Advancing global equity in liver disease research funding: the case of metabolic dysfunction-associated and alcohol-associated liver disease

The global state of research funding

Globally, liver disease accounts for more than 2 million deaths and is the 11th leading cause of death annually.¹ Currently, there is a rise in non-communicable diseases (NCDs) of the liver, such as metabolic dysfunction-associated steatotic liver disease (MASLD) and alcohol-associated liver disease (ALD), both of which are prominent aetiologies of cirrhosis. Despite the substantial disease burden, limited research funding in lower-income regions continues to hinder progress in liver disease prevention, treatment, and policy reform.

Through the World RePORT database, an analysis of investments in grants by 12 of the world’s largest international funders of health research, such as the Wellcome Trust, reveals that projects related to viral hepatitis, liver cancer, and other liver diseases accounted for less than 1% of the total award recipients.² The funding process further contributes to inequities in research funding distribution, as most health research funding in lower-income regions originates from high-income countries (HICs).³ The database also reveals differences in funding allocation by country income level. In 2022, 82 666 grants were awarded. A staggering 81 858 grants (over 99%) were allocated to HICs, leaving only 808 grants for upper-middle-income countries, lower-middle-income countries (LMICs), and low-income countries (LICs) combined. Of this remaining fraction, LICs received a negligible share of 155 grants.² Funding disparities impede progress in advancing liver disease health outcomes; in HICs like the USA, deaths per 100 000 population due to liver cirrhosis were 17.1, whereas they were 23.7 in lower-income regions like Angola.⁴

This article discusses current research priorities, explores funding mechanisms, and draws on a framework based on implementation strategies to mitigate funding disparities for liver diseases in lower-income regions (see box 1 for key messages).

Box 1. Key messages.

• Global inequities in liver disease research funding persist, with high-income countries receiving the overwhelming majority of grants, while lower-middle-income countries (LMICs) and low-income countries (LICs) remain underfunded.

• Current research funding priorities may not reflect the rising burden of non-communicable liver diseases in LMICs and LICs.

• Limited access to funding, mentorship, and research infrastructure constrains the ability of researchers from LMICs and LICs to compete for and sustain grants, further entrenching structural disparities.

• This article proposes and details a multilevel framework (community, state/national, and global) to mitigate liver disease research disparities and improve liver health outcomes in LMICs.

Current liver disease research priorities

Research funding inequities in LMICs and LICs continue to hinder progress on underprioritised liver diseases, such as MASLD and ALD.

MASLD’s global prevalence is over 30%, with the Middle East and North African regions most affected.⁵ While funding for MASLD research has increased in HICs, there are few studies investigating whether funding for MASLD research is aligned with the increasing disease burden seen in LMICs and LICs. Although the WHO has global initiatives to reduce alcohol use, few initiatives are explicitly aimed at ALD, which is rising globally and disproportionately impacts LICs like Rwanda.⁵

Limited published data on liver disease research funding in LMICs and LICs hinder the assessment of funding trends in lower-income regions. This gap makes it difficult to evaluate whether research priorities align with liver disease burden, particularly where NCD research remains limited. Nevertheless, studies show that only about 0.2% of total NCD funding is directed to LMICs and LICs, underscoring the need for greater investment.⁶

Research funding mechanisms

International health funders, such as The Wellcome Trust, originate primarily in HICs and have the resources to carry out large-scale research funding initiatives. Still, liver disease remains a minuscule percentage of funded projects.² Country-specific research investments by respective national health research funders, such as the South African Medical Research Council, are guided by knowledge of community needs. However, the impact of national health research funders depends on a country’s fiscal capacity. Smaller liver disease-specific organisations, like the American Liver Foundation, are key in promoting advocacy and funding targeted research for liver diseases within particular communities. However, these organisations often operate with fewer financial resources than national or international health research funders and are more frequently established in HICs, limiting their impact.

Global disparities in liver disease research funding

There is a scarcity of published literature and limited efforts in globally mapping research funding opportunities for liver diseases. Our group conducted a comprehensive online search of publicly available research awards offered by national health funders and gastroenterology or hepatology organisations supporting liver disease-specific research across all countries.⁷ We found that liver disease research funding remains disproportionately concentrated in HICs, accounting for the majority of both funders and award recipients. In contrast, LMICs and LICs were markedly under-represented among award recipients. Although many lower-income regions were technically eligible for awards, few received funding. These findings underscore persistent structural inequities in research infrastructure and funding access that continue to marginalise LMICs and LICs in efforts to advance liver health.

Barriers to research funding access

At the individual level, stigma limits ALD prevention and discussion, while low awareness in lower-income settings weakens advocacy and funding prioritisation. Additional barriers include limited grant-funding knowledge, mentorship, and grant-writing skills. At the health systems level, research capacity is strongly shaped by the availability of institutional infrastructure to support personnel oversight, research governance, and grant administration. Many institutions in LICs and LMICs lack dedicated research offices, regulatory support, and grant management systems. This constrains their ability to conduct research, compete for external funding, and sustain research programmes.⁸ On a global level, funding bias towards established institutions in HICs increases research funding inequity, even if LMICs and LICs are eligible to apply for research awards. Limited access to research awards in lower-income regions slows the development of local research capacity, both at the individual and institutional levels. In turn, this hinders the ability to compete for research awards.

Implementing equity: a framework for change

Collective engagement from community advocates, policymakers, researchers, research funders, and international health organisations works towards addressing existing funding inequities. We propose a multilevel framework to guide interventions that address inequities in research funding, empower lower-income regions, and advance liver disease health in the LMICs and LICs (figure 1).

Figure 1. A multilevel framework to address global research funding disparities in ALD and MASLD. ALD, alcohol-associated liver disease; LICs, lower-income countries; LMICs, lower-middle-income countries; MASLD, metabolic dysfunction-associated steatotic liver disease; NCD, non-communicable disease.

Community-level initiatives are key to the early detection and prevention of liver disease. Local organisations such as the Vietnam Viral Hepatitis Alliance and global organisations such as the WHO Global Hepatitis Programme have made remarkable strides through community education and point-of-care testing, which ultimately improves public health and bolsters support for liver disease research. Beyond hepatitis-focused programmes, we call for greater community engagement from local to global organisations in addressing insufficiently prioritised liver diseases like MASLD and ALD in LMICs and LICs. We also urge large international health research funders, such as the Wellcome Trust, which have traditionally supported basic research, to include population-intervention-based studies in their grant schemas, as this is more likely to provide immediate results. International organisations can also partner with local hepatology-based organisations to provide research grant funding opportunities in LMICs and LICs.

Even in countries with established research infrastructures and capacity, NCDs such as MASLD and ALD may be overlooked without a reassessment of health priorities at the state and national levels. National NCD strategic guidelines, developed by a country’s health ministry, serve as frameworks to reduce the burden of NCDs, with emphasis typically placed on diabetes, cardiovascular disease, cancer, and alcohol-related conditions. Liver diseases are often not explicitly addressed in these guidelines. The Global Think Tank on Steatotic Liver Disease urges the WHO executive members to champion the recognition of MASLD as a major NCD at the next World Health Assembly.⁹ Shifting this status quo is essential to leveraging existing donor infrastructures towards enhancing visibility and funding allocation towards liver disease research.

On a global scale, research leaders from HICs who study NCDs of the liver can integrate investigators from LMICs and LICs through multicentre studies, guideline committees, data coordination efforts, and grant writing efforts. Such collaboration promotes knowledge exchange and increases local research capacity in LMICs and LICs.¹⁰ Over time, this engagement builds mentorship networks, strengthens methodological expertise, and increases the visibility of researchers from LMICs and LICs to successfully compete for independent funding and steer local research initiatives.

Global research funding disparities limit scientific innovation and hinder progress in addressing liver diseases, particularly in LMICs and LICs. Addressing these challenges requires coordinated action across multiple levels to improve liver disease health outcomes in resource-limited settings.

Somaya Albhaisi is supported by an NIH T32 Translational Research Training in Hepatology grant (T32DK127977).