Smart Decisions launch event notes

By Impact Global Health 5 February 2025

10 min read

Neglected DiseasesG-FINDERNews

Funding landscape

Global funding for neglected disease R&D peaked in 2018 and has since then trended gently downwards.

Most of the money continues to go to the big three diseases and to various kinds of multi-disease funding. This category has now increased nine years in a row, and 2023 was the first time it finished higher than one of the 'big three'. A major driver for that is platform technologies.

So what’s changed? The headline is that HIV went down by a lot and TB went up.

TB funding rose and HIV funding fell 2023

The picture changes more if we zoom in on the largest proportional shifts. Here you can see leptospirosis going from just over one million dollars to about two and a half, and funding for trachoma falling all the way down to zero, albeit from less than $200k the year before.

It’s important here to be aware of the longer-term trends in funding for each disease. Three moderately funded diseases: leprosy, snakebite and dengue are all at or close to their record highs in 2023, and in all three cases that growth partly reflects an influx of private sector funding. And the big fall in the pneumonia and meningitis group is the tail end of a long, steep downward trend that’s taken them from over $130m in 2012 to less than $20m today.

Lots of big changes in funding smaller diseases 2023

Now, let’s look at changes in who provided the money. A fall in funding from high income country governments – mostly the US – is almost entirely offset by a big rise in philanthropic – mostly Gates Foundation – funding. That shift took philanthropic funding to its highest level since 2008, and left governments with their lowest-ever share of global funding. We saw a substantial, and heartening rise in LMIC funding – most of it from India – and a relatively small net decline in overall industry funding, that’s being obscured here by a big new SME participant.

So, stability, but definitely not stasis.

Those big changes in Gates Foundation and US government funding are part of a meaningful trend and not just the kind of cyclical shift we see when a government like Japan only funds PDPs every second year.

We now have more pieces of the puzzle than when the G-FINDER survey began in 2008. We now track the pipeline and product approvals, so that we can tie that steep decline in pneumonia and meningitis funding to the launch of new vaccines for each of those diseases. Or the fall in onchocerciasis drug R&D to the approval of moxidectin.

And because we now gather data on disbursements as they occur, and future funding plans as they’re announced, we can situate the big rises in Gates and TB funding in the context of their plan to invest $400m in trials of the M72 TB vaccine.

The decline in pneumonia and meningitis mostly follows the launch of new products. The same is broadly true for diarrhoeal diseases like rotavirus and cholera, and obviously for malaria, which has seen R21 and RTS,S released over this period. We’re heartened to see funders making strategic changes of direction.

The big outlier here is HIV, which has experienced by far the largest decline in vaccine funding without ending up with a working vaccine.

The largest absolute drop was for HIV vaccines 2023

So, one big trend is the gradual move away from vaccine R&D, with the big exception of M72 for TB. The other consistent theme is that industry is starting to move into new areas, especially tropical diseases that have the potential to spread in response to climate change.

The poster child for this trend is dengue R&D. This graph shows the earlier explosion in private sector dengue vaccine funding. But it didn’t result in any great vaccines, which is why, ten years later, we’re seeing sudden growth in industry funding for dengue drug R&D – something that we’ve traditionally believed wasn’t an area that pharma companies would explore on a commercial basis.

As climate scientists predicted, a warmer climate has spread the aedes mosquito – which carries dengue – into places like Eastern China and Japan. That happened in 2024, with several major outbreaks including one in parts of rural Pakistan previously outside its range.

So we can expect to see a big increase in the need for, and probably also the commercial potential of, products targeting diseases like dengue that are set to encounter new populations without any acquired immunity and health systems with no experience in dealing with them. Dengue is the leading edge, but, as the tropics expand, so will the areas exposed to tropical disease.

Our changing climate should help to make neglected disease R&D an easier sell to tropic-adjacent high income countries, in the same way as it boosted the market for dengue.

Locally acquired dengue cases in the US 2023

In this context it is worrying to see the US, which typically leads the way in R&D and which is seeing an uptick in not just dengue, but also malaria, Chagas’ disease, even leprosy, significantly reduce its funding over the last two years.

Funding from the US government is down 2023

The biggest player is obviously the NIH – and that two year dip in their funding is still well within their normal range. But that is less true of the other three organisations shown here, each of which has moved from being a moderately significant contributor to a bit of an afterthought over the last couple of years. Let’s zoom in on them. The CDC seems to have pretty abruptly stopped providing funding – just $280,000 in 2023 – and USAID has gradually fallen by more than half from its peak. A little more complicated is what’s happened with the DOD, which used to spend quite a lot of money on what it calls “bio armour for its warfighters”. Its disease-specific funding, and especially its vaccine programmes have disappeared, leaving it with not much more than snakebite that’s specifically focused on neglected disease.

Funding from the US government is down 2023 wo NIH

We mostly haven’t seen neglected disease budgets cannibalised to fund Covid or other emerging infectious disease R&D, the way we feared we would in 2020. But we have seen a big rise in funding – especially platform R&D – that’s included in our neglected disease figures but which is only really intended to be used to stop epidemics. We’re therefore a little nervous as we see that multi-disease line grow year on year and knowing that, in many cases, it’s not being driven by an actual focus on neglected disease.

Platform funding is increasingly focused on EIDs

Making smart decisions

There is not enough money to do everything that’s worth doing in global health, and choosing expensive late stage trials for a TB vaccine means choosing not to fund something else.

Impact Global Health has been very active in making the case for increased funding for neglected disease: that funding delivers a 400 to 1 return via the societal value of improved health; that it boosts the economies and scientific infrastructure of the nations where the research takes place; that it generates spillover benefits in the form of new technologies or improved regional stability; that R&D is a form of health security, a form of climate adaptation. But if there is no more funding – what do you do?

Know what you’re trying to achieve

Funders need a working model of the product and disease ecosystem they’re going to be launching into. A successful launch for M72 presumably means that there will be substantially less TB around, and that the other tools intended to manage its burden and spread will have correspondingly less value than they did in a pre-M72 world. Or, it could mean that you have a real shot at eliminating TB from certain populations, and all those other products suddenly become more valuable because they might help you finish the job. It’s critically important to know which of those two worlds you’ll be living in – which areas of funding complement what you’re already trying to do, and which ones are substitutes. If M72 comes in at 50% efficacy, then elimination is probably off the table and less TB just means less need for drugs.

Know what’s going on around you

To think about the future in that way, and what it implies for your product portfolio, you need the right data about the future funding and product landscape – that’s our job, at least in part – and you need to know what you’re trying to achieve. It’s not just a matter of trying to maximise the impact of your product portfolio, but the collective impact of product development generally – it takes a village to cure a village. And that means being aware of what others are up to, and accounting for any blind spots in what the other major funders are willing to support – how can you fill those gaps? The obvious example here is the US DOD. They’re explicitly not trying to minimise the burden of neglected disease, they just want to know what kind of bioarmour their warfighters will need to operate asymmetrically in austere environments, and if any of that R&D happens to spill over into meeting LMIC needs, that’s just a happy accident. What assets have the recent DOD cutbacks left sitting on the shelf, for example?

Another example of trying to situate your research portfolio in the context of what others are doing around you is the strange consistency in the share of R&D funding that goes to basic research. What you’d intuitively expect, and what we see with emerging infectious diseases, is for the big lump funding associated with a portfolio of products to gradually make its way through the pipeline, from basic research all the way to post registration studies. But, instead, the share of funding going to basic research has barely budged in 17 years, even as the active pipeline vastly increased in size. Could this reflect the huge role played by the NIH – which has provided 43% of all global R&D funding over that period – and the fact that it sees itself first and foremost as a scientific research organisation? To the extent that this creates a bias toward basic research for its own sake, other funders should consider what potential applications of basic research discoveries are going unfunded.

Spend less on each product, so you can afford to fund more of them

There’s a lot to be learned just from looking at international best practice in getting bang for your buck – we point to the UK’s RECOVERY trial in the report – and by trying to build R&D capacity in low income and therefore lower cost countries. One important factor, which is more within the power of regulators than funders, are the systems for assessing statistical certainty which don’t account for trade-off between cost and risk.

More than half the cost of a new product, once we already know that it’s safe, goes to meeting benchmarks of statistical certainty which were developed a long time ago, for assessing the purity of Guinness. The governments of Ghana and Nigeria took a different approach with the R21 malaria vaccine. Once they were sure it’s safe and effective, they started giving it to people and using real world observational data to confirm if they were right. We could make this decision by treating it like a calculated risk.