1This video closes out the chapter with three questions. Who funds global health research? Who sets its agenda? And where does the work get published?

2Billions of dollars are spent on global health priorities every year. From 2010 to 2019, the international community disbursed thirty-five to forty billion dollars a year in development assistance for health. In 2020 that figure jumped to fifty-five billion because of the COVID-19 pandemic, with the United States accounting for one-quarter of the 2020 total — fourteen billion dollars.

3Here is where that money has gone. Each band is a health focus area, shown as a share of the annual total, from 1990 on the left to 2020 on the right. Since the mid two-thousands, most of it has flowed to infectious disease programs — the yellow band along the bottom, which grows from a narrow strip in 1990 to the largest share on the chart. Above it, the bands for reproductive and maternal health and for health sector program support both narrow over the same period.

4That figure is a partial view. Development assistance for health includes funded research, though it covers only part of the research done in low- and middle-income countries — domestic spending on research, for instance, sits outside it. Research on global health issues inside wealthy nations sits outside it as well. Inequities in health exist everywhere, so by definition global health research is a broad domain, which makes it difficult to put a dollar amount on the enterprise as a whole.

5A 2013 analysis put global investment in health research and development above three hundred billion dollars, in 2021 dollars. Most of that comes from private industry. Very little of it is directed to pharmaceutical products and technologies for global health priorities that disproportionately affect poor countries. Less than four billion dollars in 2019. And in that accounting, public and philanthropic funders provided almost ninety percent of the money. The two leading funders were the United States National Institutes of Health, at forty-four percent, and the Bill and Melinda Gates Foundation, at sixteen percent, contributing nearly two-thirds of all research dollars between them. The model for investments in research and development for health is funding from the wealthy, to the wealthy, and, mostly, for the wealthy.

6This funding landscape matters because funders have an outsized role in setting the research agenda. Outside of industry, researchers depend primarily on grants to fund their work. And as nearly all global health research funding comes from governments and philanthropies in high-income countries, the global health research agenda is set in large part by the wealthy.

7The global health research agenda is also, in large part, carried out by the wealthy. Only a fraction of one percent of funding for biomedical research goes directly to recipients in low-income countries. In-country researchers too often only play the role of partner or collaborator, rather than principal investigator, if they are even consulted.

8Let's talk about scientific publishing. Global health research is published in medical journals, in general science journals, in discipline-specific journals, and in disease-specific journals. There are also journals that specialize in global health research itself, and you can see several of them on the right.

9Why does publication matter? Peer-reviewed journals remain the primary way that researchers share findings, build on each other's work, and establish scientific consensus. But there is a catch.

10Most journal articles sit behind paywalls, and subscription fees can run into thousands of dollars per year. For researchers, practitioners, and policymakers in low-resource settings, accessing the very evidence they need can be prohibitively expensive.

11This is more than an inconvenience. It is an equity issue. If global health research is supposed to benefit people worldwide, shouldn't those people be able to read it? The open access movement has grown in response, and many funders now require that research they support be made freely available. We will come back to strategies for finding and accessing research in a later chapter.

12So what is global health research? It is an interdisciplinary endeavor that applies scientific methods to improve health and achieve equity for all people worldwide. It spans basic science and applied research, clinical trials and implementation studies, program evaluations and policy analyses. In this chapter, we have followed the money. The funding landscape matters because it shapes whose questions get asked and whose answers get heard. Most global health research funding flows from wealthy countries, through wealthy institutions, to address problems as the wealthy define them. That has real consequences for the relevance and impact of our work. Which brings us to what comes next. If the enterprise of global health research is shaped by power, then we need to think carefully about how we build our collaborations. In the next chapter, we will explore how research partnerships can, and should, be structured more equitably.