Inequalities in investment in malaria research in sub-Saharan Africa: are they inequities?
Authors: Barbara McPake
Journal: The Lancet Global Health (2017)

In their Article, Michael Head and colleagues1Head MG Goss S Gelister Y et al.Global funding trends for malaria research in sub-Saharan Africa: a systematic analysis.Lancet Glob Health. 2017; (published online June 28.)http://dx.doi.org/10.1016/S2214-109X(17)30245-0Summary Full Text Full Text PDF PubMed Scopus (32) Google Scholar provide a thorough analysis of patterns of malaria research investment in sub-Saharan Africa, which raises new questions about the appropriate distribution of this investment. They report that of 333 research awards meeting their inclusion criteria and totalling US$814·4 million, more than one third is received by three countries: Tanzania (13·2%), Uganda (12·0%), and Kenya (11·4%). Their findings show that some countries with high malaria burden, such as the Central African Republic or Sierra Leone, receive little funding for malaria research or malaria control. The same can be said for countries with high malaria mortality. The authors argue that “investment strategies should consider more equitable research and operational investments across countries to include currently neglected and susceptible populations”.1Head MG Goss S Gelister Y et al.Global funding trends for malaria research in sub-Saharan Africa: a systematic analysis.Lancet Glob Health. 2017; (published online June 28.)http://dx.doi.org/10.1016/S2214-109X(17)30245-0Summary Full Text Full Text PDF PubMed Scopus (32) Google Scholar Their use of the term equitable implies that there is an issue of fairness, not only one of efficacy, to be addressed in the distribution of research funding or a principle that investments in malaria research should be made where they will generate the greatest return. On what might an argument for a fairer distribution of malaria research investment rest? The investments analysed by Head and colleagues1Head MG Goss S Gelister Y et al.Global funding trends for malaria research in sub-Saharan Africa: a systematic analysis.Lancet Glob Health. 2017; (published online June 28.)http://dx.doi.org/10.1016/S2214-109X(17)30245-0Summary Full Text Full Text PDF PubMed Scopus (32) Google Scholar were those made from outside of sub-Saharan Africa, not by African countries themselves, and were a mix of public funds channelled through bilateral and multilateral agencies and funds from philanthropic organisations. As part of the aid economy, consideration of more equitable investments might focus on the fairness of the distribution of economic benefits. Alternatively, it might be considered that the health benefits from malaria research are concentrated in those countries in which research is done, and hence those countries in which research is not done do not gain proportionately in reduced burdens of malaria or hardships resulting from malaria burden. Both arguments have limitations. The economic argument is sensible only at the level of the total aid envelope wherein established and significant inequities exist that, in many cases, are reflected in the inequalities identified by Head and colleagues.1Head MG Goss S Gelister Y et al.Global funding trends for malaria research in sub-Saharan Africa: a systematic analysis.Lancet Glob Health. 2017; (published online June 28.)http://dx.doi.org/10.1016/S2214-109X(17)30245-0Summary Full Text Full Text PDF PubMed Scopus (32) Google Scholar For example, the scarcity of health aid funding in countries affected by conflict and fragility—where needs are greatest—has been identified by other research2Patel P Dahab M Tanabe M et al.Tracking official development assistance for reproductive health in conflict-affected countries: 2002–2011.BJOG. 2016; 123: 1693-1704Crossref PubMed Scopus (12) Google Scholar and is unarguably an equity issue, implying that the populations of those countries have fewer opportunities to escape ill health than those with fewer needs in more stable countries. However, if two countries had an equitable share of total aid (however assessed), but one had more agricultural aid while the other had more industrial aid, no equity concern would exist unless one type of aid offered more or better opportunities for populations than the other. Moreover, the opportunity to specialise in agriculture or industry, or in one industry rather than another, or in malaria research rather than in HIV research should in principle allow for more advanced development of expertise in their respective specialisations in both countries and, where outputs are traded, gains from trade. Outcomes from publicly or philanthropically funded research are not generally traded but instead have global public good characteristics. If research outcomes are purely considered global public goods, an argument for specialisation of a few countries in malaria research makes good sense, and the argument that benefits from malaria research are concentrated where research is done is contradicted. For example, evidence3Picard J Aikins M Alonso PL Armstrong Schellenberg JR Greenwood BM Mills A A malaria control trial using insecticide-treated bed nets and targeted chemoprophylaxis in a rural area of The Gambia, west Africa. 8. Cost-effectiveness of bed net impregnation alone or combined with chemoprophylaxis in preventing mortality and morbidity from malaria in Gambian children.Trans R Soc Trop Med Hyg. 1993; 87: 53-57Summary Full Text PDF PubMed Scopus (46) Google Scholar that insecticide-impregnated bednets provide cost-effective protection against infection might need to be tested in a range of settings to ensure generalisability across variations in climate, altitude, population distributions, and mosquito species. However, that intervention can then be applied widely across Africa to generate benefits in terms of reduced malaria burdens in settings distant from where research has been done. In practice, the extent to which the outcomes of malaria research might be considered public goods depends on the type of research. The development of diagnostics, vaccines, and therapeutics will generally have wide applicability, whereas implementation-focused research, which considers how to apply new products in context, has much narrower applicability. Even implementation research relies on claims to generalisability to a subset of contexts because, even in an ideal world, implementation research cannot be done everywhere, far less in a world in which the total expenditure on malaria research in sub-Saharan African is only about US$50–100 million.1Head MG Goss S Gelister Y et al.Global funding trends for malaria research in sub-Saharan Africa: a systematic analysis.Lancet Glob Health. 2017; (published online June 28.)http://dx.doi.org/10.1016/S2214-109X(17)30245-0Summary Full Text Full Text PDF PubMed Scopus (32) Google Scholar Given the underinvestment in malaria research in sub-Saharan Africa, the importance of ensuring the maximum impact for each research dollar is magnified when addressing the central equity concern of reducing the burden of malaria across the whole of Africa. Malaria, after all, remains a disease of poverty and one whose burden, from a global perspective, is disproportionately borne by African populations.4Cibulskis RE Alonso P Aponte J et al.Malaria: global progress 2000–2015 and future challenges.Infect Dis Poverty. 2016; 5: 61Crossref PubMed Scopus (129) Google Scholar A strategy of development of institutional capacity for malaria research in a few African settings, ensuring excellence through concentration of the activities of global partnerships in these settings and through development of career-long trajectories of funding for individual researchers, is plausibly the right one. Should investment grow towards its target levels (a pattern not discernible in figure 1 of the study by Head and colleagues), a case might exist for expansion of the number of such institutions and settings, but other than as part of an overall evaluation of the equity of aid disbursements, that case would not primarily be premised on equity arguments but on the economies of scale, scope, and specialisation in malaria research. I declare no competing interests. Global funding trends for malaria research in sub-Saharan Africa: a systematic analysisSome countries receive reasonably large investments in malaria-related research (Tanzania, Kenya, Uganda), whereas others receive little or no investments (Sierra Leone, Central African Republic). Research investments are typically highest in countries where funding for malaria control is also high. Investment strategies should consider more equitable research and operational investments across countries to include currently neglected and susceptible populations. Full-Text PDF Open Access