The Global Fund: Heal thyself THE Global Fund to Fight AIDS, Tuberculosis and Malaria was founded in 2002 to help the world's most afflicted. In recent years, however, the Global Fund itself has needed treatment. Donations have dwindled because of the financial crisis and reports of mismanagement. In November 2011 the Global Fund said it would make no new grants until 2014. In January its director said he would step down. There are signs of recovery. This month a new system of grants was approved and a new director, Mark Dybul, appointed. He led America's global AIDS programme and speaks ardently about the opportunities. "Science has provided the tools to completely control HIV, tuberculosis and malaria," he says. But there is much debate over which of those tools are worthy of the Global Fund's limited cash. Dr Dybul has his work cut out, as a recent brawl over malaria shows all too well. By most measures the millennia-long fight against malaria has now had enormous success. Between 2000 and 2010 malaria rates plunged by more than 50% in 43 countries. But questions remain how best to stamp out the disease. On November 15th the Global Fund's board said it would end a controversial pilot scheme for treating malaria. Discussions about this scheme began in 2002. The malaria parasite had long developed ways to fend off one type of drug, chloroquine, and doctors feared it would increasingly resist artemisinin, a newer treatment. After much deliberation a committee at America's Institute of Medicine proposed a new way to supply artemisinin-based combination therapies (ACTs). A funding agency could negotiate prices with drug manufacturers and subsidise the medicine at the local level. The ACTs would be available at public facilities and sold by tiny drug shops, in many villages the only source of medicine. Use of older drugs would drop. The Global Fund introduced the Affordable Medicines Facility-malaria (AMFm) in seven African countries and Cambodia in 2010. To date it has spent $463m on the programme. Uncertain medicine To its supporters, AMFm was a way to expand good treatment dramatically. But the approach was criticised from the start. Oxfam, a charity, worried that the poor could not afford ACTs and that shops would sell drugs to those who did not need them. The American government was sceptical and declined to fund it. The Global Fund was due in November to decide whether to expand or scuttle the scheme. The prior weeks brought a frenzy of papers and passionate debate. The London School of Hygiene and Tropical Medicine and ICF International, a consultancy, conducted the main independent review of the scheme. They found that the supply of ACT jumped in six of eight sites where the pilots were held, rising by 26-52%. Prices dropped in most places. But critics pointed to gaps in the voluminous report. Young children are malaria's main victims, but the report did not track whether the programme boosted their use of ACTs, noted the American government's President's Malaria Initiative (PMI). There was no urgent need to lower the use of artemisinin, as its use was already rare in most pilot sites. Without diagnostic tests, PMI warned, many malaria drugs were likely to go to people suffering from pneumonia or other illnesses. Oxfam called AMFm a "dangerous distraction." Members of the Institute of Medicine's committee mounted a strong defence in the Lancet, a medical journal. The Clinton Health Access Initiative presented evidence that subsidised ACTs did improve treatment for children. Nevertheless, the Global Fund's board decided to roll AMFm into its general grant process, rather than expand it as a separate programme. Countries may still use it as a way to obtain ACTs, but they must weigh the programme's cost against other priorities. Some supporters are already in mourning. "It has very little chance of survival at this point," argues Ramanan Laxminarayan, who helped hatch the idea and who was one of authors of the Lancet article. Without a dedicated programme, he predicts, ACT production will drop and prices will rise. Oliver Sabot of the Clinton Health Access Initiative says that donors are thinking of ways to help countries that want to keep working with private pharmacies. Mohga Kamal-Yanni of Oxfam is relieved by the Fund's decision. She now wants the Fund to supply free ACTs and direct money to community health workers rather than private drug shops. The Global Fund itself is mulling ways to adapt its subsidies and expand diagnostic testing. AMFm did not require such tests. As malaria rates drop, tests can prevent improper treatment that might breed resistance. But there is little agreement on where to deploy tests. Despite the cloudy horizon, Dr Dybul remains optimistic about all the changes which are going on at his new employer. In the business world, he points out, "if you're not changing, there's something very wrong with you."