How a travelling ‘health train’ has become a vital source of free healthcare in South Africa

JOHANNESBURG — Thethiwe Mahlangu woke early on a cold morning and walked through her bustling South African township, where minibuses honked to pick up commuters and smoke from breakfast stalls on the sidewalk hung in the air.

Her eyes had worried her. But instead of going to her nearby health clinic, Mahlangu went to the train station for an unusual form of care.

A passenger train known as Phelophepa — or “good, clean, health” in the Sesotho language — had been converted into a mobile health facility. It travels around South Africa for much of the year, providing medical care to the sick, young and old, who often struggle to get the care they need in overcrowded local clinics.

For the past 30 years — since South Africa broke with its former racist apartheid system — the train has carried doctors, nurses and ophthalmologists on a journey that takes in even the most rural villages, providing primary care to around 375,000 people each year.

The free care it provides is in stark contrast to South Africa’s overburdened public health system, on which approximately 84% of people depend.

Healthcare reflects the country’s deep inequality as a whole. Only 16% of South Africans are covered by health insurance, which is beyond the financial reach of many in a country with an unemployment rate of over 32%.

Earlier this year, the government began to address that gap. President Cyril Ramaphosa signed the National Health Insurance Act in May, which aims to provide funding so that millions of South Africans without health insurance can receive care from the better-resourced private sector.

But the bill is divided. The government has not said how much it will cost or where the money will come from. Economists say the government should raise taxes. Critics say the country cannot afford it and warn that the system — which has yet to be implemented — is open to abuse by corrupt officials and businessmen. They say the government should instead fix the public health system.

For Mahlangu and others who see the train as a rare source of free treatment, the situation at local health clinics is one of desperation.

Long queues, shortages of medicines and rude nurses are some of the challenges at the clinics in Tembisa, east of Johannesburg, which treat thousands of patients every day.

“We are not treated well there,” Mahlangu said. “We have to sit in the sun for a long time. You can sit there from 7 in the morning until about 4 in the afternoon, when the clinic closes. If you ask, they say we should ask the president to build a bigger hospital for us.”

The health train has grown over the years from a single three-car operation to two 16-car trains. They are run by the Transnet Foundation, a social arm of Transnet, the state-owned company.

When the train started in 1994, many black people in South Africa still lived in rural villages with little access to health care. It was a time of change in the country. The train started as an eye clinic, but it soon became clear that the needs were greater than that.

Now both trains cater to the rapidly growing populations of South Africa’s capital Pretoria and nearby Johannesburg, the country’s economic hub. You could spend two weeks in Tembisa alone.

“The big metros are really struggling,” said Shemona Kendiah, the train manager.

But the travelling clinic is far from the solution to South Africa’s healthcare problems.

According to public health expert Alex van den Heever, there have been significant increases in the health budget and the employment of nurses and doctors in the public sector since the country’s first democratic government in 1994. The budget of the Department of Health in Gauteng province, which includes Pretoria and Johannesburg, has grown from R6 billion ($336 million) in 2000 to R65 billion ($3.6 billion) today.

Van den Heever accused the African National Congress, the ruling party since the end of apartheid, of allowing widespread corruption that undermines the public sector, including health care.

“This has led to a rapid deterioration in performance,” he said.

For South Africans who have seen the decline first-hand, it may come as a relief as the health train rolls into town.

Mahlangu — with her new glasses — was one of hundreds of people who left satisfied with the train’s service and already looking forward to the train’s return next year.

Another patient, Jane Mabuza, received a full health check and dental care, and said she hoped the train would reach many more people.

“Here on the train you never hear that anything is finished,” she said.

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