Breakthroughs Blog: USAID

The US Agency for International Development (USAID) released a new report on its global health research and development (R&D) programs for fiscal year 2022 that includes unprecedented insight into the product development programs the agency supported—and highlights the need for additional, dedicated resources for global health research.Why it matters: The report gives insight into an agency that is a key sponsor of global health product development.Due to a lack of commercial incentive for industry investment, most global health research is supported by public funders, most notably the US government.Several US agencies support global health research, but USAID is the only agency with a mandate to improve global health and development. The agency excels at pushing products through the end of the research pipeline and advancing tools to suit the needs of people in low-resource settings.What’s new: This report includes an unprecedented 13-page appendix detailing USAID’s individual product-level investments. By our count, USAID supported at least 59 products in 2021 covering multiple health areas and product types.By the numbers: In 2021, USAID spent US$165 million in baseline funding and $50 million in COVID-19 supplemental funding on health product development and research to assess the best way to implement new products and practices.Research spending from baseline funds increased slightly over the prior year (+$4 million) — but continued to decline as a proportion of total global health spending. In 2021, proportionate spending on research dropped slightly to 5.1 percent, continuing a years-long pattern. If the trend continues, GHTC estimates that proportionate spending on R&D will drop to 4.2 percent by 2026 unless Congress passes a policy like the Supporting Innovative Global Health Technologies (SIGHT) Fund to direct more dedicated funding to R&D.Our take: GHTC applauds the release of the report and the additional detail provided by USAID. We call policymakers’ attention to the continued need for additional, dedicated resources for global health research at USAID that this report exposes.

On May 16, with negotiations over fiscal year 2023 (FY23) appropriations underway on Capitol Hill, the Global Health Technologies Coalition (GHTC) hosted congressional staff and coalition members for a virtual briefing on the Supporting Innovative Global Health Technologies (SIGHT) Fund—a proposal for a new $250 million appropriations line in the FY23 State, Foreign Operations, and Related Programs bill dedicated to global health research and development (R&D) at the US Agency for International Development (USAID).Emily Conron, senior US policy and advocacy officer for GHTC, kicked things off with a presentation on the basics of the SIGHT Fund and the challenges it is designed to solve. She noted how 15 years ago, USAID spent about 8 percent of its global health funding on innovation, but that while USAID’s global health budget has doubled in that time, spending on innovation has not kept pace, dropping to less than 5 percent as a share of global health investment. She also emphasized that the pace of global health progress in the future will depend on the reversal of these investment trends today, with more resources urgently needed for R&D: “Today's global health tools like antiretrovirals for HIV/AIDS, oral rehydration therapy to save lives from diarrheal diseases, vaccines that have dramatically reduced child mortality globally—these tools are the product of robust R&D investments begun decades ago….We need to invest proactively today to ensure continued progress in global health in the years to come, and establishing the SIGHT Fund with an initial investment of $250 million dollars—which I should note is a level of investment representing less than 3 percent of all current US spending on global health—could really catalyze the development of tools that accelerate progress against emerging and enduring global health challenges. This would save US taxpayer dollars, maximize the impact of our programs, and ultimately improve and save lives around the world.” Rachel Cohen, regional executive director of the Drugs for Neglected Diseases initiative (DNDi), North America, followed with the perspective of a leading global health product development partnership on why the SIGHT Fund could be transformative for global health innovation. She described previous R&D partnerships DNDi has had with USAID, but how budget limitations cut this promising work short—work that a new source of dedicated innovation funding could be tapped to continue. USAID’s disease-focused programs, with their limited funding, “shouldn't have to make these kinds of trade-offs—between critical funding for service delivery and funding for the next generation of lifesaving tools,” Rachel noted. “That's why DNDi is supporting the SIGHT Fund and why we need a mechanism that perhaps could be more crosscutting and catalytic.” She noted how the fund could complement work advanced by other US agencies, ensuring that promising innovations do not languish in the dreaded R&D “valley of death” when early-stage R&D funding often drops off: “One important example of this would be, for example, to take some of the funding that NIH, the National Institute of Allergy and Infectious Diseases, is funding for broad-spectrum antiviral drug discovery,” she shared. “Once those tools are perhaps ready for clinical trials, USAID could fund the development of broad-spectrum and spectrum antivirals for a range of viral pathogens of pandemic potential.” She also noted new R&D areas the fund could support, such as funding “in a more transformative way the R&D needs of infants and young children, ensuring gender-responsive R&D, or addressing the health consequences of the climate crisis.” Another innovator perspective was shared by Dr. Anand Anandkumar, co-founder and chief executive officer of Bugworks Research Inc. Anand shared background on the growing crisis of antimicrobial resistance (AMR), a global threat Bugworks is combatting through the development of novel broad-spectrum antibiotics designed to be affordable and accessible globally. “We all know from the experience of COVID that none of us is safe until everyone is safe—these are global problems requiring global solutions,” he reflected. “This [SIGHT Fund] could actually fill in a lot of key global gaps and make the United States a leader in connecting and finding solutions that are important globally.” He shared a helpful image of a triangle to describe three interconnected gaps in the current global innovation ecosystem he believes the SIGHT Fund could help address. “One axis of the triangle is support funding of clinical development for phase 2 and 3 with an eye on LMICs [low- and middle-income countries],” he said. “There are already fascinating programs like CARB-X that have created a good pipeline to phase 1, fascinating programs like GARDP out of DNDi that are trying to support phase 2 and phase 3, and AMR Action Fund, that are trying to support phase 2 and phase 3—but that valley is a complex valley. It needs more support.”“Number two, USAID, through the SIGHT Fund, can build clinical trial capacities on the ground in LMICs,” he noted. “You have patient population that have multidrug resistance, a very rich patient population—that’s the right place to do clinical trials, to find out how your drugs are going to work on the worst, difficult patients, but they [LMICs] don’t have capacities.” “And third and last point: a fund like SIGHT could actually bring regulators together, take lessons from COVID, and accelerate these highly needed treatments for unmet population,” he concluded. “So one vertex of the triangle is supporting clinical development to plug the phase 2, phase 3 gap, one vertex is creating clinical trial capacities where it matters the most in LMICs, and the third is regulatory harmonization.” The final intervention was made by Dave Milestone, former acting director of the USAID Center for Innovation and Impact, who shared what he experienced leading innovation activities during his tenure at USAID and why that has made him a supporter of the SIGHT Fund proposal today. “We know that there's a need for innovation,” Dave shared. “We're slowing our progress toward the achievement of our health SDGs [Sustainable Development Goals]. If we just go with sort of the status quo today, even if we deploy all the existing solutions that we have, there's a number of studies that say that we would still fall short. We need innovation. We need new local solutions. We need new partners, and we need to start with local problem solvers to make sure that we're identifying those right problems and then engaging the global R&D community to address those needs.” Dave described several successful innovation partnerships from his time at USAID, including Grand Challenges, which crowded in new thinkers and problem solvers to address leading challenges such maternal and child health, Ebola, and Zika. But he noted that many of these partnerships, while very successful, were short term and ad hoc. “USAID funding for R&D and innovation isn't institutionalized. It's not consistent. It's not long term,” he emphasized. “We should think about a more strategic, holistic approach,” which he noted includes, but is not limited to, the level of funding: “It's also about crowding in the right skill sets and mindsets to how we work with innovation…bringing in the sort of people who understand the practice of innovation, who have portfolio management expertise. These are new skill sets and mindsets that should come with the [establishment of the] SIGHT Fund at USAID.” He concluded with a strong call to action: “If our goal is to end the need for foreign aid, then we need to do this. The status quo isn't cutting it, and we need to be prepared to solve tomorrow's problems with tomorrow's solutions—and the SIGHT Fund is an important step in that right direction.”Jamie Bay Nishi, executive director of GHTC, finished the event by leading a question and answer session with the speakers, in which they emphasized the far-reaching impact that $250 million in new annual funding could have, how the fund could improve USAID’s responsiveness during health emergencies like COVID-19, and how it could advance not only discrete global health innovations, but also innovate the practice of R&D, strengthening the capacity of global partners to lead this work. On this last topic, Rachel offered an inspiring closing point: “If COVID has taught us nothing, it's that …this whole concept that ‘trickle-down innovation’ is going to work—I think we have all been disavowed of that myth. By that, I mean [the belief that] all the innovation happening in high-income countries…[will, with enough good will] eventually make their way to low- and middle-income countries.” She emphasized that “the model of the future needs to be—especially for diseases that are highly prevalent in low- and middle-income countries—driven by the incredible innovation capacity that exists in those countries. But that cannot happen if all the money is flowing only to organizations and academic institutions that are based in high-income countries. We just have to break that cycle…[and] make sure that the experts, the scientists, the clinicians, and the policymakers from low- and middle-income countries are helping to set the priorities, to make the decisions, to allocate the resources, and ultimately to drive the innovation agenda of the future.” You can watch the recording of the full session below, and learn more about the SIGHT Fund here. 

Last Friday, President Joe Biden signed into law a $1.5 trillion spending bill that will fund the US government through the remainder of fiscal year 2022 (FY22), which began October 1, 2021, and concludes in September. The outcome followed months of tense negotiations by Congress—which had passed a series of temporary funding measures, known as continuing resolutions, to keep the government funded at FY21 levels since the start of this fiscal year—and last-minute maneuvering to try to pair annual spending with emergency aid for Ukraine and the COVID-19 response domestically and globally.While the bill ultimately included welcome boosts across key agency programs that fund global health and medical research, summarized below, in very disappointing news, emergency funding for COVID-19—including $4.5 billion for the global response—was stripped from the final package at the 11th hour due to disagreements on how to cover costs. This leaves an uncertain path ahead for the Biden administration to execute its COVID-19 plan, as previously appropriated funds for the domestic and global response are nearly depleted—raising the prospect of having to halt ongoing government-sponsored COVID-19 research trials, among other impacts. House Democrats have promised to advance a stand-alone COVID-19 emergency funding package, which could provide an influx of urgently needed funds, but it’s unclear whether such legislation could gain the 60 votes needed in the Senate since Republicans are demanding any new bill be paid for via offsets of unspent funds, a requirement many Democrats are opposed to.Below GHTC takes a detailed look at the spending bill and its impact on accounts that finance global health research and development (R&D) programming.State and Foreign OperationsThe final spending bill included $9.8 billion in funding for Global Health Programs at the State Department and US Agency for International Development (USAID), which represents an increase of $630 million, or 6.9 percent, over FY21 enacted levels. The vast majority—$510 million—of that increase is designated for global health security programming at USAID, a 268 percent increase over FY21 funding. This funding includes a $100 million allocation for the Coalition for Epidemic Preparedness Innovations (CEPI) to support vaccine development for potentially epidemic threats, which is both welcome news and higher than the $50 million pledge for this fiscal year announced by USAID Administrator Samantha Power at the CEPI pledging summit just a few days prior.Beyond global health security, the remainder of the increase—$130 million—was spread across other global health accounts. The tuberculosis and maternal and child health program lines at USAID received the largest increases at $52 million (16.3 percent) and $34.5 billion (4 percent) respectively, while nutrition, malaria, and neglected tropical diseases were each increased by $5 million and vulnerable children was increased by $2.5 million. USAID’s HIV/AIDS and family planning lines received flat funding compared to last fiscal year while the President’s Emergency Plan for AIDS Relief, or PEPFAR, under the State Department, was boosted by $20 million (0.5 percent). No global health-related accounts at USAID or State saw their funding cut. In other important news, in the joint explanatory statement accompanying the bill, Congress included language, for which GHTC advocated, directing USAID to develop and publicly release a new multi-year strategy on health R&D detailing its goals and how it plans to invest across health areas. USAID’s current health R&D strategy runs through 2022, so the fulfillment of this congressional directive will help ensure continuity and that research remains a priority for USAID’s global health programming.While it was positive to see Congress provide a major funding boost for health security programming and some modest increases to other global health accounts, overall, these funding increases fell short of what many advocates had hoped for, and in many cases what the House and Senate bill drafts released in 2021 had proposed. The COVID-19 pandemic has increased both the challenges and costs of operating health and research programs worldwide, so this funding package, even with increases, fails to match the scale of today’s expanding needs.Health and Human ServicesThe spending bill provided much larger, but uneven, increases across Department of Health and Human Services (HHS) subagencies and programs that support global health R&D. The National Institutes of Health (NIH) received $44.96 billion in funding, representing a $2 billion, or 4.7 percent, increase over FY21 levels. This included an increase of $253.1 million, or 4.2 percent, for the National Institute of Allergy and Infectious Diseases and a $2.8 million, or 3.4 percent, increase for the Fogarty International Center, which works to strengthen research capacity in low- and middle-income countries.Meanwhile, the Biomedical Advanced Research and Development Authority (BARDA)—an agency that supports development of medical countermeasures against health threats and a central player in COVID-19 R&D through then Operation Warp Speed—received a significant funding boost from Congress. It was appropriated $745 million in funding, a $148 million, or 24.9 percent, increase over the prior fiscal year. This funding envelope supports the agency’s entire research portfolio, which covers chemical, nuclear, radiological, and biological threats—both man-made and naturally occurring—so it is at the agency’s discretion to determine what of this funding it ultimately spends on R&D for naturally occurring health threats, including emerging infectious diseases, pandemic influenza, and antimicrobial resistance. Congress included in the bill’s accompanying joint explanatory statement language requested by GHTC expressing support for BARDA to expand its work on naturally occurring threats and provide more detailed reporting on such spending.The Centers for Disease Control and Prevention (CDC), which is a smaller but still important player in supporting global health R&D, received overall funding of $8.5 billion, a $582.4 million, or 7.4 percent, increase from the prior year. Within that, the Center for Global Health received a $54 million, or 9.1 percent, increase, with 93 percent of that increase designated for the global public health protection line focused on health security and the remainder spread across accounts funding global immunization, HIV/AIDS, tuberculosis, and parasitic diseases and malaria. The National Center for Emerging and Zoonotic Infectious Diseases, which funds select R&D for diagnostics and vaccines against infectious diseases, received a $45 million, or 6.9 percent, increase over FY21 enacted levels. These CDC increases were seen by many advocates as disappointing compared to evident needs. Challenges faced by the agency during the COVID-19 pandemic have underscored the need for a more significant influx of funding for this historically under-resourced agency to modernize its systems and improve staff retention.In addition to providing increases for the three HHS agencies above, Congress appropriated $1 billion for HHS to set up a new Advanced Research Projects Agency for Health, modeled after the Defense Advanced Research Projects Agency, to speed development of medical breakthroughs by funding high-risk, innovative projects. This funding was far lower than the $6.5 billion requested by the Biden administration and interestingly was designated to HHS to establish the agency under the Office of the HHS Secretary, rather than within NIH as the Biden administration and some congressional leaders had proposed. GHTC has pushed for this proposed agency to focus on poverty-related and neglected diseases, as a key area of market failure by industry; however, it remains unclear what health areas this new agency will initially prioritize as it is stood up.While FY22 was a bit of a mixed bag for global health R&D, with important increases across some programs but other areas falling short, advocates are already gearing up for the budget battle ahead for FY23, with the Biden administration expected to release its FY23 budget proposal soon.