One of the biggest donor agencies in the fight against malaria has made a major change in its drug policy. But, the change means that fewer people will be treated or the agency will be facing a big funding gap.

Chloroquine has been Africa's anti-malaria drug of choice for decades. But malaria-causing parasites that are immune to chloroquine are spreading across much of Africa. The death toll from the disease is already more than one million a year, and it's rising along with rising drug resistance.

This January, the donor agency known as the Global Fund to Fight AIDS, Tuberculosis, and Malaria came under blistering criticism for continuing to give developing countries money to buy chloroquine. An article in the British journal The Lancet charged the fund with medical malpractice. International health scholar Amir Attaran of the British Royal Institute for International Affairs was the lead author.

"Money was being wasted in giving these medicines to patients and lives were being wasted when in fact they weren't cured of malaria and went on to die," he says.

Dr. Attaran said the Global Fund and others should be insisting that countries buy new, highly effective artemisinin-based drug combinations. He says money was the only reason they hadn't: artemisinin drugs cost ten times what chloroquine does.

But now another British journal, Nature, is reporting that the Global Fund has recently made the change. Countries buying malaria medicine with Global Fund money are now required to buy artemisinin drugs. Global Fund senior adviser Vinand Nantulya says the Lancet article was a factor.

"It's partly that, and partly not," he says. "It was a process that was already taking place. But I think that the article has accelerated the process."

Dr. Nantulya says a number of countries, including Ghana and Senegal, had already switched to artemisinin using Global Fund money and others had started the process. And he says the medical malpractice charge is unfair because the Global Fund did not refuse countries artemisinin drugs. But Dr. Nantulya says now that artemisinin is the only option, at ten times the cost, some patients might be refused care.

"If we do not increase allocations to these countries, they will treat 10-fold less patients than they would have treated with the old treatment regimens," he explains. "Therefore, we are left with a funding gap."

Dr. Nantulya says that gap adds up to nearly $1 billion over the next five years. He adds that the international community that finances the Global Fund will have to come up with the money.

Critic Amir Attaran says rich countries like the United States can afford to give more money to the Global Fund, but don't.

"The principal barriers right now are that the countries which should be paying for this and putting the money into the Global Fund are not," he says. "And in that sense, the United States is probably the worst country on Earth, because we are really very far behind what public expectations are for the Global Fund."

The Bush administration has proposed giving $200 million to the Global Fund next year. That's down sharply from this year's $547 million contribution. And Dr. Attaran criticizes the U.S. Agency for International Development (USAID) for not spending any money on artemisinin drugs.

"The United States government doesn't buy so much as one single dose of artemisinin combination therapy for so much as one single child in Africa," he says. "That has to change. And if it does change, then we might have the several hundred million dollars we need to do this properly and we might save several hundred thousand kids from dying."

USAID focuses on technical support rather than buying drugs, according to the agency's senior advisor Dennis Carroll. For example, he says it was U.S. government-sponsored research that showed artemisinin works in Africa. USAID gives money to other agencies, like the Global Fund, to actually buy the drugs. Dr. Carroll points out that nearly a third of the Global Fund's budget last year came from the United States. But he agrees with critics that the amount President Bush is proposing to give the Global Fund next year is not enough.

"Clearly, significantly more resources than the $200 million are needed," he notes. "And I think even beyond that, we need to look at much greater contributions being made by partners other than the United States."

Some European countries have also been criticized for not giving their fair share to the Global Fund. The fund expects to spend more than $3 billion next year, but so far it has received pledges of less than $1 billion. That leaves the fund short of money for all its activities, including the extra cost of buying artemisinin drugs.