key: cord-0959386-keq8bb11
authors: Antonio, E.; Alobo, M.; Tufet-Bayona, M.; Marsh, K.; Norton, A.
title: Funding and COVID-19 Research Priorities - Are the research needs for Africa being met?
date: 2020-10-14
journal: nan
DOI: 10.1101/2020.10.12.20211565
sha: eeaf2a146072618568ba51942b1118a0e6e67240
doc_id: 959386
cord_uid: keq8bb11

Introduction Emerging data from Africa indicates remarkably low numbers of reported COVID-19 deaths despite high levels of disease transmission. However evolution of these trends as the pandemic progresses remains unknown. More certain are the devastating long-term impacts of the pandemic on health and development evident globally. Research tailored to the unique needs of African countries is crucial. UKCDR and GloPID-R have launched a tracker of funded COVID-19 projects mapped to the WHO research priorities and research priorities of Africa and less-resourced countries and published a baseline analysis of a Living Systematic Review (LSR) of these projects. Methods In-depth analyses of the baseline LSR for COVID-19 funded research projects in Africa (as of 15th July 2020) to determine the funding landscape and alignment of the projects to research priorities of relevance to Africa. Results The limited COVID-19 related research across Africa appears to be supported mainly by international funding, especially from Europe, although with notably limited funding from United States-based funders. At the time of this analysis no research projects funded by an African-based funder were identified in the tracker although there are several active funding calls geared at research in Africa and there may be funding data which has not been made publicly available. Many projects mapped to the WHO research priorities and 5 particular gaps in research funding were identified namely: investigating the role of children in COVID-19 transmission; effective modes of community engagement; health systems research; communication of uncertainties surrounding mother-to-child transmission of COVID-19; and identifying ways to promote international cooperation. Capacity strengthening was identified as a dominant theme in funded research project plans. Conclusions We found significantly lower funding investments in COVID-19 research in Africa compared to High-Income Countries, seven months into the pandemic, indicating a paucity of research targeting the research priorities of relevance to Africa.

The Coronavirus 2019 (COVID-19) pandemic hit at a time when pandemic preparedness was at the fore of global health policy but under-resourced. The 2014-2016 West Africa Ebola outbreak had exposed glaring gaps in the international outbreak response mechanism and, in its wake, many evaluation panels were commissioned to consider lessons learnt for response to future outbreaks.

Several global and regional initiatives were commissioned to support the activities of existing initiatives such as Global Outbreak Alert and Response Network (GOARN) and African Coalition . CC-BY 4.0 International license It is made available under a perpetuity.

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The copyright holder for this this version posted October 14, 2020. . https://doi.org/10.1101/2020.10. 12.20211565 doi: medRxiv preprint for Epidemic Research, Response and Training (ALERRT). These include Regional Disease Surveillance Systems Enhancement (REDISSE) for strengthening disease surveillance in West Africa, Coalition for Epidemic Preparedness and Innovation (CEPI) and a World Bank-funded $500 million bonds scheme to promote pandemic preparedness in developing countries (1) (2) . Importantly, the Africa Centres for Diseases Control, a Pan African initiative to promote collaboration and partnership among African nations and advance public health was established.

The WHO R&D Blueprint was also launched, highlighting priority pathogens of outbreak potential and developing a coordinated research response mechanism in preparation for disease outbreaks (3) . Ebola outbreak and concluded global pandemic preparedness was inadequate. Further, it set out the crucial steps to be taken by governments, donors and funders to ensure sustainable preparedness plans in response to the next pandemic (6) .

As of 30 th September 2020, there were 1,182,927confirmed COVID-19 infections and 25,881 deaths in Africa, representing 3.5 % and 2.6 % of global infections and mortalities respectively (7) .

Despite emerging evidence of high levels of transmission of the virus, Africa is one of the least directly impacted continents when disease burden alone is considered and there is keen interest in the evolution of these trends as the pandemic progresses. Emerging evidence from Europe and the United States are indicative of severe long-term sequelae following even mild COVID-19 infections (8) (9) (10). These aftereffects, the magnitude of which is yet to be determined, could further burden health systems in Africa. In spite of the apparently low direct mortality, the cumulative effects of comprehensive control efforts are projected to have major long-term impacts which could potentially offset decades of health, economic and developmental gains in the subregion.

Africa is made up of diverse countries with unique contextual characteristics likely to influence COVID-19 outcomes, prevention, control and management. The projected transgenerational . CC-BY 4.0 International license It is made available under a perpetuity.

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The copyright holder for this this version posted October 14, 2020. . https://doi.org/10.1101/2020.10.12.20211565 doi: medRxiv preprint impacts of suspended education, immunizations and maternal and child health programmes resulting from disruptions caused by the pandemic are grave. The observation of a higher proportion of deaths among younger people living with HIV in South Africa speaks to the influence of infectious diseases on COVID-19 outcomes (11) . Importantly, tuberculosis, malaria and other infectious disease burdens which are disproportionately higher in Africa could potentially worsen the prognosis of COVID-19 infections.

Coupled with the aforementioned, the rising burden of non-communicable diseases has stretched existing health systems to capacity, and COVID-19 could rapidly overwhelm health systems, as has been witnessed across the globe in even the best resourced countries. Overcrowded informal settlements and refugee camps, inadequate water, sanitation and hygiene (WASH) and high illiteracy levels, which hinder understanding of diseases and fuel misinformation, may make compliance with public health interventions for COVID-19 control difficult in some settings. The interplay of these among many factors gives rise to multiple vulnerabilities which are likely to influence the impact of COVID-19 in Africa.

The global research response to COVID-19 has been governed by the WHO's Coordinated Global Roadmap: 2019 Novel Coronavirus in line with the WHO R&D Blueprint mechanism, which was rapidly mobilised at the onset of the outbreak (12) . This Roadmap outlines 9 mid-to long-term broad research priority actions and corresponding sub-priorities for controlling the pandemic.

Following the declaration of a global pandemic, the African Academy of Sciences (AAS) engaged African researchers through a survey and consultative workshop to assess the applicability of these research priorities to Africa and found a general agreement of African researchers with the WHO research priorities. However, important context-relevant research priorities falling outside the WHO framework were also identified and outlined in the Research and Development goals for COVID-19 in Africa Report (13) .

In May 2020, a further collaborative effort between the United Kingdom Collaborative on Development Research (UKCDR), AAS and the Global Health Network (TGHN) led to a mixed methods study to determine the R&D priorities for COVID-19 by building on both the WHO Roadmap and the prior AAS study, with a special focus on less-resourced countries. This study found several WHO research priorities which required greater research emphasis and, more importantly, outlined new research priority areas which were not captured in either the WHO framework or the AAS study (14). is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

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In order to guide funding investments in research and promptly identify gaps and synergies to maximise the impact of research for this and future pandemics, UKCDR and Global Research Collaboration for Infectious Diseases Preparedness (GloPID-R) have launched the COVID CIRCLE (15) . This learning and coordination initiative has, as part of its activities, initiated a live COVID-19 Research Project Tracker, which identifies research by key global funders classified against the WHO research priorities (16) . A section of the Tracker is dedicated to monitoring the Building on this review, this article offers an in-depth analysis of the funded COVID-19 research projects in Africa, presenting the most comprehensive overview of funded research activities in Africa to date (to the best of our knowledge).

In-depth analyses of findings from the LSR previously mentioned was done to determine the state of funded research in Africa. Similar methodology to the LSR were employed where both descriptive and thematic analyses were done using Microsoft Excel 2019. Key variables extracted for the LSR and study protocol are available at Wellcome Open Research (17) . All projects listed in the UKCDR/GloPID-R Tracker (the Tracker), as of 15th July 2020 were eligible.

Research projects were mapped to the nine WHO broad research priory areas and corresponding sub-priorities and research priorities for Africa and less-resourced countries (14). The detailed methodology for data coding onto the Tracker is outlined in the LSR protocol.

Data entry was carried out cooperatively in a nine-person team and verification done by an independent reviewer to ensure consistency across extracted data. Projects were first assessed for a primary WHO research priority area(s) of focus. 'N/A' was assigned for projects which focused on innovation, research implementation/administration or clearly fell outside the WHO priorities.

Next, projects were assigned to a WHO sub-priority area(s) of research focus. This process was repeated to assign broad secondary research priority and sub-priority area(s) of focus where indicated. Hence, all projects were assigned to multiple primary and/or secondary research priority areas of research focus where possible. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted October 14, 2020. . https://doi.org/10.1101/2020.10.12.20211565 doi: medRxiv preprint

Subsequently, research projects were stratified by continent and all projects involving at least one African country (as defined by the African Union) were included in the analysis. Descriptive analyses of funding amounts, funders and research locations were made. Further analyses for potential gaps in research funding and thematic analyses of projects involving capacity strengthening were done.

Research locations and funding investments were compared between two sections of the Tracker 

Eighty-four projects of the 1,858 included in the LSR involved at least one African country. Four projects with non-specific country details but listed as being conducted in 'multiple African countries' or in 'Africa' were included in the analysis. Thirty-six African countries were represented in the Tracker and more West-African countries than countries from the other sub-regions were involved in research as shown in Figure is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted October 14, 2020. . https://doi.org/10.1101/2020.10.12.20211565 doi: medRxiv preprint COVID-19 in existing research cohorts in African countries. Six such projects were identified and this likely highlights the usefulness of existing research networks, which can be rapidly pivoted, in emergency response to outbreaks.

involving African countries but this value is underestimated given that only 32% of projects involving Africa included information on funding amounts. Importantly, funding amounts for EDCTP and ANRS, which are the top funders of projects involving African countries, were not available at the time of this analyses. Funding information for EDCTP projects are now available and subsequent updates of this analysis will incorporate these and any further updates on research investments made to the Tracker.

• WHO Research Priorities is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted October 14, 2020. . https://doi.org/10.1101/2020.10.12.20211565 doi: medRxiv preprint carried out in Africa. Of the 17 projects identified, most involved laboratory capacity strengthening activities whilst the remainder involved capacity for clinical management and surveillance.

In the Tracker version analysed (15 th is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted October 14, 2020. . https://doi.org/10.1101/2020.10.12.20211565 doi: medRxiv preprint out in the best resourced settings. Indeed, a similar finding was noted after the 2014 -2016 Ebola outbreak where the majority of R&D investments were in preclinical research in research institutions in Europe and USA (19), however context specific research is vital. The launching of the WHO access to COVID-19 tools (ACT) initiative is intended to enhance equitable and fair access to research discoveries to promote global recovery from COVID-19 moving forward (21).

Seven months into this pandemic, these trends of a slow research funding response may be early indicators of the limited uptake of the GPMB recommendations for pandemic preparedness and the lack of full operationalisation of many post-Ebola initiatives, many of which had still not reached their financial targets prior to this pandemic (1) .

All projects with sufficient information for classification mapped to WHO research priorities and this signifies the alignment of researchers and funders to these priorities. There is a global lack in research projects focused on 'Ethics considerations for research' since this broad priority, as framed in the WHO Roadmap, outlines actions to be taken by the WHO itself including the crafting of guidance protocols for ethical research practice during the pandemic. No preclinical research projects were identified in Africa, supporting the earlier discussion concerning lack of research capacity with few clinical trials (mainly funded by EDCTP). is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted October 14, 2020. survival and thus, priority should be given to research for determining the optimal approaches to engage families and communities to prevent undesirable child health outcomes.

The relevance of community engagement in Africa cannot be overemphasised as it is pivotal for understanding of and adherence to public health interventions to control COVID-19. Likewise fostering international cooperation and investigating modes of facilitating cooperation among various actors through transdisciplinary science and data sharing is crucial for control of this pandemic since "No one is safe until everyone is safe" (33) .

In general, few projects mapped specifically to the additional research priorities of relevance to Africa and less-resourced countries. This finding is likely due to the overall limited research activity captured in Africa. The dominant projects identified concerned understanding COVID-19 in populations that are particularly vulnerable to adverse outcomes such as refugees and migrants, minority groups, persons with HIV and tuberculosis. Some projects fell under crosscutting uses of technology in the pandemic response and building capacity for viral genotyping. These may represent research funding gaps. However, considering only a few research projects are being conducted or funded in Africa, a more comprehensive assessment can be made once more funding calls are announced. The AAS funding call, Global Effort on COVID-19 (GECO) health research and similar funding calls, which specifically focus on low-and-middle-income-countries (LMICs), will be important to consider (34) .

As several R&D candidates advance to large trials in diverse populations, inadequate research capacity can delay initiation of vital research and in the long run hinder the global research response. Laboratory capacity is particularly indispensable for the monitoring of trends in infection . CC-BY 4.0 International license It is made available under a perpetuity.

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The copyright holder for this this version posted October 14, 2020. . https://doi.org/10.1101/2020.10.12.20211565 doi: medRxiv preprint and determining recovery rates. It plays a key role in surveillance and clinical management which were also identified for capacity strengthening in this study. One concern is that capacity strengthening activities highlighted in this analysis may turn out to be short-lived due to their rapid mobilisation in response to the pandemic. Effective research capacity strengthening involves sustained deliberate actions geared at various aspects of the research process and at various levels of coordination at global, regional and national levels. These processes will enable countries with the greatest need to fairly and openly compete for research without compromising on quality (35) .

Moving forward, cooperation among research funders, enhanced mobilisation of domestic funding for capacity strengthening and periodic evaluations to guide future investments, as highlighted by the ESSENCE group of funders, are key steps for building sustained research capacity in Africa (36).

This analysis was based on the earlier Baseline LSR of funded COVID-19 projects initiated by the COVID CIRCLE and is similarly limited by variable completeness of data provided for classification of research projects and data on funding amounts invested in research funding. The Tracker also does not present a complete picture of repurposed research grants for COVID-19, as these details have not yet been provided by funders or are yet to be identified. There are pending funding calls related to Africa which could alter the findings of this analysis and thus this analysis can be viewed as a baseline assessment of research funding in Africa for which follow up analyses can be done to observe trends. Comparisons made to past Ebola outbreaks are made cautiously with full cognisance of the fact that this is an ongoing pandemic likely to evolve whereas findings from past outbreaks have been gleaned from retrospective review in the recovery phase. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted October 14, 2020. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted October 14, 2020. . https://doi.org/10.1101/2020.10.12.20211565 doi: medRxiv preprint is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted October 14, 2020. . https://doi.org/10.1101/2020.10.12.20211565 doi: medRxiv preprint is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted October 14, 2020. . https://doi.org/10.1101/2020.10.12.20211565 doi: medRxiv preprint is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted October 14, 2020. . https://doi.org/10.1101/2020.10.12.20211565 doi: medRxiv preprint is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted October 14, 2020. . https://doi.org/10.1101/2020.10.12.20211565 doi: medRxiv preprint Establish capacity for genotyping virus e.g. to detect new mutations over time. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

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We are grateful to all the funders who have provided data for the Tracker to date. We also thank Nicole Advani, Adrian Bucher, Emma Clegg, Alice Cross, Henrike Grund, Sheila Mburu and Laura Scott from UKCDR and Gail Carson, Morgan Lay and Genevieve Boily-Larouche from GloPID-