JOHANNESBURG — Thethiwe Mahlangu woke early on a chilly morning and walked through her busy South African township, where minibuses hooted to pick up commuters and smoke from sidewalk breakfast stalls hung in the air.
Her eyes had been troubling her. But instead of going to her nearby health clinic, Mahlangu was headed 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 transformed into a mobile health facility. It circulates throughout South Africa for much of the year, providing medical attention to the sick, young and old who often struggle to receive the care they need at crowded local clinics.
For the past 30 years — ever since South Africa's break with the former racist system of apartheid — the train has carried doctors, nurses and optometrists on an annual journey that touches even the most rural villages, delivering primary health care to about 375,000 people a year.
The free care it delivers is in contrast to South Africa's overstretched public health care system on which about 84% of people rely.
Health care reflects the deep inequality of the country at large. Just 16% of South Africans are covered by health insurance plans that are beyond the financial reach of many in a nation with unemployment of over 32%.
Earlier this year, the government began to address that gap. President Cyril Ramaphosa in May signed into law the National Health Insurance Act, which aims to provide funding so that millions of South Africans without health insurance can receive care from the better-provisioned private sector.
But the law has been divisive. The government has not said how much it will cost and where the money will come from. Economists say the government will have to raise taxes. Critics say the country can't afford it and warn that the system — yet to be implemented — will be open to abuse by corrupt officials and businessmen. They say the government should fix the public health care system instead.
For Mahlangu and others who look to the train for a rare source of free treatment, the situation at local health clinics is one of despair.
Long lines, shortages of medicines and rude nurses are some of the challenges at the clinics that cater for thousands of patients a day in Tembisa, east of Johannesburg.
"There we are not treated well," Mahlangu said. "We are made to sit in the sun for long periods. You can sit there from 7 a.m. until around 4 p.m. when the clinic closes. When you ask, they say we must go ask the president to build us a bigger hospital."
The health train has grown from a single three-carriage operation over the years to two 16-carriage trains. They are run by the Transnet Foundation, a social responsibility arm of Transnet, the state-owned railway company.
When the train began in 1994, many Black people in South Africa still lived in rural villages with little access to health facilities. It was a period of change in the country. The train began as an eye clinic, but it soon became clear that needs were greater than that.
Now both trains address the booming population of South Africa's capital of Pretoria and nearby Johannesburg, the country's economic hub. One would spend two weeks in Tembisa alone.
"The major metros are really struggling," said Shemona Kendiah, the train's manager.
But the traveling clinic is far from the solution to South Africa's health care problems.
Public health expert Alex van den Heever said there have been substantial increases in the health care budget and the public sector employment of nurses and doctors since the country's first democratic government in 1994. The health department's budget in Gauteng province, which includes Pretoria and Johannesburg, has grown from 6 billion rand ($336 million) in 2000 to 65 billion ($3.6 billion) rand now.
But van den Heever accused the African National Congress, the ruling party since the end of apartheid, of allowing widespread corruption to undermine the public sector, including the health care system.
"This has led to a rapid deterioration of performance," he said.
For South Africans who have witnessed the decline firsthand, it can be a relief when the health train pulls into town.
Mahlangu — with her new pair of glasses — was among hundreds who walked away satisfied with its services and already longing for the train's return next year.
Another patient, Jane Mabuza, got a full health checkup along with dental services. She said she hoped the train would reach many other people.
"Here on the train, you never hear that anything has been finished," she said.
