Olivia LaFond

JSIS 201
Research Paper
March 10, 2013
The International Influences on South Africas Post-Apartheid Health Care System and the
Ability of its Citizens to Access Medicine

The Apartheid is a dark period in South Africas history. It was a time of racial
segregation, political authoritarianism, and isolation from the rest of the world. Emerging from
the period of African colonialism, the ideologies that shaped the Apartheid were built upon the
central motive of discrimination. The system originated during World War II when the National
Party of South Africa began enforcing racial segregation throughout the country on a Whitesupremacist platform. Beginning in 1948, social apartheid was delivered through a wealth of
legislation that segregated residential areas, banned inter-race marriage and sex, and created
separate transport, recreational, educational, and health facilities (Baker). Segregation of health
care was achieved by encouraging surplus Africans to move out of White areas in an attempt
to separate development and maintain White supremacy in the region (Price). During the
Apartheid, the countrys socioeconomic divisions were dictated by race. This system lasted until
1994, when Nelson Mandela became the president and a series of negotiations finally put an end
to Apartheid. South Africas slow progression out of a segregated society was marked by his
election as well as the implementation of the African National Congress (ANC), which continues
to rule the country today (Baker). The racial inequalities from the Apartheid era prevailed despite
this monumental change in the countrys politics, and therefore, the White minority in South
Africa still held a majority of the power and access to amenities.

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While this shift from an authoritarian government to a constitutional democracy was a
step in a positive direction, it also created new expectations for social improvements in the South
African society. This strong commitment to social change was overshadowed by the
transformation of a number of state institutionsframed by the global environment in which the
country found itself (Klug). South Africa had a large number of HIV/AIDS infected citizens
during the time of Apartheid, and the health conditions of the country did not instantly improve
when the authoritative state of the government was abandoned. However, due to many
immediate policy changes that occurred during the post-Apartheid period, it is surprising that the
HIV/AIDS epidemic was not dealt with in a more organized manner. Why did South Africas
post-Apartheid health care system remain unequal despite the domestic and international policy
changes that were put in place by the African National Congress? In this paper, I will argue that
the health care inequalities were the result of the countrys relationship with multinational
pharmaceutical companies as well as the adoption of the TRIPS (Trade Related Aspects of
Intellectual Property Rights) Agreement. First, I will explain the specific policy changes that
occurred in South Africa under the new African National Congress. Then, I will explain the
significance of the TRIPS Agreement and the multinational pharmaceutical companies, most
notably their influence on South Africas health care system. Finally, I will use the HIV/AIDS
epidemic in South Africa to analyze the implementation of these domestic policies and the
influence of international factors on the distribution of essential medicine. These pieces of
evidence will paint a clear picture of the persistent inequality that plagued South Africa after the
Apartheid.
The political revolution that occurred in South Africa in 1994 altered many aspects of
society, especially health care, which was strictly divided between the African majority and the

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White minority during the Apartheid. This shift in the nature of political leadership, as well as
the countrys interaction with many international policies, shaped the decisions that were made
about health care and the distribution of medicine. The government had a new goal of
broadening access to health care by integrating the public and private health care systems
(Klug). These intentions were associated with the improvements that were made during the
political transformation of the country. The improvements included the resource shift to the
primary health care level and the improvement of race representation in the health care
workforce (Baker). However, the integration of the public and private sectors proved difficult
because it lacked the implementation of a social health care insurance system as well as a
radical shift to the primary care level (Baker). These discrepancies in the domestic policy
changes that occurred after the Apartheid illustrate the fact that the country initially found it
difficult to escape racial segregation in health care. The health care system in South Africa was
also influenced by the prospect of multinational pharmaceutical companies providing medicine
to patients in the public and private sectors of society. The goal of integrating the public and
private health care systems would have easily accommodated for multinational pharmaceutical
companies to distribute medicine to all members of society. However, the politics involved in
communicating with these companies was multifaceted. It involved a reliance on trade
agreements, as well as negotiations with the developed countries regarding intellectual property
rights to medicine.
Initially, when the Apartheid ended in South Africa, the country was pressured to
reestablish international trade relations. This led to an overenthusiastic embrace of the TRIPS
Agreements presented by the World Health Organization (Klug). Prior to the implementation of
the TRIPS Agreement in 1995, developing countries were able to circumvent paying the

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expensive prices charged by multinational pharmaceutical companies by purchasing or
manufacturing comparable generic products for a small percentage of the market price (Bass).
The TRIPS Agreement established a framework that sets standards and conditions for the
protection of intellectual property (WHO). The WHO also states that TRIPS provides for a
number of safeguards which may be used to protect public health and promote competition.
Later, competition law was implemented in South Africa with the Competition Act of 1998. This
piece of legislation proposed multiple economic improvements, including the expansion of
opportunities for South African participation in world markets, while recognizing the role of
foreign competition within South Africa (Government Communication and Information
System). This new adjustment affected the governments policies by emphasizing market
orientation, but it was problematic for multiple reasons (Klug). The traditional concerns that
were associated with competition law were also present in South Africas economic and political
spheres, including the alteration of price setting, improper use of market power, exclusion of the
black majority of the market, and the racial structure of corporate ownership (Klug). These
economic policy changes were significant to the development of South Africas integrated health
care system, because they influenced the way in which the country interacted with multinational
pharmaceutical companies. South Africas adoption of these international trade agreements
occurred at the same time the country was eager to improve its economy, which means that the
downfall of health care was likely associated with the domestic concerns of competition law.
Although South Africa had the rare opportunity to transform their entire society after the
Apartheid, the developed countries influences made it difficult for the government to do so.
Since the trade agreements were focusing on South Africas market, this brought another issue to
the table: the access to medicine to those within the market.

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Intellectual property rights are directly connected to a countrys access to medicine.
Several industrialized countries have the property rights for medicines and immunizations, and
therefore they have the authority to make decisions about the prices and methods of international
distribution. Developing countries such as South Africa regularly have internal disputes over
both the affordability and distribution of medicine. The relationship between intellectual property
rights and the health care system illustrates the international influence that occurred through
economic facets. Intellectual property rights will inevitably produce inequalities, since the
market is focused on profit. This is a problem that South Africa encountered during the postApartheid era when they began interacting more with the international market. According to
Rawls, ignoring economic factors and incentives in favor of providing treatment to every
individual in need of medicinemay undermine the ability of a company to function as a viable
business (Gewertz). The profit-seeking pharmaceutical companies perpetuated the existing
racial inequalities in South Africa by catering to the citizens that were able to afford expensive
medicine.
Pharmaceutical companies need assurance of both a strong market and a patent
agreement in order to do business with a country. Patent protection for pharmaceutical products
necessarily entails balancing the interest of both private and public good (Gewertz). This aspect
of multinational pharmaceutical companies is relevant to the post-Apartheid health care system
in South Africa because it shows that these companies must value the interests of both the private
and the public sectors. While these patents benefit patients by providing economic incentive for
corporations to invest in costly research and development of new drugs, the downside for
developing countries is that price sensitive patientsoften can be priced out of the market
(Gewertz). Furthermore, paying for expensive pharmaceutical products licensed to extremely

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profitable international drug companiesintensifies the problems South Africa faces in meeting
its public health policy objectives (Bond). Bond argues that this issue was even more significant
in the South African society where patients have little access to treatment until full-blown AIDS
develops. The fact that developing countries are negatively affected by their interactions with
multinational pharmaceutical companies while developed countries prosper implies that the
presence of these companies did not aid South Africas progression into an equal health care
system in 1994.
The government had not been focused on combatting the AIDS epidemic during the
Apartheid. The authoritative government had been focused on segregating the population. Once
the ANC came into power, it was necessary to enter into international trade in order to gain
access to medicine and vaccines that fight HIV/AIDS. However, entering into international trade
compromised equality in the treatment of the many HIV-positive patients. During the
implementation of TRIPS, the widespread infection of HIV/AIDS became an epidemic in South
Africa. AIDS had spread to many South African citizens, which in turn affected other social
aspects of the society (i.e. education, family planning, employment). In 1993, the National
Health Department recorded that HIV infections had increased by 60% and by 1995, 2.1% of the
total population were believed to be HIV-positive (HIVSA). Preoccupied with the slow progress
to recover from the Apartheid, South Africa needed assistance from developed countries to fight
these diseases.
The AIDS epidemic accelerated the rebuilding of the South African health care system
that had been left fragmented after the Apartheid. The inability for the majority of South Africans
to obtain essential medicines exacerbated this terrible health care crisis. The price of medicine
was far too expensive for the majority of HIV-positive patients, and they were denied access to

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the medicine until the government rolled out the public sector program (Klug). The integration
of the public and private sectors allowed for this government program to be implemented.
However, the issues over intellectual property rights and the presence of pharmaceutical
companies initially stalled the process. The problems were not comprehensively addressed until
the ANC proposed four developments to the health care system in 1996.
The developments created preconditions for the confrontation over access to essential
medicines in South Africa, and they simultaneously began to combat the HIV/AIDS crisis.
Citizens were promised anti-retroviral treatment, which treated AIDS as a chronic condition. A
new constitution included a right to health among new socioeconomic rights. The South African
government adopted the GEAR (Growth, Employment, and Redistribution) plan, an economic
program designed to attract foreign investment by implementing strict fiscal discipline and
putting in place export-led development strategies. Finally, the establishment of the National
Drug Policy guaranteed access to essential medicines, regulating the pharmaceutical markets to
assure the supply of affordable drugs in public and private sectors (Klug). These developments
gave South Africans hope in the face of the HIV/AIDS crisis, and laid the groundwork for
accessing the essential medicines that the country desperately needed. However, globalization of
the pharmaceutical industry brought forth new issues that undermined these developments and
made it increasingly difficult for all of the citizens to access affordable medicine. Global
pharmaceutical industry sales rose from $22 billion in 1980 to more than $260 billion by the
mid-1990s and Third World countries adopted these tendencies despite structural adjustment
programs that drastically reduced most residents living standards (Bond). The conflicting
international power relations between developing countries and the pharmaceutical industry
stunted the progress that was possible in the 1990s (Bond). Although domestic developments

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allowed essential medicines to slowly become more available to the public and private sectors of
South Africa, Bonds evidence shows that health care remained racially unequal because
medicine was not affordable for a majority of the citizens. International agreements and pressure
from the pharmaceutical companies ultimately dictated the direction of the countrys health care
system in the 1990s.
The political institutions during and after the Apartheid set the stage for significant social
changes that inevitably occurred in South Africa. The nature of governments are an underlying
determinant of global health, which can likely explain why the political shift to a stronger
government caused the standards of health to rise dramatically in the country over a short period
of time (Gloyd). Although there were many positive changes that occurred regarding the ability
of poor citizens to access essential medicines, the HIV/AIDS epidemic did not achieve the
developments possible at that time due to underlying economic factors. South Africas battle for
access to HIV/AIDS medicine after the Apartheid is a case study that allows for analysis of the
ways in which governments interact with multinational pharmaceutical companies. South
Africas improvements in the political climate made negotiations with developed countries
possible, but they still faced the difficulty of granting health care at an affordable rate. The
countrys domestic policies, such as the implementation of competition law, and international
pressures, such as intellectual property rights increased South Africas willingness to interact
with foreign markets. This decision, in turn, caused South Africa to be overshadowed by the
developed countries competitive prices for medicine. Therefore, the international agreements
after the Apartheid maintained many aspects of the previously segregated society, despite the
domestic policy changes that were being made by the ANC. This made it difficult for the country

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to truly integrate the private and public sectors, and created an even more prominent demand
for medicine to fight HIV/AIDS.

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