As a person living in Switzerland, you are much more likely to suffer from cancer, cardiovascular disease, or diabetes as opposed to diseases like malaria, tuberculosis, or HIV. The good news for you: the expected course of the diseases you may get in Switzerland is much better. There are many types of medication on the market that can cure patients that suffer from these diseases, or that help patients live longer with them after diagnosis. The reason why you can get good treatments is not only because you are living in a high-income country where there is better infrastructure, better health conditions, and more money invested in the health system. It is also due to the unequal way in which resources in research are distributed globally.
The concept of disease burden is often used as an estimate of how resources should be distributed to counteract diseases. The burden of disease for society generally entails how often it occurs on the population level, if it can be treated, how severe the disease’s symptoms are, and how likely it is to cause death. Resources that are allocated to these diseases include biomedical research, which enables the development of better methods to diagnose, treat, and prevent them. Generally, more biomedical research funding and overall attention are given to diseases that pose a high burden on society. However, a major bias and unequal distribution exist in the focus and funding of biomedical research when we look at it from a global perspective.
Resources are allocated unequally
As illustrated earlier, depending on the wealth status of a nation, different diseases affect their populations to different degrees. Various infectious and parasitic diseases are for example known as ‘diseases of poverty’. Those diseases in low- and middle-income countries have a much higher burden compared to those in high-income countries (1,2). One explanation for this is, that the burden of disease can for example be estimated by the number of healthy years of life that are lost. Cancers and cardiovascular diseases affect mostly older people, whereas infectious diseases affect people of all ages, including infants and children. Therefore, mortality due to infectious diseases takes away many more healthy years of life.
But this doesn’t explain the vast gap. The way that research and distribution of funding and medication are conducted reinforces inequality in itself. The imbalance between global disease burdens and research attention is a concept that is well documented and was even brought up already 20 years ago. In the nineties, it was estimated by the Global Forum for Health Research that only about 10 percent of the global biomedical research budget is allocated to diseases accounting for about 90 percent of the world’s health problems (3). The relevance of this statement persists until today, although transparency of research funding allocation is limited.
How disparities in global health arise
The output of biomedical research such as the number of scientific articles published is a more accessible indicator of research focus. It is estimated that there are ten times more publications on diseases that are more prominent in rich countries. However, low- to middle-income countries make up approximately 85% of the global population, and 90% of the global disease burden (1).
Yet, 80% of research efforts are produced by high-income countries (1). Moreover, research funding and institutions that perform biomedical research on an academic level are largely based in high-income countries. The top three largest funding organizations are the United States National Institutes of Health ($26.1 billion), followed by the European Commission ($3.7 billion), and the United Kingdom Medical Research Council ($1.3 billion) (4). In fact, low- to middle-income countries produce only 0.6% of the world’s research publications. This shifts research priorities towards national or continental health needs, rather than global health needs.
On the level of the private sector, pharmaceutical companies invest heavily in biomedical research on diseases that can be then bought by high-income countries. For example, the market and profits for selling antidiabetic drugs in high-income countries are much higher than antibiotics in low-income countries.
Another contributing factor in the academic sector is prestige and evaluation pressure in terms of publications. Researchers are much more likely to be able to publish a study that covers high-income countries’ diseases than those in low-income countries in prestigious journals, that are also mainly based in high-income countries. This propels the selection of topics that apply to high-income countries, which ultimately contributes to the career development of researchers.
The Covid-19 pandemic as a prime example
Few diseases pose a major and relatively equal burden on the entire world’s population, which then also translates into extensive investments and resources. One notable example of such a disease is the Covid-19 pandemic, which rapidly spread across the globe in 2020. The pandemic led to a major spike in research efforts and funding for this disease, estimated to have hit $4.4 billion in investments in 2022 (5). The Ebola epidemic in West Africa which captivated the world in 2014, had the potential to become a pandemic and has an even higher disease burden and mortality rate than Covid-19. Despite this, resources in response to this outbreak were more limited and led to investments of up to little more than $1 billion until 2015 (6). The fact that this epidemic did not spread beyond Africa likely contributed to this reduced prioritization of resources.
Another example of unfair distribution of resources in the case of Covid-19 is the access to vaccines. Many low-income countries faced major difficulties in obtaining the highly sought-after vaccines that were developed in the pharmaceutical sector, which has a major profit interest. An important cause of limited vaccine access was the formation of production monopolies by the companies who own the intellectual property rights to the vaccine patents and therefore do not allow other companies to produce the same formulations in other locations (7). This increased pricing and decreased vaccine access at the same time. Namely, many low-income countries could not pay the prices of vaccines that were already negotiated by high-income countries or moved them into debt (7). In addition, excessive pre-purchasing by high-income countries vastly limited access to vaccines in low-income countries.
Overall, this bias in attention, funding allocation, and resources, in general, undermines the needs of people affected by diseases in developing nations. It ultimately perpetuates the cycle of global health inequity where public health in low- to middle-income countries is falling behind.
Bridging the gap globally
The Covid-19 pandemic has taught us the important lesson that universal collaboration is a very powerful approach. All nations shared the goal of reducing the number of transmissions, which reduced the risk of aberrant virus mutations arising. The rapid development of the Covid-19 vaccine was made possible due to international collaboration and the sharing of data across countries of all wealth levels. For example, the large clinical trials required for vaccine development were conducted simultaneously across many nations. The WHO's Global Roadmap for Covid-19 Research and Innovation played a crucial role in guiding and accelerating research efforts to combat the global threat of Covid-19.
On the political level, countries adopted policies based on the analyses of case numbers and strategies from other nations. The results of the Covid-19 research benefited all income levels and the development of the vaccine against Covid-19 is estimated to have prevented 18 million deaths in the first year of vaccination (8). Universal collaboration in terms of sharing resources and expertise should be utilized more, as it fosters global solidarity and fairness as well.
In addition to collaboration, active steps should be taken to bridge the gap between funding resources and the global health burden. Funding should be actively redirected towards research that is more relevant to low- and middle-income countries. Governments of high-income countries, and their large funding bodies should allocate budgets for research in these fields specifically. Scientific journals should provide the capacity to publish more biomedical research studies on diseases of poverty, which in turn would create visibility and promote attention and further studies on these diseases. Moreover, it could be mandated that pharmaceutical companies follow human rights guidelines concerning not only access to medicines but also the development of therapies. The UN has already drafted such guidelines that recognize the human rights responsibilities of pharmaceutical companies (9).
In turn, governments of low-income countries should invest and get help in building local research capacity by providing funding, infrastructure, and training to scientists. This would increase the number of local researchers and ultimately reduce the dependence on funding and expertise from high-income countries. Establishing public-private collaborations between pharmaceutical companies, biotech firms, and research institutes of low- and middle-income countries could provide additional funding for research and help to bring new treatments and vaccines to the market.
Solving the unequal distribution of biomedical research resources calls for sustained effort and commitment from all stakeholders. It will require a universal collaborative effort and significant long-term investment. However, addressing these inequalities is crucial in achieving global health equity and improving health outcomes for people around the world.
Coached by: Salome Erni
Expert review by: Bettina Zimmermann
Yegros-Yegros, A, van de Klippe, W, Abad-Garcia, MF, et al. (2020). Exploring why global health needs are unmet by research efforts: the potential influences of geography, industry, and publication incentives. Health Research Policy and Systems, 18, 47. doi: 10.1186/s12961-020-00560-6
Evans, JA, Shim, JM, & Ioannidis, JPA. (2014). Attention to local health burden and the global disparity of health research. PLOS ONE, 9(4), e90147. doi: 10.1371/journal.pone.0090147
Global Forum for Health Research & World Health Organization. (1999). The [Ten-ninety] 10/90 report on health research. World Health Organization. Retrieved from: https://apps.who.int/iris/hand...
Viergever, RF, & Hendriks, TCC. (2016). The 10 largest public and philanthropic funders of health research in the world: what they fund and how they distribute their funds. Health Research Policy and Systems, 14, 12. doi: 10.1186/s12961-015-0074-z
The Global Fund. (2023). COVID-19. Retrieved from https://www.theglobalfund.org/...
Fitchett, JR, Lichtman, A, Soyode, DT, Low, A, Villar de Onis, J, Head, MG, & Atun, R. (2016). Ebola research funding: a systematic analysis, 1997-2015. J Glob Health, 6(2), 020703. doi: 10.7189/jogh.06.020703
Sekalala, S, Forman, L, Hodgson, T, et al. (2021). Decolonising human rights: how intellectual property laws result in unequal access to the COVID-19 vaccine. BMJ Global Health, 6, e006169. doi: 10.1136/bmjgh-2021-006169
Watson, OJ, Barnsley, G, Toor, J, et al. (2022). Global impact of the first year of COVID-19 vaccination: a mathematical modelling study. The Lancet Infectious Diseases, 22(9), 1293–1302. doi: 10.1016/S1473-3099(22)00320-6
UN Special Rapporteur on the right to the highest attainable standard of health. (2008). Human rights guidelines for pharmaceutical companies in relation to access to medicines. Published in the report to the General Assembly of the United Nations. UN document: A/63/263.
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