United Nations Public Service Awards Case Studies

The legacy of apartheid in South Africa has resulted in a fragmented and discriminatory health system, such as a heavily overburdened primary health care sector and quite an advanced tertiary health sector. To address the former, government has decided to redistribute resources from the tertiary to the primary, the result of which is that both sectors are equally under-resourced. While the South African Constitution now recognizes the universal right of access to health care services, inadequate access to these services still plagues the lives of the majority of South Africans.
The national budget allocates R54.4 billion to Health, which is not insignificant vis-a-vis budgets for other sectors such as education and welfare. Unfortunately the politicization of the health sector has had negative consequences for the prioritization of funding in sectors that really matter. It has been recorded that since 1994, doctors and nurses have been leaving the country in droves. The increasing spread of HIV/AIDS throughout the country (917 deaths per day in 2006) and its associated epidemic Tuberculosis (529 320 cases in 2004, 66.4% HIV+) along with the chronic under-servicing and under-resourcing of the rural sector all have devastating consequences on infant mortality (48 deaths per 1000 live births), maternal health (3406 deaths between 2002 and 2004), and life expectancy (50.8 years). The result has been a decline in South Africa’s ranking on the Human Development Index. Whereas South Africa was rated 67th according to the Human Development Index in 1995, the most recent HDI ranked South Africa 121st.

What is the initiative about? (the solution)
The Phelopepa Health Care Train is a 16-coach train that travels to 36 remote rural areas each year, for a period of one week each, to provide primary healthcare services and health education to the rural poor. Services rendered on the train include: health screening, cancer screening, diabetes screening, eye testing and provision of spectacles, dental restorative processes and extractions, oral health education, individual counselling therapy and community counselling workshops. Patient fees are no more than R30, e.g. a health clinic consultation costs R2.50, dispensing a prescription costs R2.50, spectacles cost R30, and extracting a tooth costs R10. All of the train’s clinics and offices are equipped with computers and connected to the internet via satellite which enables its staff to transmit data, consult with other medical professionals and establish referrals and appointment times for individual patients. In its classroom, Phelopepa gives a full-time 5-day training course to 16 community members in basic healthcare measures. Graduates of this programme become volunteers in the community who disseminate the information they received from Phelopepa. Following the train’s departure, the Order of St John gives these 16 people a week of instruction in home-based care, with a focus on HIV/AIDS. Phelopepa also runs several community outreach programmes throughout the course of its stay. These include: a school outreach programme through which it offers screenings and examinations as well as oral health education to children at community schools and pre-schools in the surrounding villages; and a counselling outreach programme wherein staff visit local schools to conduct sessions with teachers, children and parents on a topic of their choice. The Phelopepa Health Care Train is increasing access to health care services in deep rural areas. Since its inception in 1994, the Phelopepa Health Care Train has reached over 4 500 000 people. The health clinic sees between 20-25 thousand patients each year. The eye and dental clinics see 120-150 patients per day. Phelopepa dispenses about 80 pairs of spectacles daily. Since 1994, counselling programmes have reached 263,570 people. More than 8,000 community members have been trained in basic health care and 1,443 people have received home-based care training. In addition, Phelopepa creates temporary employment for 50-60 local community members at each stop who provide translation services, record patients’ basic personal information, or work as cleaners, security staff and assistant cashiers. Such individuals earn between R30-60 for the week. Phelopepa is the only health care train in the world.

Who proposed the solution, who implemented it and who were the stakeholders?
The Phelopepa Health Care Train was conceived in 1993 as a 3-coach optometric clinic by the Rand Afrikaans University Department of Optometry and Transnet’s (a parastatal transport corporation) corporate social investment department. The Transnet Foundation, who took over ownership of the project, provided all of the funding for the initial stages of the project and currently funds about half of the train’s expenses. The Transnet Foundation is the implementing agency. Dr. Lynette Coetzee, the Transnet Portfolio manager, is one of the key people in creating and implementing the idea of the train. Phelopepa works with several government departments. The Department of Safety and Security provides security services to the train during its stays. The Department of Public Enterprises (DPE) regards Phelopepa as a flagship programme within Transnet, of which DPE is the major shareholder. The Departments of Social Welfare and Education support some of Phelopepa’s services by, for example, registering orphans for social grants at school outreach programmes. The Department of Health recognizes Phelopepa as a legitimate source of health care support and strives to inform as many people as possible about the train’s arrival. Transnet business units carry out much of the technical work required for the train’s operation. Spoornet and Transwerk conduct infrastructure maintenance, stock upgrading and technical assistance to the train. Transtel and Arivia.kom supply and maintain the communications equipment and services to the train including a satellite dish, telephones, and computer equipment. Private sector partners include Roche Products, the Colgate-Palmolive Foundation, and the Canon Collins Education Trust for Southern Africa (CCETSA). These partners offer some funding support; provide technical, provisional and logistical support; and share their expertise in subjects such as diabetic care, medicine, cancer treatment, oral hygiene, and education/curriculum development. St. John’s Red Cross Society (NGO) provides the week-long training courses in home-based care offered to graduates of Phelopepa’s 5-day basic health care training. For Phelopepa to secure credibility and function most effectively, it must establish community support, gather input and ensure community participation. A week ahead of the train’s arrival, a Phelopepa team arrives in the area that the train will be visiting and finalizes arrangements with the community. They engage in discussion with all local medical personnel in the area, and set up referral mechanisms. The team consults with local community leaders and authorities and selects 16 persons to participate in a week of health instruction on the train; and identifies individuals to be recruited for translation, clerical, cleaning and other services. They also identify the schools to be visited by outreach programmes and the village in which to hold Health Day activities.

Describe how and when the initiative was implemented by answering these questions
a. What were the strategies used to implement the initiative? In no more than 500 words, provide a summary of the main objectives and strategies of the initiative, how they were established and by whom.
Phelopepa’s primary objective is to deliver efficient, credible and cost-effective mobile healthcare services to poor rural communities where health care facilities are either inadequate or non-existent. In addition, the project seeks to enhance basic health care awareness in rural South Africa and to empower people to enhance their physiological and psychological health. The train makes visits to 36 locations in 4 provinces in one year and the remaining 4 provinces in the following year. Gauteng is excluded as the network and spread of its health services is considered to be superior to that of the remaining 8 provinces. Mobility is a key feature of Phelopepa’s operations. The Phelopepa Health Care Train can reach much larger numbers of people, being mobile, than it could if it were permanently stationed in one location. Since Phelopepa only visits each location for a week, it became clear to its implementers that something had to be done to ensure that their visit left a lasting impression and lasting benefits for patients. So, Phelopepa launched a health education programme to achieve maximum impact on the health of the communities they visit. This programme allows them to teach 16 people in each community basic health care procedures so that they can continue to treat and educate patients once the train has left. Reaching as many people as possible is the aim and object of Phelopepa’s outreach programmes. Not everyone is able or willing to come down to the train, so the train’s staff make visits in the community to conduct outreach activities. At each stop, Phelopepa staff also conduct 2 ‘Health Days’ in one of the local villages. This comprises of a full day of health-related activities in order to raise awareness about health and health care issues. Phelopepa hopes that health education and awareness will help community members to avoid contracting some preventable illnesses. Almost immediately after the inception of the original mobile optometric clinic idea, Transnet expanded its work to include primary healthcare and dental services because the need for these services in deep rural communities was so obvious. They later added psychological and diabetes programmes because the train’s staff had found a high number of cases in which the underlying cause of a patient’s physical complaint was either diabetes or something related to their psychological state. Still, Phelopepa offers only primary health care services. For chronic diseases like cancer and HIV/AIDS, they make referrals to the nearest hospital or clinic that can accommodate the patient. Phelopepa does not deliver ARVs, family planning or immunization drugs as these should be supplied by local state health facilities.

b. What were the key development and implementation steps and the chronology? No more than 500 words
The Phelopepa Health Care Train was conceived in 1993 as a 3-coach optometric clinic by the Rand Afrikaans University Department of Optometry and the Transnet Foundation. The Transnet Foundation, who took over ownership of the project, quickly decided to expand the range of health services the train offered and added another 12 coaches over the next two years, and subsequently an office coach. In 1994, the train had only the health clinic, and eye clinic onboard. In 1995, it opened a dental clinic. Phelopepa also opened its Edu-Clinic in 1995 where it gives its 5-day training course in basic health care. Outreach to schools began in 1995 with health, eye, and dental screenings. In 1996, Phelopepa opened its psychology clinic. In 2000, it began giving lessons in oral health to local school children. General health education in schools did not start until 2003. In 2002, Phelopepa launched its HIV/AIDS Action Programme in 27 districts across the Eastern Cape. 719 volunteers trained by Phelopepa facilitate the programme’s activities. In 2005, volunteers distributed 475,570 condoms, registered 16,978 child orphans with social services, and taught 21,535 individuals how to grow their own food gardens; in addition to providing HIV/AIDS counselling, awareness and education, and TB testing. In total, this programme has reached 2,997,204 people since its inception. The HIV/AIDS Action Programme was handed over to the Small Projects Foundation (NGO) in April 2006 because it was so successful that it grew too large for Phelopepa to manage on its own. Also in 2002, St. John’s Red Cross Society partnered with Phelopepa to provide a follow-up programme to the Edu-Clinic’s 5-day basic healthcare training in home-based care, with a focus on HIV/AIDS patients. The most recent programme to be attached to the Phelopepa Health Care Train was diabetes screening and education which began in 2005.

c. What were the main obstacles encountered? How were they overcome? No more than 500 words
Phelopepa can only visit locations where maintained railway lines are available. Until 2006, the Eastern Cape’s railway infrastructure was inadequate to support the Health Care Train. After seeing much of the good that Phelopepa had been doing elsewhere in the country, and recognizing the dire need for health care services in the mostly rural province, the Eastern Cape Department of Transportation conceded to invest in the refurbishing of their railway lines. Phelopepa has since been visiting the remote areas of the Eastern Cape. Weather-related obstacles are very difficult to overcome. Extreme cold, rain and hail are the worst of these. Because the areas that Phelopepa visits often lack road infrastructure, a very wet day might make it impossible for the staff to conduct outreach activities as they may not be able to get into the community. Hail can disturb satellite signals and make it very difficult to go about the business of making referrals and setting appointments with other doctors. These sorts of problems are inevitable and unpredictable. Given the rural nature of the places that the train visits—the lack of infrastructure, electricity, internet access etc.—there is little that Phelopepa can do to solve weather-related problems when they do arise. However, the communities they visit are often of great assistance in devising temporary solutions. In the past, getting universities to release their students to the train was difficult. Phelopepa realized that it had to provide something to the students that would really add value to their education. For example, Phelopepa invested in state of the art equipment for dentistry students. The project staff also worked on marketing the Phelopepa experience to universities as an essential to their students’ education. One of Phelopepa’s biggest concerns is that it cannot accommodate all of its patients at present. This is partially a result of the great need and poor health infrastructure in rural areas. To address the issue, Transnet has commissioned the project to build a second train which will enable the project to accommodate twice the number of patients per year (92 000 patients versus the current 46 000).

d. What resources were used for the initiative and what were its key benefits? In no more than 500 words, specify what were the financial, technical and human resources’ costs associated with this initiative. Describe how resources were mobilized
This initiative costs R25 million per annum, approximately R20 per person that it reaches. The train is equipped with its own generator, laundry and storage coach, kitchen car, dining car, and accommodation coaches. Onboard, there is an eye clinic with fully equipped optometric and refractory rooms, a dental clinic that contains 6 modern high-tech dental chairs, and a health clinic with 5 private consulting rooms. In addition, the train houses an x-ray clinic, a pharmacy, a counselling clinic, an office and a classroom. Phelopepa requires significant stocks of medical supplies and equipment for its clinics as well as computers, and appliances for kitchen and laundry facilities. Phelopepa also has 8 minivans which staff use to do outreach work as well as several hundred chairs and awnings for waiting patients. Everywhere the train stops, staff set up a satellite dish that allows for internet access and telephone services. Arivia.kom supplies and maintains the computer equipment. A seventeen-member team live permanently on the train and are assisted by 650 student interns per year who stay for 2 weeks at a time (37 students/2weeks). Interns are final year nursing, dental, optometry, pharmacy, clinical psychology and catering students, drawn from most major South African universities and training colleges. Their experience on the Phelopepa Health Care Train gives them the opportunity to practice what they have learned and helps to develop a sense of social responsibility. Phelopepa also employs 50-60 community members at each location to perform translation, clerical, cleaning, security, and cashier work.

Is the initiative sustainable and transferable?
This initiative is sustainable. It receives 49% of its funding from Transnet who, as the implementing agency, will continue to fund this initiative indefinitely. The rest of the project’s funding comes from a range of corporations including a few large companies like Roche Products and Colgate-Palmolive. Because of its successes, and its national and international exposure, Phelopepa is unlikely to see funding dry up in the near future. Phelopepa is also socially and culturally sustainable as a result of having achieved significant community buy-in and participation in each of the locations that it visits. Having been in operation for over 10 years, Phelopepa’s organizational structure, policies and procedures are well-entrenched. Phelopepa’s work follows a clear routine from week to week. The fact that Phelopepa can integrate 37 new staff every week without confronting serious problems or delays speaks to the abilities of project management to effectively structure and organize people, tasks, and time. The valuable experience that Phelopepa offers student interns makes it an attractive volunteer opportunity and has led to a consistent influx of student volunteers. The initiative is transferable. In fact, the Minister of Public Enterprises has requested that a second train be built, to be operational in 2008. While initially quite an expensive venture, Phelopepa is a cost-effective method of healthcare service delivery. The key aspect to replicate here is mobility, and not necessarily a train per se. In South Africa, a train works well because of the existing railway infrastructure that had previously served the mines and transported conscripted workers during the apartheid era to and from the mines. Also, a train can hold a lot of people and equipment and is able to expand simply by adding another coach. In another region, however, another mode of transport may be more feasible. The major requirements for implementing a similar initiative elsewhere are funding and access to medical supplies and human resources. The Phelopepa Health Care Train is a profoundly important initiative that deserves replication. It has received national and international exposure and some its staff have been recognized nationally. In 2006/07, Impumelelo Awards Trust awarded its top honour Phelopepa (R50 000) to disseminate information about its model of service delivery.

What are the impact of your initiative and the lessons learned?
This project is fortunate enough to have sustained support from its largest sponsor, Transnet. It also benefits from excellent financial management and stock control for medications, skills which most of the rural clinics in South Africa are currently lacking. Preparation is a key element to the success of the initiative. Project management is involved in extensive planning of almost every aspect of the train’s operations. Planning is thorough and Phelopepa staff have long checklists. They repeat the same routine each week, which has helped to ensure that the train runs smoothly and that there are no surprises. The selection of stopover locations and negotiations with community leadership including hiring of temporary staff, and logistics planning for community outreach activities are all finalized well in advance of each stopover. The commitment of the Phelopepa staff cannot be overlooked. They work long hours and live on the train away from their families for 36 weeks per year. It is an extremely demanding job that not everybody can do. Much of Phelopepa’s success rides on the competence and dedication of its staff members.


Institution Name:		Transnet Foundation
Institution Type:		Public-Private Partnership
Contact Person:		Lynette Coetzee
Title:		Managing Director
Telephone/ Fax:		+27-011-308-3141
Institution's / Project's Website:		+27-011-308-2927
E-mail:		lynette.coetzee@transnet.net
Address:		150 Commissioner Street
Postal Code:		2000
City:		Johannesburg
State/Province:		Gauteng
Country:		South Africa

The Problem

Solution and Key Benefits

Actors and Stakeholders

(a) Strategies

(b) Implementation

(c) Overcoming Obstacles

(d) Use of Resources

Sustainability and Transferability

Lessons Learned

Contact Information