Charity begins at home in global health research funding
Authors: Seye Abimbola, Joel Negin, Alexandra Martiniuk
Journal: The Lancet Global Health (2016)

In the closing chapter of his 2013 book The Great Escape: Health, Wealth and the Origins of Inequality,1Deaton A The great escape: health, wealth, and the origins of inequality. Princeton University Press, Princeton2013Google Scholar Angus Deaton—winner of the 2015 Nobel Prize in Economics—argued against international development aid, stating that government-to-government aid weakens the capacity and willingness of governments in low-income and middle-income countries to govern, raise tax revenue, and respond to their citizens. Deaton encouraged high-income countries to increase funding to develop drugs for diseases that disproportionately affect people in poor countries, and to provide technical (as opposed to financial) support to governments of low-income and middle-income countries. Deaton also gives voice to the argument that aid should be prioritised for those living in disadvantage in high-income countries.2Deaton A Rethinking Robin Hood. Project Syndicate.https://www.project-syndicate.org/commentary/globalization-hurts-poor-in-rich-countries-by-angus-deaton-2016-06Date: June 13, 2016Google Scholar For example, in the USA, where millions of people live on less than $2 a day,3Chandy L Smith C How poor are America's poorest? US$2 a day poverty in a global context. Brookings Institution, Washington, DC2014Google Scholar maternal mortality increased by 26·6% from 2010 to 2014,4MacDorman MF Declercq E Cabral H Morton C Recent increases in the U.S. maternal mortality rate: disentangling trends from measurement issues.Obstet Gynecol. 2016; 128: 447-455Crossref PubMed Scopus (275) Google Scholar and all-cause mortality of middle-aged (especially less educated) white people increased considerably from 1999 to 2013.5Case A Deaton A Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century.Proc Natl Acad Sci USA. 2015; 112: 15078-15083Crossref PubMed Scopus (1452) Google Scholar These important and persuasive arguments can inform how high-income countries prioritise and provide international development aid, and are in line with a long tradition of international development aid critique, from Peter Bauer in the 1970s to William Easterly in the 2000s.6Shleifer A Peter Bauer and the failure of foreign aid.Cato J. 2009; 29: 379-390Google Scholar To determine whether such arguments might have influenced global health research funding, we did a search of the databases of the main national medical and public health research funding agencies of two high-income countries—Australia and Canada. This search was informed by an equity perspective on global health as advocated by Paul Farmer and colleagues,7Farmer P Kim JY Kleinman A Basilico M Reimagining global health: an introduction. University of California Press, Berkeley2013Crossref Google Scholar who define global health as an endeavour to achieve equity in health outcomes globally, whether in settings of poverty or wealth. For Australia, we obtained grants data from the National Health and Medical Research Council and Australian Research Council websites; for Canada, we obtained data from the Social Sciences and Humanities Research Council and the International Development Research Centre websites; the Canadian Institutes of Health Research provided data for selected years (2002–12) on request. Notably, these funding agencies were either created with a specific global health mandate and have global health as a priority or participate in partnerships on health that include a global health component. We examined funded grants to determine which grants were awarded with the potential to enhance global health equity (appendix). We looked for funding in four global health categories: basic sciences, epidemiology, health policy and systems research, and research on disadvantaged populations in high-income countries. From 2002 to 2012, global-health-relevant research received a total of CA$1·38 billion from the Canadian research funding agencies and AU$710 million from the Australian agencies. Of all global health research funds in each country, 21·7% were awarded for basic science research by Canada and 59·2% by Australia. Canada awarded 29·5% and Australia awarded 52·2% of their individual global health research funds for research performed specifically for disadvantaged indigenous, rural, or remote populations in their own countries. The categories of basic science and disadvantaged communities in-country constituted 73·8% of all Canadian and 88·8% of all Australian global health grants. In Australia, 6·4% of global health research funds were on epidemiological research and 4·9% were on health policy and systems research. In Canada, 17·6% of the global health research funds were on epidemiological research and 8·6% were on health policy and systems research. Australian and Canadian research funding flows appear to follow Deaton's recommendations through prioritisation of funding for basic science research and for research aimed at disadvantaged populations in high-income countries. Perhaps the reason for this pattern is to honour the social contract between the governments and citizens of high-income countries, such that governments prioritise research to address health inequities within their own country and also to support basic research and development efforts within academia. But are these priorities sufficiently well coordinated and transparent? Although many high-income countries set targets to increase support for global health research,8The LancetThe Bamako call to action: research for health.Lancet. 2008; 372: 1855Summary Full Text Full Text PDF PubMed Scopus (54) Google Scholar whether as a commitment or an aspiration, the public and the scientific community should be aware of what becomes of such targets and how those funds are allocated. Indeed, the past two decades have seen repeated calls for improved coordination of funds for global health research, especially given the paucity of common standards for research classification and methods for priority setting.9Terry RF van der Rijt T Overview of research activities associated with the World Health Organization: results of a survey covering 2006/07.Health Res Policy Syst. 2010; 8: 25Crossref PubMed Scopus (10) Google Scholar, 10Moran M Guzman J Abela-Oversteegen L et al.Neglected disease research and development: is innovation under threat? Policy Cures.http://www.policycures.org/downloads/g-finder_2011.pdfGoogle Scholar An analysis of the databases over time suggests the situation has not improved. Over 11 years of grants searched (figure), the only discernible patterns were that the majority of global health research funds were spent in high-income countries, with much fewer funds awarded to epidemiological and health policy and systems research in low-income and middle-income countries. Funds for global health research increased during the 11-year period, with a peak in 2008–09 coinciding with the global financial crisis. These patterns are in keeping with the increasing trend in funding for global health over the past decade,11Burke MA Matlin SA Monitoring financial flows for health research 2008. Global Forum for Health Research, Geneva2008Google Scholar with only 5·2% of the US$2·6 billion allocated to global health research by foreign public, non-profit, and for-profit funders in 2005 spent on health policy and systems research.12Mills A Bennett S Bloom G González-Block MA Pathmanathan I Strengthening health systems in developing countries: the promise of research on policy and systems. WHO Alliance for Health Policy and Systems Research. Global Forum for Health Research, Geneva2004Google Scholar, 13Pratta B Loffa B Health research systems: promoting health equity or economic competitiveness?.Bull World Health Organ. 2012; 90: 55-62Crossref PubMed Scopus (25) Google Scholar This low percentage either reflects the priority of funders, the fact that epidemiological and health policy and systems research costs less to conduct than do other categories, or that basic science grants are more often awarded to teams within Canada and Australia compared with grants for epidemiology and health policy and systems research, which are more likely to be spent in low-income and middle-income countries. However, the pattern might also reflect unintended skews in funding caused by a lack of effective coordination and prioritisation systems. The pattern of global health research funding might not reflect the pattern of international development aid. In addition, our analysis is limited to Australia and Canada, which provide much less development aid compared with the USA and the UK. Nonetheless, we hope to stimulate analyses on where funds for global health and development are spent, and hope that arguments (like those of Angus Deaton) on aid will take into account where allocated funds are actually spent. Such arguments should also note that support for research to enhance global health equity is not necessarily zero sum. Research on issues in high-income countries might provide insight into similar issues in low-income and middle-income countries, and vice versa. The current era has been described as the "new Gilded Age",14Schrecker T A new gilded age, and what it means for global health: Comment on "Global health governance challenges 2016 – are we ready?".Int J Health Policy Manage. 2016; 5: 1-3Google Scholar similar to the late 19th century when inequality was concentrated within the national boundaries of high-income countries. Debates on how and to what extent high-income countries should provide their development aid need to be informed by the current practices of those countries. This information can help to avoid false dichotomies about where global health funds should be spent and unnecessary resentment among citizens of high-income countries, many of whom already overestimate the level of international development assistance their country provides.15Mollyann B Hamel L Hanna B 2013 Survey of Americans on the US role in global health. The Kaiser Family Foundation, Menlo Park2013Google Scholar, 16Hanson F The Lowy Institute Poll 2011: Australia and the world: public opinion and foreign policy. Lowy Institute for International Policy, Sydney2011Google Scholar We declare no competing interests. We thank Aneuryn Rozea (Northern Sydney Local Health District, Sydney, NSW, Australia) and Olivia Hibbitt (NSW Agency for Clinical Innovation, Sydney NSW, Australia) who contributed to identifying and searching the databases. Download .pdf (.29 MB) Help with pdf files Supplementary appendix