Analysis BMJ Glob Health: first published as 10.1136/bmjgh-2018-001047 on 4 March 2019. Downloaded from Investing in health R&D: where we are, what limits us, and how to make progress in Africa Victoria Simpkin,1 Evelyn Namubiru-Mwaura,2 Lorcan Clarke, 1 Elias Mossialos1,3 To cite: Simpkin V, ABSTRACT Summary box Namubiru-Mwaura E, Clarke L, Global research and development (R&D) pipelines for et al. Investing in health R&D: diseases that disproportionately affect African countries ► Health science research, funding and research ca- where we are, what limits us, appear to be inadequate, with governments struggling and how to make progress pacity are insufficient to address Africa’s current to prioritise investment in R&D. This article provides in Africa. BMJ Glob Health unmet health needs, and there are ambitious coun- insights into the sources of investment in health science 2019;4:e001047. doi:10.1136/ try-set targets and frameworks for progress still to research, available research capacity and level of bmjgh-2018-001047 be met over the coming decade. research output in Africa. The African region comprises ► There are substantial disparities in within-continent 15% of the world’s population, yet only accounted for Handling editor Seye Abimbola research and development (R&D) investment; esti- 1.1% of global investments in R&D in 2016. There were mates from 2016 indicated South Africa, Egypt and ► Additional material is substantial disparities within the continent, with Egypt, Nigeria contributed almost two-thirds of the total do- published online only. To view Nigeria and South Africa contributing 65.7% of the total please visit the journal online mestic spending on R&D in Africa. R&D spending. In most countries of the Organisation for (http:// dx. doi. org/ 10. 1136/ ► Measures of R&D outputs and capacity suggest bmjgh- 2018- 001047). Economic Co-operation and Development, the largest both inter-regional and intraregional disparity based source of R&D funding is the private sector. R&D in Africa on investments, university rankings, number of re- is mainly funded by the public sector, with significant searchers, number of publications, patent holdings, Received 7 July 2018 proportions of financing in many countries coming from clinical trial networks and pharmaceutical manufac- Revised 31 December 2018 international funding. Challenges that limit private sector turing capacity. Accepted 4 January 2019 investment include unstable political environments, poor ► Disparities in R&D capacity within Africa suggest governance and corruption. Evidence suggests various the likely value of support for collaborative sci- research output and research capacity limitations in Africa ence, technology and innovation networks between when considering a global context. Metrics that reflect African nations, with any new partnerships harness- this include university rankings, number of researchers, ing the substantial momentum of R&D initiatives that http://gh.bmj.com/ number of publications, clinical trials networks and already exist. pharmaceutical manufacturing capacity. Within the ► Development of clear and context-relevant financing continent there are substantial regional disparities. strategies and mechanisms can foster further public, Incentivising investment is crucial to foster current and private and international investment in R&D across future research output and research capacity. This paper the region. outlines some of the many commendable initiatives on September 25, 2021 by guest. Protected copyright. under way. Innovative and collaborative financing mechanisms can stimulate further investment. Given the vast inequalities across Africa in R&D, strategies need to and supporting capacities for health science reflect the different capacities of countries to address this research across Africa. © Author(s) (or their disparity. Many African countries have adopted targets employer(s)) 2019. Re-use permitted under CC BY. that reflect aims of improved prosperity and Published by BMJ. achieving middle-income country status in 1Department of Health Policy, the coming decade. Science, technology and 3 London School of Economics innovation are key to these goals. As themes, and Political Science, London, INTRODUCTION they are central pillars to the African Union’s UK 2 Africa produces about 2% of world research Science Technology and Innovation Strategy Africa Centre, Stockholm output, yet the region, as defined by the 4–6 Environment Institute, Nairobi, for Africa (STISA 2024) and Agenda 2063. Kenya Unesco, accounts for 15% of the global popu- Infrastructure, financial and knowledge 1 3Institute of Global Health lation and 25% of the global disease burden. resources in African nations present a diverse Innovation, Imperial College Research and development (R&D) pipelines set of challenges to investment in R&D.7 Yet London, London, UK for diseases that disproportionately affect rising gross domestic product (GDP) coupled African countries and address Africa’s unmet with young, and growing, populations and Correspondence to 2 Professor Elias Mossialos; health needs are insufficient. More needs to increasing urbanisation in many countries e. a. mossialos@ lse. ac. uk be done. This includes leveraging investment may continue to drive growth in Africa and Simpkin V, et al. BMJ Glob Health 2019;4:e001047. doi:10.1136/bmjgh-2018-001047 1 BMJ Global Health BMJ Glob Health: first published as 10.1136/bmjgh-2018-001047 on 4 March 2019. Downloaded from 8 capacity for R&D growth. Health science research can Table 1 Levels of gross domestic expenditure in R&D (% play a central role in this. of GDP) This analysis offers an overview of funding and capaci- Expenditure ties for health science research and research capacity in on R&D (% Africa. It highlights challenges, opportunities and recom- of GDP) Countries mendations for progress. Our analysis is informed by a >0.6 Egypt, Kenya, Malawi, Mali, Morocco, South semi-systematic literature review and expert interviews. Africa, Tunisia The literature review examined peer-reviewed and grey 0.4–0.6 Ethiopia, Gabon, Mozambique, Senegal, literature obtained using relevant search terms in online Tanzania, Uganda databases, with additional resources obtained through 0.2–0.4 Botswana, Ghana, Nigeria, Seychelles, Sudan, citations and institutional publication archives. Only Togo, Zambia English-language literature was reviewed, leaving scope 0.1–0.2 Burkina Faso, Burundi, Gambia, Mauritius, for further review of evidence from French-speaking or Namibia Arabic-speaking authors. We undertook semi-structured 0<0.1 Algeria, Cabo Verde, Democratic Republic of the interviews with nine representatives from governmental, Congo, Lesotho, Madagascar non-governmental and academic institutions to enrich No data Angola, Benin, Cameroon, Central African the scope of our research and engage further relevant Republic, Chad, Comoros, Congo, Cote d’Ivoire, literature (online supplementary appendix A for further Djibouti, Equatorial Guinea, Eritrea, Guinea, 9 information). Interviewees were selected using a judge- Guinea-Bissau, Liberia, Libya, Mauritania, Niger, ment sampling approach.10 Rwanda, Sao Tome and Principe, Sierra Leone, Somalia, South Sudan, Swaziland, Zimbabwe Sources: refs13–15. SUPPORT FOR AFRicaN HEALTH SCIENCE RESEARCH GDP, gross domestic product; R&D, research and development. R&D funding across Africa In 2016, Africa accounted for 1.1% (US$22.3 billion) of research capacity require extensive capital resources. global investments in R&D.11 Egypt, Nigeria and South However, rates of return are often unpredictable, and it Africa accounted for 65.7%, or US$14.66 billion, of Afri- is difficult to prioritise spending versus pressing govern- ca’s total R&D spending.11 ment priorities in education, health and infrastructure. In 2007 African Union countries committed to investing In most countries of the Organisation for Economic at least 1% of GDP in R&D. This recognised the impor- Co-operation and Development, the largest source tance of R&D to sustainable development and the need of R&D funding is the private sector. African R&D has to address Africa’s health needs. This goal has remained historically been mainly funded by the public sector, with unrealised. Across sub-Saharan Africa the average share international sources forming a substantial proportion of GDP devoted to R&D activities was only 0.4% in 2015, http://gh.bmj.com/ of expenditures in many countries (see figure 1). For or the most recent available year.12 Countries closer to the instance, foreign sources contributed significantly to 1% target included Egypt, Kenya, Mali, Morocco, South 2015 R&D expenditures in Ghana (31%), Senegal (41%) Africa, and Tunisia while countries including Algeria, and Burkina Faso (60%).15 South Africa has been an Cabo Verde and Lesotho invested less than 0.1% of GDP exception, hosting substantial private sector support.17 in R&D (online supplementary file A).13 R&D intensity Encouraging governments to increase public funding is a sentinel indicator for economic policy. However, on September 25, 2021 by guest. Protected copyright. of R&D and incentivising strong private sector engage- data on R&D investment are extremely limited for many ment in the funding and performance of R&D activities African countries (see table 1).13–15 remain a key regional challenge. Globally, pharmaceutical companies are among the top Sources of funding investors in R&D in the health science sector, but this is The landscape of institutions funding African R&D is not the case in Africa. Few African companies have R&D complex. Sources for domestic R&D include public units or R&D directors to oversee product development sector, private sector and international funding. A and technology transfer.3 country or region’s relative GDP devoted to R&D activi- ties is known as gross expenditure on research and devel- opment (GERD). R&D intensity is conventionally meas- CURRENT caPACITIES ured as the ratio of GERD to GDP. Most of the world’s According to Unesco, Africa had an estimated 198 largest developed economies have overall levels of R&D researchers, in all fields, per million inhabitants in expenditure exceeding 2% of GDP.