In 2023, tuberculosis was again the top infectious disease killer on the planet, having temporarily been overtaken by COVID-19. Even so, investment in TB research is far below what United Nations agencies estimate is needed. Catherine Tomlinson unpacks a new report on global TB research funding, zooming in on the situation in South Africa.
The World Health Organization estimates that 1.25 million people around the world died of tuberculosis (TB) in 2023. This meant that, after a few years of COVID-19, TB is again the world's top infectious disease killer.
Yet, despite the seriousness of TB being widely acknowledged - the United Nations (UN) have had two high-level meetings on it in the last decade - funding allocated to TB research remains significantly short of the levels UN agencies estimate is needed.
In 2023, UN member states agreed to collectively increase TB research spending to $5 billion annually by 2027.
New York-based advocacy organisation Treatment Action Group (TAG) and the UN-hosted Stop TB Partnership have urged countries to contribute their "fair share" to this global goal. To meet their fair share target, they say countries must allocate 0.15% of their gross expenditure on R&D (GERD) to TB research. TAG says that these targets are linked to countries' actual research budgets to promote shared responsibility and fairness in the global TB response, while also linking national spending targets to countries' ability to pay.
TAG and the Stop TB Partnership released their annual report on tuberculosis research spending. The report examines how much was spent on TB research in 2023, as well as what entities and countries contributed funds.
How SA is doing
South Africa's fair share target for 2023 was R56 million. TAG used GERD data from the Organisation for Economic Co-operation and Development (OECD) to calculate the target. South Africa out spent this target with an investment of R72.7 million in 2023 - up from R69 million in 2022. It was one of only two countries to meet its fair share target for TB research financing in 2023 - the other was India.
Attainment of the fair share target reflects a prioritisation of TB research within government's research budget. But it is also, in part, a consequence of South Africa's low investment in research. Although South Africa pledged to increase research spending to 1.5% of its Gross Domestic Product (GDP), it remains below 1%.
Small in absolute terms
While South Africa was one of only two countries to meet its fair share target in 2023, the country's contributions made up only 0.3% of total global TB research spending.
The total global spend on TB research in 2023 was $1.2 billion. While, according to TAG, this was more than was spent in any previous year - it remains far below the $5 billion global target.
South Africa was ranked 15th in terms of total spending by country. The United States, which spent $476 million - or over R8.7 billion - on TB research in 2023, gave much more to TB research than any other country, but fell short of its fair share target.
The report does not specify how much foreign money is invested in TB research in South Africa. The country is an important site for TB research given the country's disease burden, strong clinical trials infrastructure, and the expertise of local scientists and researchers. Research units and universities conducting TB research in South Africa commonly receive funding from other countries and philanthropic donors. These investments likely also add up to tens of millions of rands per year.
What South African entities gave to TB research in 2023?
TAG and the Stop TB Partnership delve into South Africa's TB research spending in a special section in this year's report. They note that six South African public entities reported on their 2023 spending: the Department of Science and Innovation (DSI), the South African Medical Research Council (SAMRC), the National Research Foundation (NRF), the Council of Scientific and Industrial Research (CSIR), the Technology Innovation Agency (TIA), and the National Health Laboratory Services (NHLS).
The SA MRC allocated R34 million across 38 grants. The largest grant given by the SA MRC for TB research in 2023 was a R5.8 million grant to support the Regional Prospective Observational Research on Tuberculosis (RePORT III). This initiative supports basic science and biomarker research to advance the development of TB diagnostics, drugs and vaccines. The second largest was a R4.58 million grant to support preclinical development of two mRNA vaccine candidates.
The DSI spent R33 million across 68 grants. These grants, which were disbursed by the SA MRC and the SA NRF, supported a wide range of efforts, including basic science research, drug and diagnostic development, and operational and epidemiological research. The DSI also supported research on blood-based, point-of-care diagnostics at the CSIR.
#InTheSpotlight | Over the last decade, it has become clear that South Africa's progress against #TB depends on diagnosing more people more quickly. In this Spotlight special briefing, @marcuslowx asks how we can best go about it.https://t.co/Q7UicKtBGZ pic.twitter.com/zmlYpVNrrm
-- Spotlight (@SpotlightNSP) November 19, 2024
The third largest South African funder of TB research in 2023 was the North-West University (NWU). NWU reported spending R4.5 million from strategic funds of the NWU to support pre-clinical trials of a locally developed TB vaccine candidate. The pre-clinical trials were conducted jointly by NWU and Walter Sisulu University.
Another South African entity that funded TB research in 2023 was The Innovation Hub - a subsidiary of the Gauteng Growth and Development Agency. The Innovation Hub awarded local company AI Diagnostics R300 000 for its efforts to develop AI-powered, low cost, point-of-care TB diagnostic technology. AI Diagnostics also reported private investments of R3.95 million to advance the development of its TB diagnostics technology.
The scaling up of TB vaccine trials
A key finding in the new report is that global funding for TB vaccine research is growing, with significant contributions from philanthropic donors. Yet, despite these gains, investments remain far below estimates of what is needed. US$227 million was spent on TB vaccine research in 2023 - far below the $1.25 billion advocated for by the Stop TB Partnership.
For the first time, TAG and the Stop TB Partnership this year delineated vaccine research spending by vaccine candidate. However, they cautioned that while this breakdown offers a useful overview of overall spending, it should not be regarded as a comprehensive review, as some funders did not report their expenditures or provide a detailed breakdown of spending by vaccine candidate.
$64.9 million and $21 million were, respectively, invested to advance R&D of the M72/AS01E and MTBVAC candidate vaccines. The VPM1002, ID93/GLA-SE (QTP101), AEC/BC02 vaccine candidates each received over $1 million for their advancement. Another $13 million was invested in the development of mRNA and DNA vaccines against TB.
Several large funding commitments were made to advance TB vaccine research in 2023, including by the Gates Foundation, Wellcome, Open Philanthropy, and the European Commission's Health Emergency Preparedness and Response Authority.
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South African trial sites have played a central role in much of the research conducted to advance promising TB vaccine candidates to date - a role that will continue as trials are advanced through larger and later stages. Much of the funding for this work comes from international donors.
Maybe most notably, South Africa is one of seven countries participating in the M72/AS01E phase III trial. The first vaccines in the trial were administered at a clinical trial site at the University of the Witwatersrand in Johannesburg in March 2024.
There are several others. The MTBVAC phase III trial in neonates is being conducted in South Africa, Senegal and Madagascar. Four of the six trials sites are in South Africa. The MTBVAC Phase IIa trials of safety and immune response in adults and adolescents are ongoing in South Africa. The MTBVAC phase IIb trial will be conducted in South Africa and other sub-Saharan African countries.
South Africa's prominent role as a hub for TB vaccine clinical trials offers numerous benefits to the country. It ensures that new vaccines are thoroughly evaluated within our population, allowing for an accurate assessment of their effectiveness. This, in turn, provides valuable insights for the potential future rollout of vaccines in the country. Additionally, conducting trials locally helps maintain and strengthen the nation's clinical trial infrastructure, creates opportunities for local researchers, and positions South African TB researchers at the forefront of global advancements.
Disclosure: Tomlinson was involved in the development of the TAG/Stop TB Partnership report on which this analysis article is based.
