Contain This: The Latest in Global Health Security

Who is funding R&D for emerging infectious diseases? Dr Paul Barnsley, Policy Cures Research

• Indo-Pacific Centre for Health Security: Department of Foreign Affairs and Trade • Season 2 • Episode 25

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Last month at the Global Health Security Conference in Singapore, Policy Cures Research launched their second edition of the Landscape of Emerging Infectious Disease Research and Development funding report, supported by the Australian Government. 

Our guest this week is Dr Paul Barnsley, Senior Analyst at Policy Cures Research, and the lead author of the report, who joins us to talk about its key findings. 

We discuss how R&D funding for Ebola ultimately led to success in creating a stable of products that limits its risk of its pandemic potential. Plus, how the unprecedented R&D response to the Covid-19 pandemic is reshaped the funding landscape for emerging infectious disease R&D into the future. 

Dr Barnsley also speaks about the promising new entrants in EID R&D funding from low to middle income countries, given that they are often the countries that epidemic disease does most harm.  

We hope you join the conversation at @CentreHealthSec and follow Policy Cures Research at @PCuresResearch. 

Please note: We provide transcripts for information purposes only. Anyone accessing our transcripts undertake responsibility for assessing the relevance and accuracy of the content. Before using the material contained in a transcript, the permission of the relevant presenter should be obtained.   

The views presented in this podcast are the views of the host and guests. They do not necessarily represent the views or the official position of the Australian Government.

Dr Klara Henderson 00:05

Hello, and welcome to contain this. I'm Klara Henderson, an advisor from the Indo-Pacific Centre for Health Security. I want to acknowledge the Traditional Owners and Custodians of country throughout Australia and the region. We recognise their continuing connection to land, waters, and community and we pay our respects to Elders past, present and emerging. Last month at the Global Health Security Conference in Singapore, Policy Cures Research launched their second edition of the Landscape of Emerging Infectious Disease Research and Development funding report, supported by the Australian Government. Policy Cures Research produces G-FINDER, widely seen as the gold standard in tracking funding for global health R&D. It's used by the WHO Executive Board and at the World Health Assembly. It serves as a primary source of neglected disease R&D funding data for the WHO Global Observatory on Health R&D, and for donors around the world interested in neglected and emerging disease R&D funding trends. As the lead author of the Emerging Infectious Disease Research and Development funding report, Dr. Paul Barnsley joins us today from his home on his final day of COVID isolation, here to talk about the report's findings. Paul holds a PhD in Economics from the University of Sydney, focusing on subjective well-being. And prior to joining Policy Cures Research, he worked on the evaluation of healthcare interventions. Welcome, Paul. 

Dr Paul Barnsley 01:54

Thanks Klara, it's great to be here. 

Dr Klara Henderson 01:56

Last month, you launched your second report on investment in emerging infectious disease R&D at the Global Health Security Conference in Singapore. What were the biggest stories that emerged from looking at that data? 

Dr Paul Barnsley 02:09

So, I think one of the biggest areas of interest for us was the progress against Ebola. We began gathering emerging infectious disease R&D data in 2014, in response to the first West African Ebola outbreak, and we've followed with interest the progress of that funding over time. Typically, what we see with outbreaks is that funding response response to outbreaks with a bit of a lag, and that reflects probably two underlying phenomena. First is sort of level of political interest that when a disease is active, that tends to draw response from funders. And the second part of that is the opportunity to perform clinical development. One of the challenges with emerging infectious disease is that you often only have a limited window to trial the products you've created. And so you need to move very fast during the course of an outbreak in order to attempt to complete your clinical trials, while there are still subjects available to participate. So with Ebola, we saw that initial very fast ramp up in funding after 2014, peaking in 2015, as a lot of product development was happening during the peak of the West African outbreak. And then that began to drop off, as we brought the West African outbreak under control and sort of it hit a bit of a lull in 2017. With the arrival in 2018 of the Democratic Republic of Congo outbreak in North Kivu, funding rebounded. But what happened in 2019, with the new data that we that we were launching was in some ways a surprise. That was the first time that we saw the progress, the funding become decoupled from the progress of the outbreak. Mortality was still increasing in North Kivu, but funding began to drop. And with the benefit of hindsight and looking at product, product registration data, what we were able to see is that the reason funding was dropping even in the face of rising mortality is that that product development work was largely finished. We had successfully created two working vaccines, two working biologics and a working rapid diagnostic test and achieved registration for those products, emergency use authorisation and registration for those products. That enable them to be used in 2019 and 2020 to bring that outbreak in North Kivu under control, and when we saw two follow up outbreaks in 2021 in the same region, those products were able to be used, and instead of seeing fatalities numbering north of 10,000, this was the case in West Africa, north of 2000 as was the case in the first DRC outbreak, each of those subsequent outbreaks in 2021 killed under 10 people. So it was a story, I guess, of product development from the initial global response in 2014, how that had to be put on hold, as the outbreak waned, and then ultimately success, I guess, in creating a stable of products that give us the tools to respond to future outbreaks in a way that really appears to limit the risk of the pandemic potential of Ebola. So that was a really interesting story, and one that lets us tie the story of R&D funding about $2.5 billion of total R&D funding to product registrations and then to ultimately controlling the pathogen. 

Dr Klara Henderson 05:39

Yeah, that's that's a great story. And I can say it brings together the rapid support from donors, which you mentioned, the clinical trials that were executed in a timely manner. And finally, access to products when they were needed. That's that's a great example of a global health response to a need with a innovation. And so what about COVID? We were expecting to see a jump reported in your second edition of the report in terms of COVID investment. Can you give us a sense of the scale of what actually occurred and which donors were behind it? Was it traditional funders? Or did new players step in with financial support for that development? 

Dr Paul Barnsley 06:29

Yeah, so we were expecting based on the pledge data that we gathered in real time in the course of 2020, that the global COVID response would be, like nothing we'd ever seen before, and would dwarf the response to Ebola. And that's definitely what we saw in the data. So that figure I quoted was a bit over $2.5 billion in total for Ebola. And that's over the seven years between 2014 and 2020. What we saw in a single year for COVID, was funding directed to product developers of about $3.9 billion. So that's more than 50% more than the seven year total for Ebola. Or another way of thinking of it is that it's significantly more than the seven year total for every other WHO priority pathogen. So it was a massive response and that's not unexpected. But it's I suppose, shocking to see on paper, how much faster we were able to respond to a genuinely global pandemic. And I suppose one of the questions we raise in a report is, could our initial response to the West African outbreak, had it looked more like the COVID response in scale, have been successful in completing some of that product development during the West African outbreak rather than needing a second round of product development in the DRC outbreak and could we have averted some of that future harm? So the scale was genuinely impressive. And a lot of the names at the top of the list of funders were familiar. The big change was that the biggest global funder of COVID R&D and therefore 2020 EID R&D overall was the US BARDA, rather than the US National Institutes of Health as has had been the case over the previous the preceding six years. 

Dr Klara Henderson 08:18

Can you just tell us who BARDA is for those that may not know. 

Dr Paul Barnsley 08:22

So the top global funder of EID R&D and COVID R&D in 2020 was the US BARDA and that's the Biomedical Advanced Research and Development Authority. They had been a major contributor prior to 2020 and we're responsible for a lot of the product development funding for Ebola and Zika. But in 2020, they displaced the US National Institutes of Health, the NIH, from the top spot. The NIH traditionally is much more focused on basic research, and its contributions through to 2020 were over a much wider range of priority pathogens and focused much more heavily on basic research. So that was a that was one of the big shifts we saw. But beyond that, the list of top funders for COVID looks pretty similar to the existing funders and several of those top funders, [the US, sorry] the UK Department of Health and Social Care, the Norwegian Ministry of Foreign Affairs, the German government, were all delivering their funding primarily via CEPI. So those were organisations that had contributed to EID R&D both bias at the end directly in years gone past and in response to COVID they massively increased their contributions and directed them primarily via CEPI. 

Dr Klara Henderson 09:43

So CEPI's really been part of the solution and has been a broader change in the global pandemic response funding architecture. 

Dr Paul Barnsley 09:55

CEPI had begun to play a really key role in neglect in EID R&D starting in 2018, when they began dispersing funding for their priority pathogens, which is a slightly different list than the list of priority pathogens adopted by the WHO, which we use for our report. But CEPI began to roll out its funding in 2018, and particularly in 2019, that funding hit a peak, and it was really able to transform the funding landscape, and particularly the product development landscape for its priority priority targets. And that's Rift Vallley fever, Nipah Lassa fever and dispersed a lot of funding to pathogens where almost all the funding had previously come from the US NIH, and which had previously been very focused on basic research. So that was the initial impact of CEPI. But the real test that it faced was how it would respond to a genuine global pandemic. And our view is it passed that test quite well. Firstly, with the speed of its response, in the first month of 2020, CEPI was responsible for nearly half of global R&D funding for COVID-19. So CEPI was well positioned to act as a first responder in the vaccine R&D space, and it took advantage of that opportunity to provide early seed funding that I think made a real difference to our ability to develop the vaccines in record time. The other thing that it served to do though, was act as a coordinator for the global R&D response that it was able to serve as a clearinghouse for funders, large funders, like the UK DHSC, like the Norwegian government, but also new funders providing funding for the EID R&D for the first time, organisations that probably wouldn't be equipped to back a portfolio of vaccine candidates without CEPI's assistance. They worked very well in that role and we think represented a really important part alongside the US BARDA of the global response to, to COVID-19. The other thing I guess we saw with COVID-19 funding and sort of hardening trend, while the top names are relatively familiar, for people who are familiar with the funder funders of EID R&D, there were a lot of new entrants, and those entrants skewed disproportionately towards low and middle income country funders, which is something we're very excited to see. And a lot of organisations that have never provided any funding for EID R&D before. So 130 different organisations, according to our data provided funding for COVID R&D. And that's more than twice as many as provided funding for Ebola over that full seven-year period that we track. So we're excited to see that influx of new funders, we were excited to see the role that CEPI was, was able to play in coordinating them. And we're excited to see a an increasing skew towards funding from the low and middle income countries where epidemic disease does a lot of its harm. So those were all positive trends, I think in the global funding response alongside just the sheer size of it. 

Dr Klara Henderson 12:58

Yeah, absolutely. And I think it's encouraging to hear about those, those positive elements that have come out of the response to the pandemic, the swiftness of the response, the clinical skill brought in to develop those innovations, and the diversity and breadth of support for R&D and scientific innovations. One thing I think your your team has a luxury of being able to see and understand is a bit about the R&D funding opportunities, and where those those health gaps are or those R&D tools are missing. So we've got a couple of categories that we think about these tools. One is the neglected tropical disease, and that's the one series of reports that Policy Cures Research produces, and then there's the emerging infectious diseases, which does include disease X. And just wondering if if you have any comments on how, how those two are interacting in terms of donor support and, and trends in relation to prioritisation for support to R&D, the neglected tropical diseases, vis a vis emerging infectious diseases. 

Dr Paul Barnsley 14:27

Our primary focus has always been on neglected disease, and this is our 15th year of gathering data on neglected disease R&D funding, so we're well positioned to to follow the long term trends in neglected disease funding. And overall those trends have been positive. We've seen a big rise in R&D funding for neglected disease over the last few years peaking in 2018. In 2019, funding was almost exactly unchanged. And then in 2020, in the first year of the pandemic, we saw only a really small fall in neglected disease R&D funding, a drop of about 4% from a very, very high level, historically speaking. And that was a big relief to us, we'd been really concerned that even though the Ebola pandemic didn't appear to distract from funding for neglected disease, obviously, the scale of the COVID response was going to be much larger. And we were worried that neglected disease funding would fall by the wayside a little a little bit. In the first year at least, we didn't see that. And as I say, that was a big relief to us. We remain concerned that this amount of money this $3.9 billion in COVID funding is going to have to come from somewhere. And we're hoping it doesn't come in future at the expense of R&D for neglected disease, which remains extremely important and addresses a really wide range of unmet needs in low and middle income countries. So we conducted some analysis to try to determine the scale of that risk, I guess that the extent to which neglected disease funding is exposed to a shift in emphasis. We looked at changes from individual funders and whether big funding for COVID was a predictor of reduced funding for neglected disease R&D overall. We found a statistically significant effect in a very small one that every million dollars that an organisation committed to COVID predicted a $30,000 drop in their R&D funding. So that's not the direction we'd hoped for, but the size of that effect is pleasingly small. But the other thing we asked is, what about overall fiscal shifts, I guess, that when governments have to tighten the purse strings in response to COVID, or in response to anything else, is that likely to leave vital neglected disease R&D funding vulnerable? And our answer there was it was a qualified yes, we did find a statistical relationship in the past between when governments cut their overall funding and the amount they provide for neglected disease. So our concern is that neglected disease is vulnerable to a sort of fiscal tightening that might emerge in a post-COVID world or a post-COVID recession. We remain nervous about that. And I guess we encourage funders not to lose their focus on neglected disease, in favour of sort of pivoting to the next big thing. 

Dr Klara Henderson 17:17

In case of your reporting, it's a bit of a watch and wait and see what what data emerges in the coming 12 months, and you're able to report on. 

Dr Paul Barnsley 17:29

That's right. And we have... we've just completed gathering the data for 2021. And we're in the process of painstakingly cleaning that and cross checking it and checking what's recipients have reported and what donors have reported, with a view to publishing that towards the end of this year. So we'll see what the second year of the pandemic held for neglected disease R&D relatively soon. And hopefully it continues that fairly comforting message of funding remaining higher near historical peaks. That's fingers crossed, too early to say. 

Dr Klara Henderson 18:03

That that actually brings up another question for me, which is about to do these clinical trials, which which take sometimes years to execute. We know that the developers need multi-year financial support. Is that data showing that that trend is continuing in your reports? Or do you see that there is a bit of in and out in terms of donor commitments over time? 

Dr Paul Barnsley 18:41

I think that's a really important question and a really important lens through which to look at the data. But it's one that in some ways we are poorly placed to analyse. Our view is that cash speaks much louder than words and so we focus exclusively on dispersed funding. But often underlying those annual disbursements, which can fluctuate a bit from year to year is an agreement between the parties for a multi-year commitment and an understanding that that funding is going to fluctuate. So we are obviously laser focused on big fluctuations in funding. And I spent a lot of my year looking at spreadsheets and looking at what's changed and trying to figure out why whether it's a change in approach from a funder, or whether it's an error in the data that we need to fix. But often when we look at those changes, and find even a really big swing in the data that we wonder if there's an explanation for, we'll reach out to a funder and say, 'look, you've cut your neglected disease funding by 70% this year, are you are you still committed to a neglected disease R&D?' And the funder will reply 'yes', and there's not really much we can do with that. So because we are an organisation that relies on our relationships with funders to obtain this gold standard data, we're not necessarily best placed to analyse the motivation behind changes. When we have a very long data series like we do for neglected disease, we can start to pick up genuine strategic pivots in the data that an organisation appears to be changing its whole approach away from, for instance, HIV and towards platform technologies. But individual year to year fluctuations, it's difficult for us to say whether that's a funder being inconstant in its support, or whether that reflects an understanding and an agreement between donor and recipient. So that's something we'd like to do more of. And I agree, it's a really important question to understand whether the fluctuations are actually harming product development, or whether they are, for example, as in EID, the result of limitations in clinical development, or perhaps simply hitting a hard problem. So we saw an enormous amount of funding flow into Zika, in response to the South American outbreak, but as it emerges, Zika is just a really hard clinical development problem. The single biggest thing you're worried about is congenital Zika syndrome, which affects unborn children. But it's nearly impossible to design a trial to determine whether your products are effective at preventing congenital Zika syndrome. So sometimes funders pivot because an outbreak is brought under control. Sometimes funders pivot because an approach doesn't seem to be bearing fruit. And those can be rational responses. So we don't want to point at fluctuations and try and name and shame. But we would like to understand instances where there is a genuine failure of continuity, I guess, a boom and bust cycle of research the way we probably saw for MERS and SARS prior to COVID, for example, what we did see early peaks in those and then funding dwindling to almost nothing in 2019. And with the benefit of hindsight, that doesn't look like an optimal allocation of funds. Sorry, that was a long answer to an important question. 

Dr Klara Henderson 21:59

No, no, that that was great. And actually provided some useful information on my my penultimate question, which was about how you engage with decision makers and donors on their investment strategies, do you, do you find there's interest and call for from them for slicing and dicing the data in different regards to enable them to make more informed decisions about future strategies? 

Dr Paul Barnsley 22:35

Yeah, so I think it's important for us to always be aware of that R&D funding data which we have, and a map of unmet needs, which we have, and a map of the burden of illness, which we have, are still only part of the picture, when trying to decide how best to invest your 10s of millions of dollars in global health R&D. And something like the landscape of the EID report that we've just published, I hope represents a really useful starting point for thinking about where to target your investments. But it's certainly not the last word that the part of the picture we're not seeing are those opportunities for research. And if someone comes to you with an idea to solve the hard problem of of showing benefit in reducing congenital Zika syndrome, that's obviously a very different situation from looking at the data and saying Zika vaccine funding seems a bit low, let's throw a little bit of money at that. So I think our data is the beginning of that analysis. But it's not the basis on which you should allocate your 10s of millions of dollars alone. We would like to get better at providing the rest of that service to donors, I guess we would like to see money optimally allocated. And the first thing we try to do is be diffident about how much of the picture we're able to provide. We try to not harm our relationship with the people who are providing us the data, if the data goes away, then we're no longer able to provide any kind of useful service. So we try to remain very polite, I guess, in our commentary on where funding should be going and very aware of the limits of what what part of the picture we're able to see. But yeah, look, we would like to be able to say, here is the right place to put your money here is an unmet need here is a valuable research strategy going unfunded. At the moment, I suppose all we can say is that it's wise to adopt a portfolio strategy that particularly with regard to EID, we're not always very good at figuring out where the next threat will come from. And something I think about a lot is the at the beginning of the pandemic in 2020, we as an organisation, with our deep knowledge of previous Coronavirus outbreaks, were a lot more relaxed about the possibility of a global pandemic, a global COVID pandemic than, for example, the National Basketball Association who do a lot less Coronavirus research than us. And that kind of reminds me of the importance of not overrating your knowledge, I guess that we don't know what the next threat will look like. And it's very hard to predict future threats on the basis of past performance. So on that basis, you we'd recommend a portfolio strategy for spread your bets, try to cover things that other people aren't. And to the extent the scale of your financing doesn't permit that spreading, then find an intermediate organisation or an organisation like CEPI for vaccines, or FIND for diagnostics that is itself large enough to adopt a portfolio strategy. But placing a big bet on a single interpretation of the likely outcome is, it's very unlikely to be the best use of your money. 

Dr Klara Henderson 25:57

Perhaps just the final note would be to provide some guidance to listeners on how they can themselves more deeply analyse and engage with the data, that Policy Cures Research produces. 

Dr Paul Barnsley 26:11

I've spent a lot of the podcast describing bar graphs, and they look a lot better on paper, they're a lot easier to follow. So I do encourage listeners with any interest in the area to look at the report. And now almost as ridiculous as describing bar graphs in this day and age is reading out URLs. But that's what I'm going to do. So all our reports are hosted on our webpage, which is www.policycuresresearch.org and they're on our analysis page. So forward slash analysis - all our reports are hosted there. There's the summary of EID funding. There's also a new report on funding for platform technologies. And there are our G-FINDER reports on funding for neglected disease. Or if you want to play with the data yourself, and you're interested in a particular disease area or a particular group of funders, all our data is freely available for manipulation and filtering at our data portal, and that's located at gfinderdata - that's one word dot policycuresresearch.org. So I encourage you to go and take a look at the portal and have a play around yourself. It's a interesting data set and one stretching back over a long period of time. So it is possible to kind of get a sense of the trends that we've seen. 

Dr Klara Henderson 27:32

And I have indeed done that myself and it does go back a fair few years, which is great. Thanks, Paul. We'll pop all of those links in our show notes on the podcast. You've been listening to Dr. Paul Barnsley from Policy Cures Research. Contain This is produced by the Indo-Pacific Centre for Health Security. You can follow us on Twitter and Facebook at centrehealthsec. And please join us for our next episode where we'll bring you another highlight from the Global Health Security conference held in Singapore last month.