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ANNECY, FRANCE — At first blush, the deal was hailed as a breakthrough.

Last fall, Novartis agreed to license a best-selling cancer drug so that generic companies could make copies for distribution to 44 low- and middle-income nations, marking the first time a voluntary license was arranged for a cancer medicine. Until then, such deals typically involved drugs for infectious diseases, such as HIV and hepatitis C. One public health official said it might point to a “paradigm shift.”

Yet for all the enthusiasm, the deal was also criticized for shortcomings that underscored uncertainty more broadly about voluntary licensing deals. And the future remains uncertain.

The thorny issues for the pharmaceutical industry and for public health were front and center at a late October gathering in this picturesque town in southeastern France, where Gilead Sciences, which has been at the forefront of voluntary licensing, assembled representatives from nonprofits, patient advocacy groups, and think tanks, among others, to brainstorm ideas.

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