The Structural Geography of Epidemic Financing Since 2000: Divergent Regional Regimes and Implications for Pandemic Preparedness

Methods: We harmonised six publicly available financial datasets covering HIV, tuberculosis and malaria for 2000-2025 (Institute for Health Metrics and Evaluation Development Assistance for Health database, UNAIDS, WHO Global Tuberculosis and World Malaria reports, the Global Fund disbursement records, the WHO Global Health Expenditure Database, and Policy Cures Research G-FINDER) at country level for 76 low- and middle-income countries (LMICs). Country-level financing was disaggregated by source (domestic vs international) and purpose (operational delivery vs research and development), and matched to age-standardised infectious-disease DALY rates from the Global Burden of Disease 2021 study used as a vulnerability proxy. We computed regional structural profiles, traced their decadal trajectory (2010 → 2024), and quantified the cross-sectional association between domestic financing share and disease burden using Spearman's rank correlation.

Findings: Across the 76 LMICs analysed, domestic financing share was strongly inversely correlated with infectious-disease vulnerability (Spearman ρ = −0.95, p < 0.001), with the pattern preserved within each region (Africa ρ = −0.88; Asia ρ = −0.95; Latin America and Caribbean ρ = −0.90). Three structural regimes emerged. Sub-Saharan Africa (n = 30) carried the highest disease burden (median normalised DALY 0.81) and depended predominantly on international financing (median domestic share 25%; total US$11.2 bn). Asia (n = 24) occupied a transitional position (median domestic share 68%; US$6.0 bn). Latin America and the Caribbean (n = 22) was largely domestically financed (median domestic share 82%; US$3.9 bn). The operational-research balance was strikingly skewed and homogeneous across regions: research and development absorbed only 9.6% of total financing in Africa, 11.1% in Asia, and 10.2% in LAC, while operational delivery absorbed the remaining 88.9-90.4%. In absolute terms, R&D investment varied across three orders of magnitude (US$0.1-360 million per country) and was inversely associated with vulnerability (ρ = −0.27). Decadal trajectories converged towards higher domestic share and lower vulnerability everywhere, but at very different rates and from very different starting points.

Interpretation: Epidemic financing has not converged towards a single global model but stabilised around three regionally distinct regimes-donor-dependent, transitional, and domestically owned-each combined with a uniformly reactive, operational-heavy portfolio. The strong inverse correlation between domestic share and disease burden indicates that the contraction of development assistance now under way is concentrated precisely where systems can least absorb it. The near-universal under-investment in research, innovation, and anticipatory prevention (≈ 10% of total financing) constitutes a parallel structural blind spot that no region has yet addressed. Stabilising international commitments, expanding domestic fiscal ownership, and rebalancing the operational-research mix should be treated as interdependent priorities of the post-pan