Setting Country-specific TB r&d funding targets Treatment action group (TAG) October 2017 Prepared by Safiqa Khimani

Why is setting country-specific targets important? Allow public resource tracking and create accountability for commitments on TB R&D funding to be announced at the Ministerial Conference / UN High Level Meeting on TB Reify the $9 billion goal between 2016 and 2020 Leverage new funding sources based on countries’ capacity to fund Focus on deliverables to catalyze progress

past efforts to set targets (1 of 3) Overall target set with each country determining their own national plan Pros: Cons: Buy in from countries Public declaration Legally binding Need political will to do so No specific funding targets Calculated R&D expenditure for countries based on their incidence rate of TB, the national budget and GDP per capita, and the size of the national treatment program https://ec.europa.eu/clima/policies/international/negotiations/paris_en https://health-policy-systems.biomedcentral.com/track/pdf/10.1186/1478-4505-11-10?site=health-policy-systems.biomedcentral.com Pros: Cons: Incorporates considerations of disease burden Integrates return on investment as an argument to increase funding Requires modelers due to complicated methodology Difficult to explain to policymakers

past efforts to set targets (2 of 3) Request for BRICS countries to triple funding and wealthy donor countries to double existing contributions Pros: Cons: Simple request from activists Intelligible to policymakers Catchy campaign slogan No specific overall goal Does not work well for countries with unknown current TB R&D funding levels Allocates a certain investment by U.S. agencies to contribute to the overall increase in funding while keeping pace with biomedical inflation Pros: Cons: Highly consistent, transparent methodology Targets available for contributing U.S. agencies Only applicable for countries whose TB R&D spending and biomedical research inflation are known Only applicable for countries with adequate current funding levels http://www.tbonline.info/posts/2015/12/3/cough-money-tb-demand-protesters/ http://www.treatmentactiongroup.org/tb/brics http://www.treatmentactiongroup.org/sites/default/files/201606/TBRD%20Policy.pdf

past efforts to set targets (3 of 3) Outlines targets for the G20 countries using each country’s portion of total GDP spent on R&D overall and accounting for past trends in R&D spending Pros: Cons: Can ensure total sums to the already-set target (i.e. $9B in the Global Plan to End TB) Applicable for countries with GERD data even if current TB spending is unknown Accounts for private sector/ philanthropic contributions to overall target by calculating public funding to fill gap left Slightly complicated methodology Difficult to explain to policymakers GERD data not available for every target country Less comprehensive (G20 only) Proposes for consideration targets for government-funded health research of all kinds: developing countries with potential research capacity should aim to commit 0.05−0.1% of GDP; developed countries should aim to commit 0.15−0.2% of GDP http://www.treatmentactiongroup.org/sites/default/files/TAG_G20_TB-Final.pdf Pros: Cons: Clear, simple methodology Target varies on countries' development status WHO Consultative Expert Working Group on R&D carries weight Weak language--"should aim to” Unclear how to translate to TB given low spending in endemic and non-endemic countries alike How to define “potential research capacity”?

GDP versus Annual Average GERD China EU Japan Germany South Korea UK Mexico Indonesia

Methodology (1 of 3) Three criteria for countries chosen: 1. G20 countries 2. WHO-listed high-burden countries 3. Top richest countries* (based on GDP per capita) *Only those classified as independent countries. This excludes any countries that are dependent or are declared territory of another country. With the overlap between the three groups, the total number of countries included is 62 countries. The targets were determined by a calculated percentage of GERD spent on TB specifically. To obtain this percentage, the annual target computed from the target set forth by the Stop TB Partnership ($8.836B) was divided by the sum of average annual GERD for all 62 countries. Sources for GERD data: UNESCO Statistics and World Bank project database Gross Domestic Expenditure on Research and Development (GERD): all expenditure (whether direct R&D activities or in support of R&D initiatives) spent on research and development in a country during a given period of time https://stats.oecd.org/glossary/detail.asp?ID=1162 https://stats.oecd.org/glossary/detail.asp?ID=1441 http://www.who.int/tb/publications/global_report/high_tb_burdencountrylists2016-2020.pdf http://ec.europa.eu/eurostat/statistics-explained/index.php/R_%26_D_expenditure

Methodology (2 of 3) Some countries' GERD data were not available on the UNESCO Statistics site The EU GERD data was calculated based on data presented on the Eurostat R&D expenditure site, which stated GERD for 2015, a 4.4% increase from the previous year (2014), and expenditure that was equivalent to that of the US for 2013. Annual GERD for these countries was created using a composite comparator based on an average of GERD for the countries with UNESCO GERD data in the same income status bracket and on the same continent as the country with missing data, then pro-rated for GDP Papua New Guinea was missing GERD data but there were no other countries of the same income status in Oceania, so we used a composite comparator of countries of the same income status in Asia.

Methodology (3 of 3) Legend: Bold = HBC Top GDP per capita Country with missing GERD data Income Status Continent GDP of country with missing GERD data (2015) Overall GERD spending pro-rated for GDP Angola Lower middle Income Africa 102,962,245,247 1,528,506,910 Bangladesh Lower middle income Asia 195,078,561,219 2,708,292,814 Brunei Darassalam High income 12,930,394,938 Central African Republic Low income 1,583,776,760 13,708,362 Congo 8,553,154,506 126,974,268 DR Congo 36,188,521,107 313,229,345 DPR Korea 16,120,000,000 120,183,628 Hong Kong SAR, China 309,403,880,389 10,054,441,207 Liberia Upper middle income 2,034,000,000 28,307,785 Myanmar 62,600,906,116 869,093,883 Nigeria 481,066,152,870 7,141,578,324 Papua New Guinea 16,928,680,397 235,022,358 Sierra Leone 4,251,779,857 36,801,234 Zambia 21,154,394,546 314,043,640 Zimbabwe 16,072,380,200 139,114,309

results

Annual TB R&D Funding Targets Legend: Bold = HBC Italics = G20 Top GDP per capita Countries would need to allocate 0.0982% of their spending on R&D to TB specifically in order to reach the $8.836B global target for 2015-2020. Country Annual TB R&D target (rounded, USD) Angola 1,500,000 Argentina 4,800,000 Australia 21,200,000 Austria 11,300,000 Bangladesh 2,700,000 Belgium 10,900,000 Brazil 35,000,000 Brunei Darussalam 12,700,000 Cambodia 100,000 Canada 25,300,000 Central African Republic 13,000 China 305,600,000 Congo Denmark 7,500,000 DR Congo 300,000 DPR Korea Ethiopia 500,000 European Union 202,400,000 Finland 7,300,000 France 55,400,000 Germany 99,700,000 Country Annual TB R&D target (rounded, USD) Hong Kong SAR, China 9,900,000 Iceland 300,000 India 46,500,000 Indonesia 2,100,000 Ireland 3,300,000 Israel 10,700,000 Italy 27,500,000 Japan 154,900,000 Kenya 800,000 Lesotho 2,000 Liberia 28,000 Luxembourg 675,000 Mexico 10,300,000 Mozambique 100,000 Myanmar 900,000 Namibia Netherlands 15,100,000 New Zealand 1,800,000 Nigeria 7,000,000 Norway 5,300,000 Country Annual TB R&D target (rounded, USD) Pakistan 2,400,000 Papua New Guinea 200,000 Philippines 700,000 Qatar 1,300,000 Russia 36,500,000 Saudi Arabia 11,900,000 Sierra Leone 36,000 Singapore 8,400,000 South Africa 4,600,000 South Korea 64,000,000 Sweden 13,700,000 Switzerland 13,400,000 Tanzania 500,000 Thailand 4,900,000 Turkey 12,500,000 U.A.E. 4,000,000 United Kingdom 40,400,000 United States 444,500,000 Vietnam Zambia 300,000 Zimbabwe 100,000

TB R&D Funding Gap by country Of countries that report TB R&D spending data, most must dramatically increase investments to meet targets. A higher rank indicates a country’s current spending is closer to meeting targets. Country Rank Reported public TB R&D spending* (2016; USD) Annual TB R&D target (USD) Funding gap Australia 7 $9,489,424 $21,200,000 $11,710,576 Brazil 18 $1,584,088 $35,000,000 $33,415,912 Canada 5 $16,898,180 $25,300,000 $8,401,820 China 24 $2,885,011 $305,600,000 $302,714,989 Denmark 25 $56,730 $7,500,000 $7,443,270 European Union 17 $23,575,253 $202,400,000 $178,824,747 France 22 $1,689,104 $55,400,000 $53,710,896 Germany 14 $14,820,938 $99,700,000 $84,879,062 Hong Kong SAR, China 23 $127,554 $9,900,000 $9,772,446 India 12 $14,768,283 $46,500,000 $31,731,717 Ireland 11 $1,110,380 $3,300,000 $2,189,620 Japan 21 $4,990,224 $154,900,000 $149,909,776 Mexico 19 $419,778 $10,300,000 $9,880,222 Netherlands 6 $9,858,859 $15,100,000 $5,241,141 New Zealand 10 $679,649 $1,800,000 $1,120,351 Norway 2 $5,503,497 $5,300,000 -- Philippines 9 $302,178 $700,000 $397,822 Singapore 15 $1,026,214 $8,400,000 $7,373,786 South Africa 1 $6,465,746 $4,600,000 South Korea 13 $12,359,135 $64,000,000 $51,640,865 Sweden 16 $1,606,583 $13,700,000 $12,093,417 Switzerland 8 $5,938,196 $13,400,000 $7,461,804 Thailand 20 $173,846 $4,900,000 $4,726,154 United Kingdom 4 $27,575,390 $40,400,000 $12,824,610 United States 3 $316,471,566 $444,500,000 $128,028,434 *Confidence is lower in the reported public spending for the following countries, since data were not reported for all institutions that may fund research: Brazil, China, Denmark, France, Hong Kong, Mexico, Singapore, Sweden, Thailand

Limitations Not all countries had GERD data available for all years between 2010 and 2015 Use of comparators for countries with missing GERD data may under- or over-estimate a country’s capacity to spend on GERD, and the percentage which countries should be allocating towards TB R&D Basing TB R&D targets on overall GERD spending lets countries underspending on research generally “get away easier” The $8.836 billion target sets a ceiling on the total for country-specific funding targets, which may under- or over-estimate a country’s capacity to spend (e.g. U.K. comes in low) Not all countries included (focus on G20, HBC, and wealthy countries) Targets do not take into account disease burden or spending on healthcare For determining TB R&D funding gap, not all countries report funding data and not all institutions are represented for countries that do report