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Abstract
Objective This study aims to characterise and evaluate the National Institutes of Health’s (NIH’s) grant allocation speed and pattern of COVID-19 research.
Design Cross-sectional study.
Setting COVID-19 NIH RePORTER Dataset was used to identify COVID-19 relevant grants.
Participants 1108 grants allocated to COVID-19 research.
Main outcomes and measures The primary outcome was to determine the number of grants and funding amount the NIH allocated for COVID-19 by research type and clinical/scientific area. The secondary outcome was to calculate the time from the funding opportunity announcement to the award notice date.
Results The NIH awarded a total of 56 169 grants in 2020, of which 2.0% (n=1108) wwas allocated for COVID-19 research. The NIH had a US$45.3 billion budget that year, of which 4.9% (US$2.2 billion) was allocated to COVID-19 research. The most common clinical/scientific areas were social determinants of health (n=278, 8.5% of COVID-19 funding), immunology (n=211, 25.8%) and pharmaceutical interventions research (n=208, 47.6%). There were 104 grants studying COVID-19 non-pharmaceutical interventions, of which 2 grants studied the efficacy of face masks and 6 studied the efficacy of social distancing. Of the 83 COVID-19 funded grants on transmission, 5 were awarded to study airborne transmission of COVID-19 and 2 grants on transmission of COVID-19 in schools. The average time from the funding opportunity announcement to the award notice date was 151 days (SD: ±57.9).
Conclusion In the first year of the pandemic, the NIH diverted a small fraction of its budget to COVID-19 research. Future health emergencies will require research funding to pivot in a timely fashion and funding levels to be proportional to the anticipated burden of disease in the population.
- COVID-19
- public health
- health policy
Data availability statement
Data are available in a public, open access repository. Data are publicly available.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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Strengths and limitations of this study
Our study is the first study to characterise and evaluate the National Institutes of Health’s (NIH’s) under funding of COVID-19 clinical research in the year the pandemic hit the USA.
We conducted a cross-sectional study using the NIH Research Portfolio Online Reporting Tools Expenditures and Results (RePORTER) datasets of all COVID-19 grants, including grants funded by COVID-19 supplemental appropriations.
We calculated the number of grants and funding the NIH allocated towards COVID-19 in 2020 to different research types and clinical/scientific areas, and the time from funding opportunity announcement to award notice date.
We only reviewed abstracts and did not review the entire funded proposals. There were other barriers to clinical research that were not captured here, including slow institutional review boards and long journal peer-review times.
Introduction
The National Institutes of Health (NIH) is the world’s largest funder of biomedical research, employing over 20 000 people with a US$45.3 billion budget in 2020, 41.7 billion appropriated by Congress with an additional 3.6 billion in COVID-19 supplementary funding.1–3 Prior research suggested that the NIH research funding has not been proportionately aligned with disease burden in the population.4–7 Throughout the 1990s, NIH funding patterns were under major scrutiny from Congress and the scientific community due to concerns that funding allocations by the NIH failed to adequately reflect the burden of disease on society.6 In 1998, the Institue of Medicine (IOM) released a groundbreaking report guiding the NIH to improve and develop disease-specific funding processes.8 A landmark study published in the New England Journal of Medicine as well as a follow-up study by Gillum et al in 2011 revealed that the NIH disease-specific funding levels were not correlated with several measures of disease burden.5 6
The COVID-19 pandemic tested the NIH’s ability to fund critical research to answer research questions that significantly affect public health and require urgent scientific clarity. We analysed the relative weight and composition of the NIH research funding of COVID-19 research in 2020 to evaluate the responsiveness of the agency to the pandemic.
Methods
Study design and settings
We conducted a cross-sectional study using the NIH Research Portfolio Online Reporting Tools Expenditures and Results (RePORTER) datasets of all COVID-19 grants, including grants funded by COVID-19 supplemental appropriations.9 10 We also reviewed the NIH Fiscal Year 2020 budget and NIH Fiscal Year 2020 supplemental appropriations to identify spending on NIH COVID-19 research.11
We reviewed all grants funded for COVID-19 research between 1 January 2020 and 31 December 2020. For each grant, we collected the date of funding opportunity announcements (NIH’s advertisements of available grant support), award notice date and the amount awarded as listed in the NIH RePORTER dataset.12 The date of the Funding Opportunity Announcement was obtained from the NIH COVID-19 grant opportunities.13
We categorised each grant into one of six research types: basic science, clinical science, translational science, public health, infrastructure and education and other (online supplemental appendix 1). Each NIH-funded grant was screened to identify one or multiple clinical/scientific areas of focus within the abstracts (online supplemental appendix 2). In order to create comprehensive definitions, we adapted definitions for research areas and subcategories of primary research subjects from NIH Research, Condition and Disease Categorization (RCDC) thesaurus and supplemented them using definitions from the Association of American Medical Colleges, National Cancer Institute, Economic Social Research Council, the Department of Health and Human Services and Methods in Educational Research.14–20
Supplemental material
Each grant was independently reviewed and categorised by at least two independent reviewers (LB, SH, CD, CK, AM, BC). For grants that were categorised differently, a study group discussed the aims of the grant and made a final decision.
Patient and public involvement
No patients were involved in this study.
Data source
RePORTER is an electronic tool developed by the NIH that works in conjunction with the NIH’s RePORT website. This tool allows users to generate lists of funded NIH studies based on specific search criteria, such as funding source and research area.11 To obtain a list of all the grants that funded COVID-19 research in 2020, we used the NIH’s pregenerated COVID-19 RePORTER dataset.9 11 The information describing 2020 NIH funding by research was found on the RCDC RePORTER database.21
Outcomes
The primary outcome for this analysis was to calculate the number of grants and funding the NIH allocated towards COVID-19 in 2020 to the six research types and each clinical/scientific area. The secondary outcome was to calculate the time from funding opportunity announcement to award.
Statistical analysis
We calculated the funding amount for research areas by compiling each grant’s total funding amount allocated by the NIH. The funding amount for the clinical/scientific area was calculated based on each grant’s categoriszation. We plotted the weekly number of COVID-19 grants awarded during 2020. Data cleaning and statistical analyses were conducted using Stata (V.16.0).
Results
In 2020, COVID-19 research accounted for 4.9% (US$2.2 billion) of the annual NIH budget of US$45.3 billion.3 22 Of the US$2.2 billion that the NIH spent on COVID-19 research, 91.0% was allocated from congressional special appropriations, while the remaining 9.0% of COVID-19 funding originated from the regular NIH annual budget that year. We found that several disease and condition-specific research areas were funded at levels much greater than COVID-19 (figure 1). Rare Diseases research received 2.5-fold more funding than coronavirus research and ageing research received 2.2-fold more research funding than coronavirus research.21
National Institutes of Health funding by research area (2020).
There were 1419 NIH COVID-19 grants from the year 2020 in the NIH RePORTER dataset. Of these, we identified 1108 COVID-19 grants with relevance to COVID-19 research, 24 were duplicates appearing in different places and 287 were categorised COVID-19 research; however, COVID-19 was not mentioned in the grant abstract or was not the focus of the grant. Of the 1108 COVID-19 grants identified, 266 grants were able to be matched to their funding opportunity announcement. The remainder had their funding opportunity announcements linked to ongoing projects and were unable to be matched with a current COVID-19 funding opportunity announcement. The average COVID-19 grant was issued funding 151 days (SD:±57.9) after its funding opportunity announcement, with a median of 137 days (IQR: 109–196) and range from 43 to 295 days. In a randomly selected pre-COVID sample of 20 grants in 2018 and 2019, the average time from the funding opportunity announcement to the awarded date was 606 days. There were 535 (48.3%) grants funded through regular 2020 appropriations and 573 (51.7%) funded through supplemental COVID-19) funding.
In the first 3 months of the global pandemic, a total of six grants were awarded for COVID-19 research. In the first half of 2020, a total of 240 grants were awarded funding (figure 2). Accordingly, in the first 3 months of 2020, the NIH spent a total of 0.04% of its annual budget on COVID-19 research. In the first half of 2020, the NIH spent 1.1% of its annual budget on COVID-19 research. The months with the most COVID-19 research grants awarded were August and October.
Number of COVID-19 grants approved by National Institutes of Health in 2020.
Regarding the type of COVID-19 research funded, basic science research comprised the greatest number of grants funded by the NIH with a total of 313 grants, compromising 6.9% of total COVID-19 research funding. There were 231 grants awarded for public health research and 231 grants awarded for clinical research, accounting for 5.7% and 26.8% of NIH COVID-19 funding, respectively. The NIH allocated the largest dollar amount to infrastructure and education research with 55.5% of all COVID-19 funds going to these purposes with 216 grants, accounting for 2.7% of the NIH’s annual budget (table 1).
National Institutes of Health (NIH) grants for COVID-19 research by research type (2020)
There was an average of 1.9 (SD:±1.0) clinical/scientific areas per grant awarded by the NIH. The most common clinical/scientific areas of research were social determinants of health (n=278 grants, 8.5% of COVID-19 funding), immunology (n=211 grants, 25.8% of COVID-19 funding) and pharmaceutical interventions (n=208 grants, 47.6% of COVID-19 funding) (table 2). Of the 208 grants dedicated to pharmaceutical intervention research, 85 grants focused on novel therapeutics development (6.4% of COVID-19 funding), 79 grants focused on existing therapeutics (28.2% of COVID-19 funding) and 69 grants on vaccine development (32.2% of COVID-19 funding). Of the 211 immunology grants, 41 grants studied immunity gained after infection of COVID-19 and 15 grants studied immune response from vaccination. Of 64 neurological grants, 13 grants focused on changes of tastes or smell.
National Institutes of Health (NIH) grants for COVID-19 by clinical/scientific area (2020)*
There were 132 grants awarded for COVID-19 testing, compromising 8.5% of all COVID-19 funding. There were 83 grants on COVID-19 transmission, representing 3.5% of COVID-19 funding. Of these, 5 studied airborne transmission, and two grants studied COVID-19 transmission in schools.
A total of 104 grants focused on non-pharmaceutical interventions, with six grants on the efficacy of social distancing and two grants on the efficacy of face masks. Additionally, 92 grants studied the effects of COVID-19 infection in paediatric populations, 10 of which examined inflammatory syndrome in children. Geriatric health and COVID-19 was awarded 68 grants and maternal health and COVID-19 was awarded 41 grants. There were no grants dedicated to studying the efficacy of face masks in children.
Discussion
Despite the escalating public health threat and poorly understood mechanism of transmission of the novel coronavirus in 2020, the NIH only spent 5.3% of their total budget that year on COVID-19 research, extending the prior literature that the NIH funding priorities misaligned with disease burden in the population.6 8 The NIH’s slow start in funding COVID-19 research was also noted in a February 2021 study in Health Affairs by Sampat and Shadlen.7 They described the current low investment in COVID-19 research as ‘small compared with the potential value of these interventions for ameliorating or preventing the disease and securing a return to normalcy’. A stronger research effort could have helped reduce transmission of the infection before a vaccine became available.
Infrastructure and education accounted for 55.9% of NIH COVID-19 funding, yet many of the major clinical questions surrounding COVID-19 transmission were unanswered at that time, such as transmission among children. Significant restrictions have been placed on the nation’s 52 million school-aged children, including school closures, 6-foot distancing requirements and outdoor masking while distancing; however, only a few grants were dedicated to studying these questions in this unique population, creating challenges for evidence-based policymaking. It is also concerning that we have identified 287 grants that are categorised as COVID-19 where COVID-19 was not mentioned in the grant abstract or was not the focus of the grant.
The lack of rapid clinical research funding to understand COVID-19 transmission may have contributed to the politicisation of the virus. Some of the most basic questions that were being asked of medical professionals in early 2020, such as how it spreads, when infected individuals are most contagious, and whether masks protect individuals from spreading or getting the virus, went unanswered. In the absence of evidence-based answers to the common questions the public was asking, political opinions filled that vacuum. Patient and public involvement in research prioritisation of funding could help direct a more urgent, focused and equitable response to health emergency.
The social and political climate of the COVID-19 pandemic has been plagued with misinformation hindering important mitigation efforts. Significant funding was made to Biomedical Advanced Research and Development Authority. However, this funding was focused on vaccines and therapeutics rather than clinical research on characteristic COVID-19.9 A resilient healthcare system in times of crisis should be able to pivot funding towards specific grants answering critical gaps in knowledge. NIH may consider developing procedures to rapidly pivot funding and guidelines for reviewing targeted proposals relevant to addressing a public health emergency.
Our study has several limitations. The type of research and the clinical/scientific areas studied were based on definitions that may not be collectively exhaustive and mutually exclusive. In addition, we only reviewed abstracts and did not review the entire funded proposals, and we did not separate the share of new grants vs continued grants in the analysis. There were other barriers to clinical research that were not captured here, including slow institutional review boards and long journal peer-review times. A rapid research protocol that protects research subjects with standard ethical principles for research could be developed for the next health emergency.
Conclusion
NIH funding patterns for COVID-19 grants did not align with COVID-19 disease burden and were allocated slowly. The NIH should develop mechanisms to rapidly pivot funding to address scientific unknowns associated with a sudden, large-scale health emergency. Supporting sound clinical research aimed at developing evidence-based recommendations is important for public policy and promotes public trust in the medical profession during a pandemic.
Data availability statement
Data are available in a public, open access repository. Data are publicly available.
Ethics statements
Patient consent for publication
Ethics approval
Not applicable.
Acknowledgments
We thank West Health Institute for their research support on this study. We thank Farah Hashim, Jonathan Teinor and Karashini Ramamoorthi for their contribution in preparing this manuscript.
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Contributors LB, CD, CW and MM designed the study. LB, CD, AM, SH, CW, CK, BC, and FM collected the data. LB and CD analysed the data. LB, CD, AM, SH and CW prepared the first draft of the manuscript. LB, CD, AM, SH, CW, CK, BC, FM, TD, GB, KS and MM made critical revisions to the manuscript. CD and LB acted as guarantors for the manuscript. All authors reviewed and approved the final draft and agreed to be accountable for all aspects of the manuscript in ensuring that questions related to the accuracy.
Funding This research was supported by a grant from the Gary and Mary West Health Institute.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.