A working group within the ANC headed by Human Sciences Research Council CEO Olive Shisana has provided an initial outline of the scheme. If it comes together as described, South Africans - in return for a small percentage of their earnings - will have access to free medical care for everything from primary health care, like coughs and colds, to sophisticated and expensive procedures by specialists. The services will be provided by a mixture of public and accredited private providers.

Olive Shisana - GPs to be accredited

Shisana, a former health DG, says the system will be based on two principles: the right to health - which will mean health services will be free at the point of use - and social solidarity, where the rich will contribute a percentage of their income to fund health services for the poor.

The size of the individual contribution being considered within the ANC’s working group is between 3% and 5% of personal income. The second and main source of funding for the NHI will be tax revenue. However, the health budget will need to rise beyond the current R62,7bn.

It is proposed that health expenditure should rise from 11% to 15% of total public expenditure, says Aquina Thulare, a member of the ANC working group.

But for it to work, an NHI would require that public-sector providers are elected as their first choice. This is because most schemes allocate funding on a per patient basis. But this would require a big overhaul of the public sector.

Because of the challenges in the public sector, this funding model is unlikely to be used immediately. "First we need to ensure standards are raised. Once we’ve done that, providers could be paid per patient. Otherwise the public sector will never improve," says Thulare.

Shisana agrees the first prong of implementation would be to "significantly strengthen the public sector".

The second prong will involve a more equitable and socially efficient distribution of health resources in the public and private sector.

Private-sector practitioners, like GPs, will be accredited as NHI providers because of their ability to provide services that meet quality standards and their willingness to accept NHI payment levels. "At the primary health-care level, private GPs can be accredited if they work in group practices, which include primary health-care nurses and a range of allied health professionals," says Shisana. Citizens would be able to choose between accredited providers in their area and would have an opportunity to change doctors within a window period.

The proposals are not yet in the public domain and Shisana’s statements to the FM are the first indication of what the ANC is thinking. They are also not yet in the domain of government, and government officials have not had a hand in the conceptual planning or been asked to crunch any numbers.

Because of the lack of information, industry and health policy experts say it is difficult to comment on the viability of Shisana’s proposals. However, one expert who has been privy to some of the work of the committee and who spoke anonymously has expressed grave misgivings about the proposal. The expert told the FM that "no sensible technical work" had been done and that the costing was "useless".

The biggest danger of an NHI for SA would be escalating costs, says the expert. If an NHI were implemented, a likely scenario would be that the use of private providers would increase and more people would use health services than now. Because private health-care unit costs are higher and utilisation rates would likely rise, costs would escalate. This, together with the administrative cost of the system, "could easily triple or quadruple the costs of the health system", says the expert.

Finance minister Trevor Manuel has also publicly expressed doubts. In an interview with the Sunday Times last week Manuel said that some of the election promises in the ANC manifesto, including an NHI, might not be possible under current economic conditions.

However, Thulare believes that a timeline of five years is easily achievable. "In other countries an NHI has been implemented within a year," she says. "It [the five years] is a realistic timeframe and we’ve been waiting for this for a long time. We cannot continue with a system where people have access to facilities only because they have private insurance."