Among the many institutions devoted to defeating diseases, there are a handful of heavyweight nonprofits that set the agenda. When one key player, the Global Fund to Fight AIDS, Tuberculosis and Malaria, launched in 2002, it ushered in an era of improved drug distribution for these infections. Now, as the board of the Global Fund meets in Sofia, Bulgaria, on 13 December, it will have to decide how to proceed with a predicted $1.3 billion dollar shortfall in funding needed to meet a growing battle against its target diseases.

Earlier this year, the Global Fund predicted that it would need $13 billion in funding for the next three years—$8.8 billion of which would go to maintaining current programs and $4.2 billion of which would go to expanding programs to implement new efforts in areas with a growing disease burden.

However, the Fund, which is based in Geneva, currently estimates that it will only receive $11.7 billion in funding, leaving only $2.9 billion to expansion.

“Overall, we had a respectable increase in donations,” says Christopher Cannan, manager of donor relations for the Global Fund. “However, it's not enough to meet the growing need—so, some tough choices are going to have to be made.”

This December's board meeting will involve a discussion of such choices of where best to expand the Fund's efforts.

With the funding shortfall, some say that the Global Fund's best bet for getting the most bang for its buck may seem counterintuitive: expand its mission to include certain neglected tropical diseases.

“The Global Fund is one of the best organizations out there for putting dollars into real results,” says Peter Hotez, president of the Sabin Vaccine Institute, a nonprofit medical research and advocacy organization based in Washington, DC. “If that's going to stay their philosophy, I don't see how they can overlook neglected tropical diseases.”

Many neglected tropical diseases are co-endemic with and often complicate AIDS, tuberculosis and malaria. Because these diseases are often inexpensive to treat, it only makes sense to add them to the Global Fund's mission, Hotez says.

As an example, Hotez points to a study he co-authored that showed that women in Zimbabwe with schistosomiasis have a threefold risk of contracting HIV and that the parasitic worm disease could be treated for as little as 32 cents a person (PLoS. Negl. Trop. Dis. 3, e430, 2009).

Treating parasitic worm diseases could also have a much greater economic payoff than tackling other diseases. Edward Miguel, an economist at the University of California–Berkeley, is currently working on a study that seems to indicate that children in poor countries who undergo deworming tend to have significantly higher salaries later in life than those who suffered from diseases such as hookworm. This philosophy behind deworming isn't anything new, Miguel says; similar efforts were launched in 1910 by the Rockefeller Sanitary Commission (Q. J. Econ. 122, 73–117, 2007).

Temina Madon, executive director of the Center for Emerging and Neglected Diseases at the University of California–Berkeley, says that although she sees the need to incorporate neglected diseases into the Global Fund's mission, doing so will require a shift in how the Fund operates on the ground.

For example, she says, the Global Fund typically administers drugs and care on an individual basis through clinical settings, whereas treatment for neglected diseases such as parasitic worms must be conducted on a much larger scale, being distributed to large groups at a time.

“I can see that, over time, the Global Fund will expand its mandate to other diseases—but now might not be the best time to shift organizational structure,” says Stephen Lewis, co-director of AIDS-Free World, a US-based advocacy organization.

Incorporating a focus on neglected tropical diseases and other diseases would add organizational strife not only to the on-the-ground efforts, but potentially also to fund-raising efforts that use the Fund's focus on the three diseases as a selling point to donors, Lewis adds.