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As the pharmaceutical industry confronts growing demands to improve global health and combat neglected diseases, a new analysis finds patchy progress as most efforts are undertaken by a handful of companies targeting only a few maladies in a small number of low and middle-income countries.

Drug makers are taking steps to reach people on very low incomes and R&D pipelines have grown, but patient access programs have been confined to just a few diseases, only some companies are tackling the risks of unethical sales behavior, and still fewer support international trade agreements designed to ensure the poorest people can benefit from medical innovation, according to the analysis.

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Some of the good news: the pipeline for priority diseases — such as HIV/AIDS, tuberculosis, and malaria — has more than doubled since 2014, reaching 285 projects. There were 447 medicines covered last year by equitable pricing strategies, up from 280 in 2016. Of 20 companies examined, 17 have set goals for ensuring access to medicines, and more boards now take direct responsibility for access issues.

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