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Going into a meeting of donors in New York City on 5 October, the Global Fund to Fight AIDS, Tuberculosis and Malaria was aiming high. Its representatives hoped to raise US$20 billion, enough to scale up the campaign against these diseases. But countries pledged just $11.7 billion for 2011–13, although the fund still hopes to raise the minimum $13 billion needed to maintain its current programmes.

The fund accounts for a quarter of all international financing to fight AIDS, two-thirds of that for tuberculosis, and three-quarters of that for malaria. By its own estimates, it has saved 4.9 million lives since its creation in 2002.

"It's a classic good news, bad news story," says Andrew Hurst, a spokesman for the fund, which is based in Geneva, Switzerland. The pledge marks a 20% increase on the $9.7 billion raised for the period 2008–10 at its last fundraising meeting in Berlin in 2007. Given today's economic climate, the outcome could have been far worse, he says.

The bad news is that the fund has not raised enough cash to reduce disease burdens among the poor by 2015, to levels to which countries have committed in the UN Millennium Development Goals. In the run-up to the meeting, the fund had estimated that it needed $20 billion to start making serious progress on this task, whereas $13 billion would buy only minimal burden reductions (see 'The human cost').

The poor funding outcome starkly highlights a chronic structural weakness of the Global Fund: its narrow base of donors. Just a couple of dozen countries donated, and a mere seven countries gave more than $100 million — the United States, France, Germany, Japan, Canada, Norway and Australia. Three other countries traditionally supportive of the fund — the United Kingdom, the Netherlands and Sweden — were unable to officially pledge at the meeting because of the timing of national budgets, but are likely to commit sums that will allow the Global Fund to reach its $13-billion lower target. Yet dozens of rich countries, including Italy, Spain and Saudi Arabia, gave nothing. The fund is seeking to persuade more nations to pledge, says Hurst, but admits that "we still have some way to go".

For the first time in its history, the fund will now be forced to reject otherwise-solid new proposals from recipient countries, and trim others. "Today marks a sad turning point in the fight against AIDS, TB and malaria, as world leaders have officially underfinanced the Global Fund," says Jennifer Cohn, HIV/AIDS policy adviser at Médecins Sans Frontières in Geneva. "This decision will result in the deaths of millions of people from otherwise treatable diseases."