differently
We are also, albeit more slowly, making progress on the question of how research funds should be invested.
That we need large infusions of funding for everything from basic science to clinical trials is not controversial. That increased research collaboration between the BRICS and between other countries are important
steps forward is also not controversial. What was controversial, however, in the run-up to the HLM was therole of intellectual property in all this.49 Negotiations on the political declaration remained open throughout
the Northern Hemisphere summer due to disagreements regarding whether and how TRIPS flexibilities* anddelinkage would be mentioned in the text.50
What the last 13 years of TB research funding data show unequivocally is that the private sector has largely
withdrawn from TB research (with industry contributing only 11% of TB research funding in 2017). It thus
seems clear that the current patent-based innovation model does not provide companies with sufficientincentives to invest in TB R&D. If it had, we would no doubt see more investment from the private sector.
* The agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) is a legal agreement between members of theWorld Trade Organization (WTO) that came into effect in 1995. The agreement set certain minimum standards for intellectual
property protection in WTO member states while also leaving members with some flexibility in formulating their domestic
intellectual property laws. In 2001, the WTO Doha Declaration on TRIPS and Public Health affirmed that these flexibilities may
be used to protect public health.
36

“Success should be measured by the degree to which effective treatment,
diagnosis, and prevention reaches the poorest of the poor—those mostvulnerable to TB and made more vulnerable by the disease. This last mileof delivery—adequately resourced systems with staff, stuff, and space—is theultimate metric for success of research. The only way to measure true successis to see a rapid drop in TB mortality. After a rise in incidence, as would be
expected with active case-finding and treatment of TB infection in contacts,
we should see a very rapid drop in rates of new TB. For the last quarter
century, this has largely not been observed. Now is a chance to put
programs in place that can achieve these attainable goals.”
Paul Farmer, Co-Founder, Partners in Health

It is in the context of this market failure that the discussion around delinkage should be understood. In short,the idea behind delinkage is to replace patent-based incentives for investing in R&D with mechanisms suchas prize funds. In other words, rather than rewarding a developer through market exclusivity, states pay thedeveloper a prize, likely in the tens or even hundreds of millions of dollars, but then have generic competition
from day one. The economics are not straightforward, but modeling suggests this will not only work but also
save money while contributing to better health outcomes.51,52
Even though the HLM political declaration explicitly mentions the Life Prize, an example of such adelinkage-based model, and also describes delinkage (without mentioning the concept by name), governments
have yet to support prize funds in TB. Thus, even as hands are wrung about the exodus of pharmaceuticalcompanies from TB in the current patent-based system, no governments have yet been willing to put up
the money to test alternative innovation models. Whether this will change in the wake of the HLM is a criticalmeasure of how seriously governments take the innovation problem in TB.
As an aside, it seems likely that United States’ resistance to delinkage language in the declaration was driven
not by what it means for TB—the idea suits TB better than almost any other disease area—but by what it
might mean for other disease areas should such prize funds succeed in TB. In this sense, tough negotiations on
the declaration were a proxy for a much larger global battle between pharmaceutical companies and patients.

Making medicines accessible
That is the innovation problem; the other side of the intellectual property and delinkage debate concerns
access to medicines. Here we are on more familiar ground, with a long-standing, ongoing global debate
between strict patent enforcement and flexibilities that allow for the overriding of patents in certain situations (so-called TRIPS flexibilities). Here the pre-HLM disagreements between the United States and South
Africa served up strong reminders of the early days of the AIDS epidemic in South Africa, when the high prices
of AIDS treatment meant many people could not access life-saving drugs.
Some well-worn debates about people versus patents resurfaced this year, but one aspect that was different
was the claim by some that TB is different from HIV and that the same access problems do not arise.
In some ways, at least, the issues are familiar. Until recently, the drug linezolid was so highly priced that doctors in Khayelitsha, South Africa, could not give the drug to all the patients who they felt might benefit from it.
Smart use of TRIPS flexibilities in this situation could have allowed for a cheaper generic to be imported from
India, which likely would have saved many lives. It is also likely that India’s threat to consider a compulsory
license for bedaquiline contributed to Janssen Pharmaceuticals cutting the price of that drug. No doubt, if
we develop the new drugs, vaccines, and diagnostics we wish to see in the coming decade, patents will again
be an issue—although it should be acknowledged that patents are one among a number of issues restricting
access to new technologies, with registration delays and lax programmatic rollout being other key concerns.

37

Hopefully, the pre-HLM debate about intellectual property and delinkage will lead governments to ask more
tough questions about the terms on which they provide funding for TB research. If governments help fund thedevelopment of a breakthrough new drug, what assurances will we have that those same governments will
not be charged exorbitant prices to buy back the drug they helped develop from a pharmaceutical company
with control over pricing? As Tenu Avafia told us when we interviewed him for this report: “It’s one thing
giving someone involved in R&D money up front, but if one is not being deliberate in thinking about how toensure that the patient at the end of the road is better off, then the objective is not achieved.”
A commitment to affordability of end products, open access publication of all trial results, collaboration withother researchers or groups of researchers, pooling of intellectual property, and data sharing should all be
conditions placed upon public funding for TB research.

Moving beyond rhetoric
Next year we will report on funding trends up to 2018, the year of the HLM, and the year after that we willreport on 2019. Over these two years, we will see what we cannot yet tell: whether the HLM will be backed
up by new investments and whether countries will step up to contribute their fair share. The numbers will notlie. If funding is to take off, the evidence will be clear for all to see in this report.
Over the coming two years, we will also see whether governments are willing to think creatively and responsibly about how they fund TB research and support innovative projects like the Life Prize, or whether weare in fact still in a world where market failure is tacitly accepted. We will see whether exciting new initiatives like the BRICS TB Research Network are just more business as usual—whether it is “all hat, no cattle,” asSharonann Lynch of the MSF Access Campaign put it—or the start of something unprecedented, on the scaleof an Apollo-style program for TB R&D.
Governments or coalitions of governments have in the past put up the money for large technological andscientific endeavors such as the Panama Canal, the Manhattan Project, the Large Hadron Collider, and theInternational Space Station. A few months after the HLM, the question remains as to why the same cannot
be done for a disease that has devastated human lives for millennia—one that still claims more lives than any
other infectious agent.
Ultimately, as Paul Farmer reminds us, the measure of whether research is successful is whether it contributes to saving lives and reducing suffering. Investments in anything from basic science to operational researchmust be guided and motivated by this ultimate goal. This means making the financial investment and doing
everything necessary to ensure that the products of that investment are available to all who need it. Like the
HLM, funding for TB research is only a means to an end, and that end is the end of the TB epidemic.

38

Endnotes
1. Stop TB Partnership (Press Release). Heads of state and although some donors do report these costs to TAG). rch andso prove health systems. PLos net]. 2018. CG revaccination. N Engl government endorse political declaration on TB.
26 September 2018. http://www.stoptb.org/news/stories/2018/ns18_071.asp.
2. Country statement by President Cyril Ramaphosa at the United Nations High-Level Meeting on Tuberculosis.
26 September 2018. http://www.thepresidency.gov.za/speeches/country-statement-president-cyril-ramaphosa-united-nations-high-level-meeting-tuberculosis%2C.
3. United Nations. Political declaration on the fight against tuberculosis, co-facilitators’ revised text: United to end tuberculosis: an urgent global response to a global epidemic. 11 September 2018. https://www.un.org/pga/72/wp-content/uploads/sites/51/2018/09/Co-facilitators-Revised-text-Political-Declaraion-on-the-Fight-against-Tuberculosis.
pdf.
4. Treatment Action Group. Funding for TB research: recent momentum must inspire bold commitments. New York:
Treatment Action Group; 2018. http://www.treatmentactiongroup.org/content/funding-tb-research-recent-momentum-must-inspire-bold-commitments.
5. Stop TB Partnership. The global plan to end TB: 2016–2020: the paradigm shift. Geneva: UNOPS; 2015.
http://www.stoptb.org/global/plan/plan2/.
6. World Health Organization. Global Tuberculosis Report 2018. Geneva: World Health Organization; 2018.
https://www.who.int/tb/publications/global_report/en/.
7. U.K. Department for International Development (Press Release). UK leads the fight against increasing drug resistant
TB. 27 September 2018. https://www.gov.uk/government/news/uk-leads-the-fight-against-increasing-drug-resistant-tb.
8. National Institute of Allergy and Infectious Diseases. NIAID strategic plan for tuberculosis research. Washington,
D.C.; U.S. National Institutes of Health; 2018. https://www.niaid.nih.gov/sites/default/files/TBStrategicPlan2018.pdf.
9. Creswell J, Sahu S, Sachdeva K, et al. Tuberculosis in BRICS: challenges and opportunities for leadership within the
post-2015 agenda. Bull World Health Organ. 2014;92(6):459–60. doi: 10.2471/BLT.13.133116.
10. Nafade V, Nash M, Huddart S, et al. A bibliometric analysis of tuberculosis research, 2007–2016. PLoS One.
2018;13(6): e0199706. doi: 10.1371/journal.pone.0199706.
11. Unitaid (Press Release). Unitaid ranked as one of the world’s leaders in funding tuberculosis R&D. 25 September
2018. https://unitaid.org/news-blog/unitaid-ranked-as-one-of-the-worlds-leaders-in-funding-tuberculosis-rd/#en.
12. Ibid.
13. Yassin, Mohammed (The Global Fund to Fight AIDS, TB and Malaria, Geneva, Switzerland). Personal communication
with: Mike Frick (Treatment Action Group, New York, NY). 2018 August 20.
14. Pai M. Time for high-burden countries to lead the tuberculosis research agenda. PLoS Med. 2018; 15(3):e1002544.
doi: 10.1371/journal.pmed.1002544.
15. Steinbrook R. The NIH stimulus—the Recovery Act and biomedical research. N Engl J Med. 2009;360(15):1479–81.
doi: 10.1056/NEJMp0901819.
16. Gupta-Wright A. Corbett E, van Oosterhout J, et al. Rapid urine-based screening for tuberculosis in HIV-positive
patients admitted to hospital in Africa (STAMP): a pragmatic, multicentre, parallel-group, double-blind, randomized
controlled trial. Lancet. 2018;392(10144):P292–301. doi: 10.1016/S0140-6736(18)31267-4.
17. Clinton Health Access Initiative. Forecasting for advanced disease diagnostics. Presentation at: 4th Diagnostic Partners Synergy Meeting; 2018 July 10–11; Geneva, Switzerland.
18. FIND (Press Release). Call for trial partners to evaluate an innovative, sensitive point-of-care test that detects tuberculosis in HIV+ people. 26 September 2018. https://www.finddx.org/news/call-for-trial-partners-now-open-to-advance-evaluation-of-an-innovative-sensitive-poct-that-detects-tb-in-hiv-people/.

3919. Ibid.
20. Schroeder L, Amukele T, Pai M. “Why the world needs an essential diagnostics list.” Forbes. 2016 August 4.
https://www.forbes.com/sites/sciencebiz/2016/08/04/why-the-world-needs-an-essential-diagnosticslist/#5f739e064015.
21. Conradie F, Diacon A, Everitt D, et al. The Nix-TB trial of pretomanid, bedaquiline and linezolid to treat XDR-TB (Abstract 80LB). Presented at: Conference on Retroviruses and Opportunistic Infection; 2017 February 13–16; Seattle,
WA. http://www.croiconference.org/sessions/nix-tb-trial-pretomanid-bedaquiline-and-linezolid-treat-xdr-tb.
22. TB Alliance (Press Release). ZeNix clinical trial announced. 7 February 2018.
https://www.tballiance.org/news/zenix-clinical-trial-announced.
23. TB Alliance (Press Release). SimpliciTB clinical trial launched with first patients in Tbilisi, Georgia. 28 August 2018.
https://www.tballiance.org/portfolio/trial/11937.
24. Low, M. SA ahead of World Health Organisation in recommending new TB medicine. Spotlight. 2018 June 19.
https://www.spotlightnsp.co.za/2018/06/19/sa-ahead-of-world-health-organisation-in-recommending-new-tbmedicine/.
25. Schnippel K, Ndjeka N, Maartens G, et al. Effect of bedaquiline on mortality in South African patients withdrug-resistant tuberculosis: a retrospective cohort study. Lancet Respir Med. 2018 Jul 9;6(9):699-706. doi: 10.1016/
S2213-2600(18)30235-2.
26. World Health Organization. Rapid Communication: Key changes to treatment ofmultidrug- and rifampicin-resistant tuberculosis (MDR/RR-TB). Geneva: World Health Organization; 2018.
http://www.who.int/tb/publications/2018/rapid_communications_MDR/en/.
27. For information on the regimen being studied in the STREAM trial, see Khimani S. Is shorter better?
Understanding the shorter regimen for treating drug-resistant tuberculosis. New York: Treatment Action Group;
2018. http://www.treatmentactiongroup.org/content/is-shorter-better.
28. Swindells S, Ramchandani R, Gupta A, et al. One month of rifapentine/isoniazid toprevent TB in people with HIV: BRIEF-TB/A5279 (Abstract 37LB). Presented at: Conference
on Retroviruses and Opportunistic Infections; 2018 March 4–7; Boston, MA.
http:// www.croiconference.org/sessions/one-month-rifapentineisoniazid-prevent-tb-people-hiv-brief-tba5279.
29. Menzies D, Adjobimey M, Ruslami R, et al. Four months of rifampin or nine months of isoniazid for latent tuberculosis
in adults. N Engl J Med. 2018;379(5):440–53. doi: 10.1056/NEJMoa1714283.
30. Gupta A, Montepiedra G, Aaron L, et al. Randomized trial of safety and isoniazid preventive
therapy during or after pregnancy (Abstract 142LB). Presented at: Conference on Retroviruses
and Opportunistic Infections; 2018 March 4–7; Boston, MA. http://www.croiconference.org/sessions/randomized-trial-safety-isoniazid-preventive-therapy-during-or-after-pregnancy.
31. Frick M, Lessem E. Falling short of the rights to health and scientific progress: inadequate TB drug research
and access. Health Hum Rights. 2016 Jun;18(1):9–24.
32. McKenna L. Reality check: the price of bedaquiline. New York: Treatment Action Group; 2018.
http://www.treatmentactiongroup.org/content/reality-check-price-of-bedaquiline.
33. Van Der Meeren O, Hatherill M, Nduba V, et al. Phase 2b controlled trial of M72/AS01E vaccine to prevent
tuberculosis. N Engl J Med. 2018. 2018 Sep 25. doi: 10.1056/NEJMoa1803484. [Epub ahead of print]
34. Nemes E, Geldenhuys H, Rozot V, et al. Prevention of M. tuberculosis infection with H4:IC31 vaccine or BCG revaccination. N Engl J Med. 2018;379(2):138–49. doi.10.1056/NEJMoa1714021.
35. Gurunathan, Sanjay (Sanofi Pasteur, Swiftwater, PA). Personal communication with:
Mike Frick (Treatment Action Group, New York, NY). 2018 September 3.
36. Singh K. Evaluating potential vaccine(s) in preventing disease in healthy household
contacts of TB patients. Paper presented at: 5th Global Forum on TB Vaccines; 2018 February 20–23;
New Delhi, India. http://tbvaccinesforum.org/program/.
37. Frick M. The TB prevention pipeline. New York: Treatment Action Group; 2018. www.pipelinereport.org.

4038. Ibid.
39. Ginsberg A. A critical juncture in tuberculosis vaccine development: overview of progress. Paper presented at: 5th
Global Forum on TB Vaccines; 2018 February 20–23; New Delhi, India. http://tbvaccinesforum.org/program/.
40. Remme J, Adam T, Becerra-Posada F, et al. Defining research to improve health systems. PLoS Med.
2010;7(11):e1001000. doi: 10.1371/journal.pmed.1001000.
41. Crowe S, Turner S, Utley M, Fulop N. Improving the production of applied health research findings: insights from aqualitative study of operational research. Implement Sci. 2017;12:112. doi: 10.1186/s13012-017-0643-3.
42. Unitaid. Strengthening paediatric TB services for enhanced early detection (TB-SPEED) [Internet].
https://unitaid.org/project/strengthening-paediatric-tb-services-enhanced-early-detection-tb-speed/#en.
43. Unitaid. Catalyzing paediatric tuberculosis services (CaP TB) [Internet].
https://unitaid.org/project/catalyzing-paediatric-tuberculosis-services-cap-tb/#en.
44. McKenna L. The tuberculosis treatment pipeline for children. New York: Treatment Action Group; 2018.
www.pipelinereport.org.
45. Ibid.
46. Treatment Action Group. Research priorities for paediatric tuberculosis.
47. World Health Organization. Roadmap towards ending TB in children and adolescents. Geneva:
World Health Organization; 2018. https://www.who.int/tb/publications/2018/tb-childhoodroadmap/en/.
48. Treatment Action Group. Research priorities for paediatric tuberculosis.
49. Thomas A. “Ending tuberculosis will take continued private-sector innovation [Opinion].” STAT News.
2018 August 23. https://www.statnews.com/2018/08/23/ending-tuberculosis-private-sector-innovation/.
50. Stephens J, Mahesh P, Citro B. “Ending tuberculosis will take lower drug prices and a new,improved innovation ecosystem [Opinion].” STAT News. 2018 September 13.
https://www.statnews.com/2018/09/13/ending-tuberculosis-lower-drug-prices-innovation/.
51. Unitaid. Unitaid discussion paper: An economic paper on delinking the cost of RD
from the price of medicines. Geneva: World Health Organization; 2016.
https://unitaid.eu/assets/Delinkage_Economic_Perspective_Feb2016.pdf.
52. Delinkage.org. Savings [Internet]. 17 September 2018. https://delinkage.org/savings/.
53. Treatment Action Group and Child & Adolescent TB Working Group. Research
priorities for paediatric tuberculosis. New York: Treatment Action Group; 2018.
http://www.treatmentactiongroup.org/content/research-priorities-pediatric-tuberculosis.

41

Appendix 1: Methodology
TAG tracks global funding for TB R&D by surveying public, private, philanthropic, and multilateral organizations with known or potential investments in TB research. The survey asks recipients to report the amountof money spent on TB R&D in a given year and categorize spending into six research areas: basic science,
diagnostics, drugs, vaccines, operational research, and infrastructure/unspecified projects. Survey recipients
may report spending by individual projects or aggregate expenditures by research area. Within these categories, the survey asks recipients to indicate any funding that supported pediatric TB research. TAG surveyed
180 organizations for this year’s report and received 120 surveys in return. From these, we identified 131
institutions funding TB research in 2017. Eleven organizations that returned surveys reported spending nomoney on TB R&D in 2016, and four groups declined to participate.
The survey asks organizations to report TB research expenditures in local currencies, which TAG converts
into U.S. dollars using the July 1, 2017, interbank exchange rates published by the OANDA Corporation.
All dollar figures in the report are published as U.S. dollars unless otherwise noted and are rounded to
the nearest dollar (all calculations, however, are performed on unrounded data). Dollar figures represent
disbursements (i.e., the actual transfer of funds made in 2017) rather than commitments or budgetary allocations for future years. Our survey is designed to capture direct expenditures on TB research and so does
not necessarily reflect indirect funding through salaries, overhead, or infrastructure that is not TB specific(although some donors may report these costs to TAG).
TAG carefully reviews each returned survey for completeness, taking careful measures to avoid double-counting awards reported by more than one funder. Double counting can arise under several scenarios, including
the fact that many organizations fund some projects while receiving outside money for others. To help minimize the risk of double counting, the survey asks recipients to note whether spending represents one of three
categories: funding given to others, funding received from others, or self-funded research. Any awards listed by more than one survey enter our database as reported by the original-source donor. For collaborative
projects supported by more than one organization, we ask funders to report only their share of the project,
not total costs.
In addition to surveying funding institutions, TAG conducted 13 qualitative interviews with leading TB scientists, policymakers, and activists and asked each to reflect on the current state of TB research in relation toavailable versus required funding. TAG invited interviewees to express their hopes—or reservations—for theoutcomes of the UN High-Level Meeting on TB with respect to TB research. Each interviewee received anembargoed copy of preliminary survey findings in early September 2018 with a list of open-ended questions.
We interviewed 11 individuals over the phone, and two submitted answers in writing. Each phone interview
was recorded and transcribed verbatim. We pulled quotations from the transcripts and written responses,
grouped them into common themes, and selected the excerpts that appear within and alongside the text of
this report. In some places, TAG edited quotations for length or clarity. TAG checked quotations drawn fromphone interviews with speakers prior to publication.

RESEARCH AREAS TRACKED BY TAG:
1. Basic science: undirected, investigator-initiated research to discover fundamental knowledge about
MTB and closely related mycobacterial organisms.
2. Diagnostics: preclinical and clinical trials of diagnostic technologies and algorithms.
3. Drugs: preclinical and clinical research on treatments and treatment strategies for MTB infection and
TB disease.
4. Vaccines: preclinical and clinical research on TB vaccines, including both preventive and immunotherapeutic vaccines.
5. Operational research: evaluations of new or existing TB control strategies and tools to guide theirimplementation in program settings. Operational research may include randomized trials, surveillance,and epidemiological and observational studies.
6. Infrastructure/unspecified projects: TB research that the funder is unable to further classify.

42Limitations to the Data
The comprehensiveness of the data in this report depends on the proportion of institutions funding
TB research that participate in the survey. This proportion cannot be calculated since the true number
of TB research funders worldwide is unknown. TAG makes a considerable effort to ensure a wide survey reach and yield. The survey is available in six languages (English, French, Spanish, Russian, Chinese,and Portuguese). TAG routinely updates the survey frame by adding new organizations, most of which
do not have known investments in TB R&D but either support health research generally or have a recordof investing in related diseases. Finally, TAG makes a particular effort to encourage the continued participation of the 30 largest funders from the previous year. The high degree of concentration of TB researchfunding means that the top 30 donors typically comprise over 90 percent of total spending, and the composition of this group has remained remarkably stable over time. This year, 29 of the top 30 funders
from 2016 participated in the survey (Eli Lilly did not return a survey despite repeated requests by TAG).

PEDIATRIC TB RESEARCH RESOURCE TRACKING METHODOLOGY
TAG’s survey asks all funders to delineate support for pediatric research and assign any relevant
spending to one of the six core research areas tracked by the report. TAG further identifies research
related to pediatric TB by conducting a keyword search of titles and abstracts contained in returned
surveys using the following search terms: pediatric, paediatric, infant, child, kid, adolescent, andpregnant. While this methodology provides a reasonable estimate of pediatric TB research spending,it overlooks research that  informs the development of pediatric products without enrolling children
or studying MTB infection or TB disease in children directly. Some funders have notified TAG thatthey cannot disaggregate pediatric research funding from their overall expenditure on TB R&D.
Otsuka, for example, did not report how much of the nearly $22.8 million it spent on TB drug
development in 2017 went to pediatric studies of delamanid. Funders supporting clinical trials,
cohort studies, and epidemiological surveys that include people of all age groups can rarely specify
the proportion of funds devoted to younger age groups. TAG encourages all funders to develop waysof disaggregating pediatric TB research spending from within larger funding totals to support moreaccurate estimation here.

In addition to Eli Lilly, several other funders with known investments in TB research did not returnsurveys this year, including the Howard Hughes Medical Institute, the French National Institute of Health andMedical Research (INSERM), Expertise France, Merck, QuantuMDx, Qiagen, Hain Lifescience, the New
Zealand Health Research Council, and the U.K. National Institute for Health Research. TAG received no
information from entities in Russia and China, despite attempts to coordinate reporting with the Ministry of
Health of the Russian Federation and the Permanent Mission of the People’s Republic of China to the United
Nations. Understanding the funding landscape and trends over time is the first step toward securing stronger
political commitments to TB research. TAG is hopeful that the governments of China and Russia will reporttheir TB research funding as part of their involvement in the BRICS TB Research Network.
TAG encourages donors not included here to participate in future report rounds. Please contact TAG
at tbrdtracking@treatmentactiongroup.org if you have information or corrections to share. Any corrections
submitted to TAG will enter print in next year’s report.
This report would not be possible without considerable time and effort on the part of the dozens of funding
officers and administrative staff who complete the survey each year. TAG is grateful to the 120 organizations
across the world that participated in this year’s survey. Appendix 2 acknowledges organizations that havereported to TAG every year since 2005 with a dagger (†) appearing next to their names.

43Appendix 2
TB R&D Funders by Rank, 2017
2017
RANK

FUNDING ORGANIZATIONFUNDER
TYPE

TOTAL

1

U.S. National Institutes of Health, National Institute of Allergy and Infectious Diseases (NIAID)†P$206,577,963

2Bill & Melinda Gates Foundation†F$127,953,459

3U.S. National Institutes of Health, Other Institutes and Centers (NIH Other ICs)†

P$41,475,012

4

U.S. Agency for International Development (USAID)†

P$33,989,472

5UnitaidM$28,556,016

6Otsuka Pharmaceuticals†C$22,773,887

7

U.K. Department for International Development (DFID)†

P$20,642,634

8

Company X†

C$20,550,920

9European Commission†P$19,275,723

10

U.S. Centers for Disease Control and Prevention (CDC)†

P$18,256,200

11European and Developing Countries Clinical Trials Partnership (EDCTP)†

P$17,708,271

12

German Federal Ministry of Education and Research (BMBF)P$16,883,110

13

Indian Council of Medical Research (ICMR)

P$14,487,377

14Company VC$13,604,436

15

U.K. Medical Research Council (U.K. MRC)†

P$13,483,589

16

Global Affairs CanadaP$13,093,570

17

Wellcome Trust†F$8,876,850

18

GlaxoSmithKline (GSK)C$8,675,541

19

Korean Ministry of Health and WelfareP$7,996,008

20

U.S. Department of Defense Medical Research and Development Program (DMRDP)

P$6,062,135

21

Dutch Ministry of Foreign Affairs (formerly listed as DGIS)†P$5,558,751

22

Australian Department of Foreign Affairs and Trade (DFAT)

P$5,354,232

23

Korean Ministry of Science, ICT and Future PlanningP$5,279,528

24

South African Medical Research Council (SAMRC)

P$5,053,092

25

Canadian Institutes of Health Research (CIHR)†

P$4,975,348

26

Japan Agency for Medical Research and Development (AMED)P$4,616,992

27

Company YC$4,550,000

28Australian National Health and Medical Research Council (NHMRC)

P$4,030,606

29

Swiss National Science Foundation (SNSF)

P$3,538,362

30

U.S. National Science Foundation (NSF)P$3,381,548

31

LegoChem Biosciences*C$3,000,000

32

Global Health Innovative Technology Fund (GHIT)

M$2,885,827

33

Swedish Research Council

P$2,644,386

C = Corporation/Private Sector; F = Foundation/Philanthropy; M = Multilateral; P = Public-Sector Agency* New Funder; † Organization has reported to TAG each year since 2005
‡ PEPFAR’s total reported here includes funding for operational research sponsored by PEPFAR headquarters and non-routine projects that country programs have designatedas surveillance, research, and evaluation, but it does not include operational research done as a part of routine programming and therefore likely significantly underestimates
PEPFAR’s support for TB research.
44

BASIC SCIENCEDIAGNOSTICSDRUGSVACCINESOPERATIONALRESEARCHINFRASTRUCTURE/
UNSPECIFIED$82,846,672$17,410,414$60,792,339$22,644,809$12,264,084$10,619,645$1,018,473$10,753,483$62,592,423$37,326,666$16,165,681$96,733$17,538,793$4,481,143$4,930,426$426,417$8,356,118$5,742,115$0$0$19,250,000$0$7,363,976$7,375,496$0$3,585,000$21,971,016$0$3,000,000

$0

$0

$0

$22,773,887

$0

$0

$0

$0

$3,959,018$10,401,360$1,040,136$5,242,120

$0

$0

$0

$20,550,920

$0

$0

$0

$2,940,086$1,805,289$3,298,128$7,480,058$3,079,102$673,060$0$5,135,297$7, 3 99,574$0$5,721,329$0$0$3,748,979$9,934,061$3,794,913$230,317$0$3,182,141$3,163,256$5,933,768$4,256,601$347,344$0$179,677$1,620,653$267,500$0$204,120$12,215,427$0$0$13,604,436

$0

$0

$0

$2,588,633$1,954,934$5,303,483$552,296$2,774,478$309,766

$0

$0

$0

$0

$13,093,570$0$6,092,268$179,903$2,055,519$385,885$163,275

$0

$0

$0

$0

$8,675,541$0$0$426,666$4,212,800$1,437,069$1,483,800$306,790$128,883$0$606,368$3,320,851$2,134,915

$0

$0

$0

$0

$3,495,346$0$2,063,405$0$0$2,561,833$2,561,834$0$230,565$0$805,840$1,200,333$1,952,764$735,591$0$585,000$1,475,643$309,448$1,702,863$26,796$1,469,942$68,401$1,790,029$190,458$600,036$732,263$1,593,420$69,143$1,141,760$251,544$624,400$2,313,848$285,440$0$0$4,550,000

$0

$0

$0

$0

$2,670,008$1,167,233$0$0$193,365$0$3,254,864$0$283,498

$0

$0

$0

$2,602,993$778,555

$0

$0

$0

$0

$0

$0

$3,000,000

$0

$0

$0

$0

$0

$1,978,314$0$907,513$0$1,924,179$183,334$454,077$0$82,796$0

The Global Fund to Fights AIDS, Tuberculosis and Malaria (Global Fund) informed TAG that it can only report its cumulative expenditure on TB operational research between 2002 and 2017,
which totaled $166.7 million. The Global Fund is exploring ways to estimate its annual spending on TB operational research moving forward.
Organizations that reported no new spending on TB research in 2017: Canada Foundation for Innovation; Danish International Development Agency (DANIDA); Netherlands Organization for
Health Research and Development (ZonMw); Nigeria Centre for Disease Control; and the Wellington Medical Research Foundation. The following organizations declined to participate: Tampere
Tuberculosis Foundation; Singapore Ministry of Health; Singapore National Medical Research Council; and the U.S. Army Military Infectious Diseases Research Program (MIDRP).
45

Appendix 2
TB R&D Funders by Rank, 2017 (continued)
2017
RANK

FUNDING ORGANIZATIONFUNDER
TYPE

TOTAL

34

Molbio Diagnostics*

C$2,468,800

35

Novartis Pharma AGC$2,400,000

36

Norwegian Agency for Development Cooperation (NORAD)

P$2,299,287

37

Dutch National Postcode LotteryP$2,273,117

38

Qurient

C$2,175,00039

Marsden FundP

$2,055,977

40

Institut PasteurF$2,036,863

41

Max Planck Institute for Infection BiologyP$2,018,000

42South African Department of Science and Technology

P$1,926,557

43Brazilian Development BankP

$1,814,040

44

Public Health EnglandP$1,771,092

45

Swiss Federal Institute of Technology in Lausanne (EPFL)

P$1,754,323

46

U.S. President's Emergency Plan for AIDS Relief (PEPFAR)‡P$1,594,335

47

Company N*C$1,500,000

48

Indonesian philanthropic donors to TB AllianceF$1,500,000

49

Indian Council of Scientific and Industrial Research (CSIR)P$1,425,732

50

SequellaC$1,356,000

51

Taiwan Centers for Disease Control

P$1,233,230

52

U.S. Department of Veterans Affairs*

P$1,179,524

53

Irish AidP

$1,142,270

54

National Institutes of Health—University of the Philippines Manila*P$1,128,864

55

Singapore Ministry of Health, National Medical Research Council

P$1,049,705

56

U.S. Food and Drug Administration (FDA)†

P$1,017,990

57

Korean Ministry of SMEs and Startups

P$1,015,500

58

World Health OrganizationM$997,004

59

French National Agency for AIDS Research (ANRS)

P$958,927

60

Irish Health Research BoardP$956,274

61

Norwegian Ministry of Education and ResearchP$875,20062

National Research Foundation of South Africa

P$778,791

63

Singapore Agency for Science, Technology and Research (A*STAR)P$671,513

64

Médecins Sans Frontières (MSF)

F$670,631

65

Indian Ministry of Science and Technology

P$664,565

66

South African Technology Innovation Agency*

P$617,134

C = Corporation/Private Sector; F = Foundation/Philanthropy; M = Multilateral; P = Public-Sector Agency* New Funder; † Organization has reported to TAG each year since 2005

46

BASIC SCIENCEDIAGNOSTICSDRUGSVACCINESOPERATIONALRESEARCHINFRASTRUCTURE/
UNSPECIFIED$0$1,851,600$617,200

$0

$0

$0

$0

$0

$2,400,000

$0

$0

$0

$692,053$346,006$0$494,764$594,560$171,904$0$0$2,273,117

$0

$0

$0

$0

$0

$2,175,000

$0

$0

$0

$2,055,977

$0

$0

$0

$0

$0

$2,036,863

$0

$0

$0

$0

$0

$1,211,000$0$0$807,000$0$0$1,440,709$276,434$209,414

$0

$0

$0

$0

$0

$0

$1,814,040$0$0$67,349$0$588,197$1,115,546$0$0$1,044,240$0$710,083

$0

$0

$0

$0

$0

$381,205$0$1,213,130

$0

$0

$0

$1,500,000

$0

$0

$0

$0

$0

$1,500,000

$0

$0

$0

$38,575$0$1,387,157

$0

$0

$0

$0

$0

$1,356,000

$0

$0

$0

$1,037,594$195,636

$0

$0

$0

$0

$500,000$0$679,524

$0

$0

$0

$0

$0

$1,142,270

$0

$0

$0

$207,399$577,710$334,966$0$8,789$0$0$0$1,049,705

$0

$0

$0

$0

$0

$1,017,990

$0

$0

$0

$0

$1,015,500

$0

$0

$0

$0

$0

$0

$0

$0

$997,004$0$0$83,478$875,448

$0

$0

$0

$0

$0

$271,157$685,118$0$0$451,781$0$423,418

$0

$0

$0

$760,417

$0

$0

$0

$0

$18,374$217,788$0$453,725

$0

$0

$0

$0

$24,745$57,114$0$588,773$0$525,364$15,121$25,559$15,430$83,091$0$0$458,647

$0

$0

$0

$158,487

47

Appendix 2
TB R&D Funders by Rank, 2017 (continued)
2017
RANK

FUNDING ORGANIZATIONFUNDER
TYPE

TOTAL

67

Japan BCG LaboratoryC$572,475

68

Japan International Cooperation Agency (JICA)

P$503,819

69

Company RC$472,041

70

Natural Sciences and Engineering Research Council of Canada*P$466,362

71

Korean Ministry of Education

P$464,812

72

GenedriveC$457,660

73

Thailand National Science and Technology Development Agency

P$389,609

74

Brazilian Ministry of HealthP$302,34075

Carlos III Health InstituteP$275,287

76

Thailand Health Systems Research InstituteP$257,811

77

Thailand Ministry of Public HealthP$254,727

78

Thrasher Research FundF

$237,296

79

Industry donors to TBVI

C

$228,45480

Japanese Ministry of Health, Labour and WelfareP$219,639

81

CRDF Global

F$212,314

82

Norwegian Ministry of Health and Care Services

P$204,787

83

Corporate donors to TB AllianceC$200,646

84

Australian Research Council

P$194,068

85

Korean Ministry of Agriculture, Food and Rural AffairsP$187,00086

Danish Council for Independent ResearchP$176,652

87

ELMA Foundation

F$175,000

88

Indian Ministry of Health and Family Welfare (MOHFW)P$173,204

89

BiofabriC$170,292

90

Else Kröner Fresenius FoundationF$156,000

91

Colombia Administrative Department of Science, Technology and Innovation

P$133,000

92

Hong Kong Health and Medical Research FundP

$127,300

93

U.K. Biotechnology and Biological Sciences Research Council

P$110,514

94

Korean Ministry of Trade, Industry and EnergyP$110,00095

Howard Hughes Medical InstituteF$100,000

96

Research Institute of Tuberculosis/Japan Anti-Tuberculosis Association

P$99,862

97

Korea Foundation For International HealthcareF$93,78698

Singapore National University Health System

P$92,994

99

Damien Foundation Belgium

F$91,181

C = Corporation/Private Sector; F = Foundation/Philanthropy; M = Multilateral; P = Public-Sector Agency* New Funder; † Organization has reported to TAG each year since 2005

48

BASIC SCIENCEDIAGNOSTICSDRUGSVACCINESOPERATIONALRESEARCHINFRASTRUCTURE/
UNSPECIFIED$125,871$0$0$446,604

$0

$0

$0

$503,819

$0

$0

$0

$0

$0

$0

$472,041

$0

$0

$0

$388,956$37,740$25,032$0$14,634$0$254,487$51,035$79,022$80,268

$0

$0

$0

$457,660

$0

$0

$0

$0

$344,833$44,776

$0

$0

$0

$0

$0

$0

$0

$302,340

$0

$0

$0

$275,287

$0

$0

$0

$0

$0

$0

$0

$0

$257,811$0$151,645$103,082

$0

$0

$0

$0

$0

$150,868$0$0$86,428

$0

$0

$0

$0

$228,454$0$0$2,676$0$0$0$31,514$185,449$76,963$120,994$0$0$14,356$0$204,787

$0

$0

$0

$0

$0

$0

$0

$200,646

$0

$0

$0

$194,068

$0

$0

$0

$0

$0

$0

$0

$187,000

$0

$0

$0

$0

$0

$0

$176,652

$0

$0

$0

$0

$0

$0

$175,000

$0

$0

$0

$63,980$0$56,715$52,509$170,292

$0

$0

$0

$0

$0

$156,000

$0

$0

$0

$0

$0

$33,000

$0

$0

$0

$100,000$0$75,637$51,663

$0

$0

$0

$0

$0

$0

$0

$110,514

$0

$0

$0

$110,000

$0

$0

$0

$0

$100,000

$0

$0

$0

$0

$0

$0

$0

$0

$0

$0

$99,862

$0

$0

$0

$0

$93,786$0$92,994

$0

$0

$0

$0

$0

$0

$91,181

$0

$0

$0

$0

49

Appendix 2
TB R&D Funders by Rank, 2017 (continued)
2017
RANK

FUNDING ORGANIZATIONFUNDER
TYPE

TOTAL

100

Foundation Jacqueline Beytout

F$86,672

101

Japan Society for the Promotion of ScienceP$67,828

102

Colombia National Institute of HealthP$61,000

103

Taiwan Ministry of Science and Technology

P$60,000

104

U.K. Department for Environment, Food and Rural AffairsP$51,682

105

Korean Institute of TuberculosisP$47,850106

LHL InternationalP$45,383

107

Brazilian Ministry of Science, Technology, Innovation and Communication

P$45,351

108

Korea Materials & Analysis CorporationC$43,500

109

World Bank

M

$43,275

110

Boditech Med Co.

C$39,150

111

Indian Biotechnology Industry Research Assistance Council

P$38,575

112

Grand Challenges CanadaP$37,856

113

LG Life SciencesC$34,800

114

Indian Science and Engineering Research BoardP$34,486

115

Taiwan Ministry of Health and WelfareP$30,000

116

Sidaction

F$28,253

117

South African National Health Laboratory Service Research TrustP$26,796

118

German Leprosy and Tuberculosis Relief Association (DAHW)*

F$22,642

119

CepheidC$20,000

120

Translational Health Science and Technology InstituteP$18,516

121

Individuals donors to TB AllianceF$18,113122

AFI Corporation

C$17,840123

Huons Medicare Co.

C$13,050

124

Argentina National Administration of Laboratories and Health Institutes (ANLIS)*P$10,885

125

Stop TB Partnership (UNOPS)

M$7,000126

Nesta (U.K. National Endowment for Science, Technology and the Arts)*

P$6,459127

FUJIFILM Wako Pure Chemical Corporation

C$4,817128

Medical & Biological Laboratories Co.

C$4,460129

Nigerian Institute of Medical Research*P$3,612130

Faber DaeuferC$3,000131

Astellas Pharma

C

$892

Total

$772,001,759

C = Corporation/Private Sector; F = Foundation/Philanthropy; M = Multilateral; P = Public-Sector Agency* New Funder; † Organization has reported to TAG each year since 2005

50

BASIC SCIENCEDIAGNOSTICSDRUGSVACCINESOPERATIONALRESEARCHINFRASTRUCTURE/
UNSPECIFIED$0$0$86,672

$0

$0

$0

$25,163

$0

$0

$0

$42,664$0$31,000$0$7,000$0$23,000$0$60,000

$0

$0

$0

$0

$0

$0

$0

$0

$51,682$0$0$47,850

$0

$0

$0

$0

$0

$0

$0

$0

$0

$26,282$19,100

$0

$0

$0

$0

$45,351$0$0$43,500

$0

$0

$0

$0

$0

$0

$0

$0

$43,275$0$0$39,150

$0

$0

$0

$0

$0

$38,575

$0

$0

$0

$0

$0

$37,856

$0

$0

$0

$0

$0

$34,800

$0

$0

$0

$0

$34,486

$0

$0

$0

$0

$0

$30,000

$0

$0

$0

$0

$0

$28,253

$0

$0

$0

$0

$0

$26,796

$0

$0

$0

$0

$0

$0

$0

$0

$0

$22,642$0$0$20,000

$0

$0

$0

$0

$15,430$0$3,086

$0

$0

$0

$0

$0

$18,113

$0

$0

$0

$0

$17,840

$0

$0

$0

$0

$0

$13,050

$0

$0

$0

$0

$2,419$3,628$0$0$4,838$0$0$0$7,000

$0

$0

$0

$0

$0

$0

$0

$6,459$0$0$4,817

$0

$0

$0

$0

$0

$4,460

$0

$0

$0

$0

$0

$0

$0

$0

$3,612$0$0$0$3,000

$0

$0

$0

$0

$0

$892

$0

$0

$0

$147,439,441$80,909,934$315,051,622$100,338,945$89,672,465$38,589,352

51

Appendix 3
TB Experts Interviewed by TAG
1Tenu Avafia	Team leader, Human Rights, Law, and Treatment Access, HIV, Health, and Development Group, UNDP

2

Irene Ayakaka

3

Grania Brigden	Deputy director, TB and HIV Department, The International Union Against TB andLung Disease4

Jennifer Cohn

Senior director of innovation, Elizabeth Glaser Pediatric AIDS Foundation

5

Paul Farmer

Co-founder, Partners in Health

6Mark Feinberg

President and CEO, International AIDS Vaccine Initiative

7

Helen Fletcher	Professor of immunology, TB Centre at the London School of Hygiene and Tropical
Medicine

8

Afrânio Kritski

Founding president, Brazilian TB Research Network

9

Sharonann Lynch

HIV and TB policy advisor, Médecins Sans Frontières Access Campaign

10

Albert Makone

Global health advocate

11

Welile Sikhondze

Technical advisor and research coordinator, eSwatini National TB Control Program

12

Kathryn Snow

Doctoral candidate, University of Melbourne

13

Kitty van Weezenbeek

Executive director, KNCV Tuberculosis Foundation

14

Mitchell Warren

Executive director, AVAC

Senior research associate, Makerere University Lung Institute

52

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