Who Sets the Global Health Research Agenda? The Challenge of Multi-Bi Financing

A major challenge in the governance of research funding is priority-setting. As a former health minister in sub-Saharan Africa noted, ‘‘Everyone is chasing the money—reputable universities, the UN agencies, partnerships, civil society groups, so who is actually doing what developing countries really need, rather than what donors want?’’ [1] The past 15 years have been called revolutionary in global health in terms of the funding raised and the number of initiatives launched. One of the side effects of having more money, institutions, and initiatives in global health is increased competition among the various parties. And, the priorities of funding bodies largely dictate what health issues and diseases are studied. In this Essay, I argue that the challenge of agenda-setting that occurs in research funding is a consequence of a larger phenomenon in global health, ‘‘multi-bi financing.’’ Multilateral funding refers to monies given to an organization that involves two or more governments or other institutions, the prime example being the United Nations; bilateral funding refers to monies given from one government or institution to another such as the US Agency for International Development (USAID) grants to Haiti. Multi-bi financing refers to the practice of donors choosing to route non-core funding—earmarked for specific sectors, themes, countries, or regions—through multilateral agencies and to the emergence of new multistakeholder initiatives. Drawing on insights from political science and international relations, I put forward an explanation for why these developments are occurring and discuss the consequences for global health research governance.