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To order additional copies of this publication, please send an e-mail to the Transport Help Desk transport@worldbank.org Transport publications are available on-line at http://www.worldbank.org/transport/ Cover photo credits: Dominic Chavez Contents Acronyms......................................................................................................................................................................................................................6 Acknowledgements..................................................................................................................................................................................................7 Executive Summary..................................................................................................................................................................................................8 1. Introduction......................................................................................................................................................................................................13 2. Study Scope and Methodological Approach......................................................................................................................................17 3. Linkages Between Accessibility and Education & Health Outcomes: The Existing Evidence.....................................20 4. Overview of Health and Education Indicators, Commitments, and National and City-Level Policy Goals........... 29 4.1. Basic health and education indicators...........................................................................................................................30 4.2. National laws and commitments to relevant international human rights treaties on education and health access.......................................................................................................................33 4.3. National and city-level transport and urban development policies to improve accessibility to education and healthcare opportunities...........................................................................................41 5. Barriers to Health and Education Accessibility: The Categories Lens..................................................................................50 5.1. Evidence from household travel surveys, and policy documents...........................................................................51 5.2. Evidence from interviews with human rights practitioners......................................................................................60 6. Barriers to Health and Education Accessibility: The Spatial Lens...........................................................................................68 6.1. The spatial reach of the public transport systems......................................................................................................69 6.2. Availability of dedicated transport to schools and health facilities.........................................................................74 6.3. Distribution of education and healthcare facilities within the cities.......................................................................76 6.4. Accessibility to health and education facilities by public transport .......................................................................85 7. Policy Implications.......................................................................................................................................................................................111 8. Annexes............................................................................................................................................................................................................. 117 Annex 1: Accessibility analysis and recommendations for Bamako, Mali.................................................................... 118 Annex 2: Accessibility analysis and recommendations for Ouagadougou, Burkina Faso....................................... 129 References.............................................................................................................................................................................................................. 140 4 MOBILITY AND TRANSPORT CONNECTIVITY SERIES CONNECTIVITY FOR HUMAN CAPITAL Figures Figure 1: Travel by children to school, by mode, in Ouagadougou (by parent gender and household income).............................. 51 Figure 2: Distance to health facility as a barrier for seeking treatment at health facility in past 5 years among 15-49 year old women: in largest cities vs. among lowest-wealth quintile in country overall (%)................................................................................. 53 Figure 3: Availability/distance of transportation vs. transport cost as “the most important constraint” or “one of the main constraints” in accessing health services, by household income in Ouagadougou (% of respondents).................. 59 Figure 4: Population within walkable distance (1 km) of public transport (%) and average population density (pop./km2)........... 70 Figure 5: Examples of cities with public transport systems with relatively low coverage of populated areas.................................... 71 Figure 6: Examples of cities with public transport systems with relatively good coverage of densely populated areas................. 73 Figure 7: Access to dedicated school transportation in Douala (% of students)........................................................................................ 74 Figure 8: Hospitals and other advanced health facilities providing maternal care in Kampala.............................................................. 78 Figure 9: Advanced healthcare facilities and public transport network in Maputo................................................................................... 80 Figure 10: Hospitals and health facilities providing comprehensive obstetric care in Nairobi............................................................... 81 Figure 11: Share of schools within walkable distance (1 km) from public transport (%).......................................................................... 82 Figure 12: Share of advanced healthcare facilities within walkable distance (1 km) from public transport (%)................................. 82 Figure 13: Share of city population within walking distance (1 km) from nearest school or advanced healthcare facility (%)....... 84 Figure 14: Travel time by public transport to nearest advanced healthcare facility in Douala vs. Harare (min)................................ 85 Figure 15: Travel time by public transport to nearest advanced healthcare facility (min)....................................................................... 86 Figure 16: Travel time by public transport to nearest advanced health facility vs. nearest public advanced health facility in Conakry (min)............................................................................................................................................................................ 87 Figure 17: Travel time by public transport to nearest advanced maternal care facility in Kampala (min)........................................... 87 Figure 18: Average travel time by public transport to nearest primary school and nearest secondary school (min)...................... 89 Figure 19: Travel time to nearest primary school vs. nearest secondary school in Harare, Nairobi and Douala.............................. 89 Figure 20: Travel time by public transport to nearest primary school (min)............................................................................................... 90 Figure 21: Average walk time to nearest primary school (min) & population within 30-minute walk of a primary school (%)....... 91 Figure 22: Travel time to nearest primary school by public transport vs. by walking in Maputo (min)................................................ 91 Figure 23: Travel time by public transport to nearest primary school vs. nearest public primary school (min)................................ 92 Figure 24: Share of population able to reach an advanced healthcare facility by public transport within the time threshold...... 95 Figure 25: Share of population able to reach a primary school by public transport within the time threshold................................ 95 Figure 26: Share of population able to reach a secondary school by public transport within the time threshold........................... 97 Figure 27: Share of population able to reach specific types of schools by public transport within the time threshold in Ouagadougou and Conakry....................................................................................................................................... 98 Figure 28: Poverty distribution and travel time by public transport to advanced healthcare facilities in Ouagadougou............... 99 Figure 29: Poverty density vs. travel time by public transport to nearest public advanced health facility in Douala...................... 100 5 REALIZING THE RIGHT TO EDUCATION AND HEALTHCARE THROUGH IMPROVED PUBLIC TRANSPORT IN AFRICAN CITIES Figure 30: Poverty rate in Kampala at the Parish level, 2016/17 (%)........................................................................................................... 101 Figure 31: Poverty headcount in Kigali (%).........................................................................................................................................................102 Figure 32: Poverty distribution in Harare and its suburbs, 2012................................................................................................................. 103 Figure 33: Poverty distribution vs. travel time by public transport to nearest public hospital in Maputo......................................... 104 Figure 34: Nighttime light intensity vs. travel time by public transport to nearest public adv. health facility in Dar es Salaam.. 105 Figure 35: Poverty proxies vs. travel time by public transport to nearest public advanced health facility in Nairobi..................... 106 Figure 36: Accessibility and resource availability disadvantages in the lower-income neighborhoods of Bamako and Conakry...................................................................................................................................................... 108 Figure 1.1: Share of housing that is informal.................................................................................................................................................... 119 Figure 1.2: Inequality in accessibility: cumulative population share able to access the nearest facility by public transport........ 120 Figure 1.3: Locations and travel time by public transport to nearest facility............................................................................................ 121 Figure 1.4: Locations and travel time by public transport to nearest primary and secondary school............................................... 122 Figure 1.5: Bamako population (height) and accessibility to employment opportunities (color)......................................................... 123 Figure 1.6: Public transport and paved road networks.................................................................................................................................. 123 Figure 1.7: Transport networks and Bamako Circle boundary..................................................................................................................... 124 Figure 1.8: Land use patterns in Bamako Circle...............................................................................................................................................126 Figure 1.9: Policy menu for Bamako to improve accessibility to health and education services......................................................... 128 Figure 2.1: Locations and travel time by public transport to nearest facility............................................................................................ 132 Figure 2.2: Locations and travel time by public transport to nearest primary and secondary school............................................... 133 Figure 2.3: Inequality in accessibility: cumulative population share able to access the nearest facility by public transport........ 134 Figure 2.4: Public primary and secondary schools accessible to the average secteur resident by bus within 30 minutestransport................................................................................................................................................................. 134 Figure 2.5: Public transport and paved road networks.................................................................................................................................. 135 Figure 2.6: Transport networks and the Ouagadougou Department boundary..................................................................................... 136 Figure 2.7: Increase in the built settlements in and around Ouagadougou metropolitan area, 2001-2019................................... 137 Figure 2.8: Policy menu for Ouagadougou to improve accessibility to health and education services............................................. 139 6 MOBILITY AND TRANSPORT CONNECTIVITY SERIES CONNECTIVITY FOR HUMAN CAPITAL Acronyms ACHPR African Charter on Human and People’s Rights ICESR International Covenant on Economic, Social, and Cultural Rights ACPHR African Commission on Human and People’s Rights IDP internally displaced person ARV Antiretroviral JNA Joint Needs Assessment (Zimbabwe) BRT Bus Rapid Transit LGBTI Lesbian, gay, bisexual, transgender, and intersex CBD central business district LMIC Low- and middle-income countries CEDAW Convention on the Elimination of Discrimination Against Women MICS Multiple Indicator Cluster Survey CFA West African Franc NMT Non-motorized transport CMOC Comprehensive Obstetric Care facility NST National Strategy for Transformation (Rwanda) CRC Convention on the Rights of the Child NTP National Transport and Road Infrastructure Policy (Mali) CREDD Strategic Framework for Economic Recovery and Sustainable Development (Mali) NUP National Urbanization Policy (Rwanda) CRPD Convention on the Rights of Persons with OHCHR Office of the United Nations High Commissioner Disabilities for Human Rights CSCOM Community Health Centers (Mali) OSM Open Street Maps CSPS Community Health and Social Center (Burkina RWF Rwandan Franc Faso) SDG Sustainable Development Goals CSREF Referral Health Centers (Mali) SOCATUR Société Camerounaise des Transports Urbains END National Development Strategy (Mozambique) SOTRACO Société de Transport en Commun de FYDP Five Year Development Plan (Tanzania) Ouagadougou GKMA Greater Kampala Metropolitan Area SOTRAMA Société des Transports du Mali GMA Greater Maputo Area SSA Sub-Saharan Africa GTFS General Transit Feed Specification UN United Nations HIV Human immunodeficiency virus UNFPA United Nations Population Fund ICCPR International Covenant on Civil and Political UNICEF United Nations Children’s Fund Rights UPR Universal Periodic Review 7 REALIZING THE RIGHT TO EDUCATION AND HEALTHCARE THROUGH IMPROVED PUBLIC TRANSPORT IN AFRICAN CITIES Acknowledgements This study was led by Aiga Stokenberga (Transport Economist, IAWT4) and Karla Dominguez Gonzalez (Gender Specialist, IAWT4), and was implemented with technical inputs from Tamara Kerzhner, Xavier Espinet Alegre, Eulalie Saisset, Cecilia Escalante Hernandez, Ana Luiza Machado, Darlen Dzimwe, Rebecca Balis, Santiago Alfonso Dutto Bravo, Ryan Engstrom, Joshua David Merfeld, Harold Coulombe (all World Bank Consultants) and David Newhouse (Sr. Economist, EAWPV). Overall guidance was provided by Riccardo Puliti (Regional Director, IAWDR), Aurelio Menendez (Practice Manager, IAWT4), Camilla Marie Lindstrom (Sr. Program Officer, SSIGL), and Eva Kloeve (Program Manager, SSIGL). Lisa Warouw (Program Assistant, IAWT4) and Tatiana Daza (Sr. Program Assistant, IAET1) provided extensive administrative support. The team would like to express gratitude to the following World Bank staff and consultants who provided helpful advice or data: Transport and Urban Development: Cheick Diallo, Vincent Vesin, Mustapha Benmaamar, Lucien Barro, Adam Stone-Diehl, Emmanuel Taban, Ramon Munoz-Raskin, Benjamin Fouchard, Fatima Arroyo Arroyo, Rima Aloulou, Vivien Deparday, Paolo Avner, Andre Herzog, Megha Mukim Education and Health: Meskerem Mulatu, Sophie Naudeau, Ruth Karimi Charo, Karine Pezzani, Halil Dundar, Kirill Vasiliev, Yoko Nagashima, Ana Ruth Menezes, Marina Bassi, Tapfuma Ronald Jongwe, Mathieu Cloutier, Nelly Gwenaelle Bachelot, Boubakar Lompo, Himdat Iqbal Bayusuf, Vincent Perrot, Toni Lee Kuguru, Haidara Ousmane Diadie, Patrick Hoang-Vu Eozenou, Loredana Luisa Horezeanu, Peter Okwero, Rogers Ayiko, Christine Lao Pena, Chenjerai N. Sisimayi, Maud Juquois, Moussa Dieng, Djibrilla Karamoko, Moussa Dieng, Ibrahim Magazi, Anthony Theophilus Seddoh, Jean-Claude Fotso, Collins Chansa, Jeremy Veillard Poverty: Nga Thi Viet Nguyen, Shohei Nakamura, Keita Shimmei, Keith Garrett, Carolina Mejia-Mantilla, Takaaki Masaki, Nadia Belhaj Hassine Belghith, Rob Swinkels The report also benefited from peer review by Pierre Xavier Bonneau (Program Leader, IAWT4), Christine Lao Pena (Sr. Human Development Economist, HAEH1), Jozefien Van Damme (Sr. Operations Officer, HAWDR), and Yang Chen (Sr. Transport Specialist, IEAT2). Finally, the team is grateful to staff of the following organizations for sharing their insights on the broader con- straints to fulfilling the rights to health and education in the cities and countries covered by the study: Office of the United Nations High Commissioner for Human Rights (OHCHR) Kenya, OHCHR Burkina Faso, OHCHR East Africa, OHCHR Uganda, OHCHR West Africa, United Nations (UN) Zimbabwe, United Nations Population Fund (UNFPA) Zimbabwe, and FATE Consulting Ltd. (Rwanda). The study would not have been possible without the generous funding from the Human Rights, Inclusion and Empowerment Trust Fund (HRIETF). 8 MOBILITY AND TRANSPORT CONNECTIVITY SERIES CONNECTIVITY FOR HUMAN CAPITAL Executive Summary Despite having made tremendous progress in ensuring Empirical evidence is not conclusive about the main equal access to education and healthcare for its peo- factors affecting student achievement (Asahi, 2014), and ple, with school enrollment rates rising and children in researchers in the education field have typically focused most countries receiving the recommended preven- on traditional schooling inputs such as teaching qual- tative care, many countries in Sub-Saharan Africa ity (see, e.g., Rockoff, 2004) or class size (Krueger (SSA) remain at the bottom of the World Bank’s & Whitmore, 2001). However, a few studies have Human Capital Index and the United Nations (UN) explored the impact of school accessibility on inter- Human Development Index. The existing data also mediate education outcomes, finding evidence that suggests that women are being overlooked in the drive it is positive and especially so for the children on to develop human capital, and only slightly over half of the edge of failing: Dickerson & McIntosh (2013) found all primary school students continue schooling until last that shorter distance between the students’ home and grade. Issues of access loom large; millions of children their closest school is positively related with the prob- are not in school at all. ability that mediocre students continue into post-com- pulsory education; Falch et al. (2013) concluded that The past two decades have witnessed a large and reduced commuting time has a positive effect on gradu- growing policy and academic interest in the social impli- ation from upper secondary schools, and this effect is cations of transport planning alongside the traditionally larger for students with low academic achievement. well-studied economic and environmental outcomes (Lucas, 2012). It is generally accepted that access to The development of transport networks has the poten- healthcare is an important determinant of health status tial to lift people out of poverty in urban areas across (Probst et al., 2007). Intuitively, transportation barriers the developing world and contribute to the fulfillment lead to rescheduled or missed appointments, delayed of their equal Rights to Education and Health. Develop- care, and missed or delayed medication use; these con- ing regions and in particular SSA are rapidly urbaniz- sequences may lead to poorer management of chronic ing, which means that the supply of transport services illness and thus poorer health outcomes. Overall, the has to increasingly play catch-up with demand. This global evidence to date supports that transporta- challenge is further magnified by the form in which the tion barriers are an important barrier to healthcare growing urban areas are developing, some seeing rap- access, particularly for those with lower incomes or idly declining densities from the immediate cores, which the under/uninsured. Poor physical access to health makes the provision of affordable transport services facilities also in developing countries has been identi- unfeasible. Therefore, in the race to close the remaining fied as an important contributor to reduced uptake of human development gaps, through improved access of preventive health services, likely more so in low-income children to schools and of vulnerable population groups settings. Variable uptake of available health interven- to essential care, transport connectivity must be closely tions in SSA has been found to undermine healthcare coordinated with strategic interventions in overall urban programs and to play an important role in child and development and, particularly, the planning of hous- maternal mortality (Rutherford et al., 2010). ing and the facilities that provide schooling and health services. Moreover, the physical availability of school 9 REALIZING THE RIGHT TO EDUCATION AND HEALTHCARE THROUGH IMPROVED PUBLIC TRANSPORT IN AFRICAN CITIES facilities and clinics and accessibility to them must be coordination in facilitating access to essential ser- accompanied by the schooling and care being affordable vices is noted in nearly all of the Government-level as well as appropriate for all, implying that the education – both national and city-specific – policy documents and health services provided should be of high enough and future strategies. At the same time, the differen- quality also for the most marginalized of people. tiated education and healthcare access needs of the more vulnerable society groups – and targeted strate- This study aims to shine light on the extent to which gies on how to serve them – have received less atten- the national level commitments to ensuring edu- tion, and the definition of sector-specific goals is not cation and health for all are reflected in concrete commonly informed by analysis of the existing spatial transport, education, and health sector policies and patterns of exclusion. targets at the country and city level and, in turn, whether the reality on the ground in some of the This may explain why public transport connectiv- major urbanized areas in SSA is one of equal and ity to advanced healthcare facilities in particular adequate access. Focusing on ten large cities across remains low in some of the cities. Analysis of the SSA and applying not only spatial modeling tools but existing and new household data suggests that trans- also policy and survey analysis and insights from inter- port availability and distances that have to be traveled views with human rights and development practitioners rank among the main constraints for households to working in the region, the study provides new evidence bring their children to school and for people, includ- on the degree to which health and education opportu- ing specifically women in child-bearing age, to travel nities can be physically reached using the existing fixed- to healthcare facilities. This is consistent with findings route public transport systems. In doing so, it also iden- from the spatial modeling undertaken in this study, tifies who is being left behind – both across the urban which shows that average travel times by public trans- space as well as across different dimensions of mar- port to the nearest advanced health facility exceed half ginalization such as poverty, disability, gender, or their an hour in three of the ten cities (Harare, Bamako, and intersection. Because of the focus on public transport Ouagadougou), and reach nearly an hour in the latter. modes – mostly buses and minibuses – and walking, Average travel times to schools are lower, although are the results should therefore be interpreted as relevant consistently higher for secondary schools than prima- for most, but not all, of the city populations, as acces- ry ones, reaching nearly half an hour in Harare. When sibility by private cars or motorcycles is likely be higher compared to traveling to schools on foot, the exist- although will certainly come up against congestion con- ing public transport systems appear to offer variable straints if all or even most people were to rely on these degrees of “value-added”, depending on the city: the modes. Recognizing that the use of health services average travel time to the nearest primary school in and ability to meaningfully take advantage of educa- Maputo is nearly half an hour longer on foot than by tion opportunities may be only partly driven by physical public transport, while in the other cities the difference access barriers, the study also highlights the broader in average travel time is only a few minutes or none. constraints faced by certain marginalized groups. Mixed-use environments and transit-orient- Awareness of the role of transport connectivity ed development promote density around corri- and improved transport and land use planning dors and allow more people to be connected to 10 MOBILITY AND TRANSPORT CONNECTIVITY SERIES CONNECTIVITY FOR HUMAN CAPITAL opportunities more quickly. And, to develop effective In contrast, the average travel times to the nearest policies to improve accessibility, understanding what primary school do not vary as distinctly with any drives performance – transport or land use – is crucial. of the two variables that characterize the extent to In other words, how accessible are health and educa- which the city development is transit-oriented – the tion opportunities in a city is a product of the efficiency share of population living within walking distance of of the transport system itself and the city’s land use transit and the share of primary schools located within patterns – the extent to which the city’s development is walking distance of transit. This may be explained by “transit-oriented”, with higher population densities near the fact that in cities like Ouagadougou and Conakry, transit routes, and the degree to which its land use is where, mostly due to the sparsity of the public trans- mixed in the sense that health and education facilities port networks, a low share of people live directly near are locally available in the areas densely inhabited by transit and where a comparatively lower share of pri- people. The overall extent of the city, its compactness mary schools are directly near transit, these transport or sprawl, and the average population densities will also deficiencies are offset by a larger number of primary determine if key social services can be made directly schools per capita and by the wide presence of prima- accessible for all, given the elevated costs of doing so in ry schools directly within residential neighborhoods. sparsely populated, outlying areas. However, this might also be at least partly due to the technical performance (slow speeds, long headways) of In the ten cities in scope of this study, average trav- the public transport services, which reduce the value of el times to the nearest primary school are closely being near a public transport route in some cities (e.g., correlated with key land use planning indicators. Ouagadougou), and the sheer distances that have to be As might be expected, the correlation is the stron- traveled in yet others (Harare, Maputo). Finally, the fact gest with the share of the city population living within that population proximity to transport doesn’t appear to walking distance (1 km) of a primary school: the cities translate into better primary school access may have to with more mixed land use have distinctly lower average do with the way informal transport routes – which dom- travel times to the nearest school. The relationship is inate many of the cities in scope – are allocating them- also quite distinct with respect to the average popula- selves. As also noted by the interviewed development tion size per primary school: average travel times are practitioners, the informal transporters likely prioritize lowest in cities like Conakry, Douala, and Ouagadou- routes that are profitable, such as those used for daily gou, where a primary school exists per every couple of commuting to jobs and major economic activity centers. thousand inhabitants, and they are the highest in cities like Harare and Maputo where population per primary In the case of accessibility to secondary schools, the school exceeds 12,000. Finally, the overall average pop- overall correlation patterns with transport and land use ulation density of a city is also quite closely correlated planning characteristics are similar although the mag- with how long an average city resident has to travel by nitudes are lower. The correlation remains by far the public transport to reach the nearest primary school: strongest with the share of population living within a average travel times increase as population densities walking distance to a secondary school - i.e., the direct decline, with the average residents of the denser cities presence of secondary schools within residentially like Conakry, Douala, and Nairobi seeing distinctly lower dense neighborhoods. travel times. 11 REALIZING THE RIGHT TO EDUCATION AND HEALTHCARE THROUGH IMPROVED PUBLIC TRANSPORT IN AFRICAN CITIES Accessibility to advanced healthcare facilities hour each way are incurred (assuming use of public stands out as being comparatively more highly transport) by approximately the same share of peo- correlated with at least one transit-oriented devel- ple in each city except for Harare, where the share of opment indicator – the share of people living within accessibility-poor people in this case is much higher. walking distance of transit. Thus, average travel times In the case of advanced healthcare facilities, assuming to nearest facility are among the lowest in cities like a one-way travel time threshold of an hour as being Kampala, Douala, and Nairobi, where the vast majority acceptable, in four of the cities – Kampala, Douala, of residents live near at least one public transport route, Nairobi, and Conakry – accessibility is universal; in con- and it is by far the highest in Ouagadougou, where less trast, nearly one in four residents of Ouagadougou is than half of the population can reach a bus route within accessibility-poor. a 1-km radius from home. This might be indicative of the “value added” of public transport services specifical- Because of the spatial patterns of cities, in which ly for reaching these types of facilities; however, it could the poor and precarious neighborhoods are some- also be just a spurious correlation, in that the same times located on their outer edges, across all the cities in which many people live near transit also have cities for which detailed poverty maps were avail- wider availability of advanced healthcare facilities per able or could be constructed, the poor populations population. Also accessibility to advanced healthcare are estimated to incur somewhat higher travel facilities, similarly to accessibility to schools, remains the times not only to the nearest facility of a specific most strongly related to the direct presence of health- type but also to the nearest public facility specifi- care facilities within residential neighborhoods: travel cally. For example, the average residents of Kigali and times are distinctly higher in Ouagadougou, Harare, Ouagadougou have to travel for 17 and 57 minutes, and Bamako, where only between 7 and 12 percent respectively, to reach the nearest advanced healthcare of the urban residents live directly near an advanced facility, while the average poor residents of these cities health facility, and by far the lowest in Kampala, Douala, incur travel times of 27 minutes and 65 minutes. and Conakry, where over 80 percent do. While alleviating physical accessibility constraints is Despite acceptable average accessibility as mea- likely a necessary condition, it is not a sufficient one. sured by travel time to the nearest facility, the Accessibility inequality in many of the cities stems spatial analysis suggests that there is sometimes from marginalization along several dimensions, significant spatial inequality within the cities, with including not only physical access. In particular, the at least several percent of the city populations range of services and medication available in the facil- facing extremely long travel times, or “accessibili- ities vary by geographical location, and typically one ty poverty.” If assuming an acceptable one-way travel needs to travel for higher quality or higher complexity time by public transport of half an hour for primary treatments. Thus, even in areas where physical access school children, the share of those who are character- appears to exist, some groups have limited access to ized by accessibility poverty ranges from a few percent health services in practice, or there are supply-side fac- in Conakry and Nairobi, to over 15 percent in Hara- tors – such as limited staffing or resources (e.g., med- re and Maputo; only in Douala all children are within ications) available, or long wait times and crowding – half-an-hour of at least one primary school. In the case impeding access to schooling or healthcare in practice. of secondary schools, travel times in excess of half an The actual use of specific health facilities and schools 12 MOBILITY AND TRANSPORT CONNECTIVITY SERIES CONNECTIVITY FOR HUMAN CAPITAL is also driven by the subjective perceptions of quality, independently because of the lack of appropriate trans- whereby in some cities people prefer to travel to the port; this, in turn, particularly excludes blind people less physically accessible hospitals while foregoing the with lower incomes who cannot afford a guide. Simi- more nearby located medical centers or clinics. larly, access to healthcare by the elderly population is reportedly restricted due to mobility constraints relat- To provide a richer perspective on the variety of con- ed to transport affordability and lack of social support. straints faced by specific marginalized groups in Inadequate transport infrastructure was noted to accessing needed care and schooling, the study team represent a barrier for gender-based violence survivors conducted a series of semi-structured interviews with to access care services. Poor pedestrian infrastruc- key staff from human rights and development organi- ture – which is the main infrastructure children rely on zations working in the countries in scope of the study. to reach schools across all the cities in scope of this As suggested by these interviews, the extent to which study – was noted to limit walkability, disproportionately transport infrastructure and services represent a affecting children with disabilities. critical barrier to accessing health services is yet more intensified for women due to a combination Policy recommendation related to these findings of constraints related to gender norms, econom- need to be tailored to the specific city context – ic dependence, and transport availability. Similar- most notably, distinguishing between the need for ly, even in areas where physical access exists, some fundamental accessibility improvements and more groups have limited access to health services in prac- limited interventions to address specific spatial tice, such as due to limited affordability of the health gaps or marginalization-based constraints. Low- service itself and the time costs associated with the er-hanging fruit interventions include regular, disag- long wait times to receive care. gregated, sub-city data collection at the level of the transport user; strategic land use preservation by city Equality in access to education was noted to be governments anticipating future facility needs; improve- affected by physical access and transport gaps; ments of transport infrastructure, notably pedestrian inequality in quality; affordability; and the exclu- and cycling infrastructure that matters tremendously sion of specific groups, such as children living in city for accessing schools in particular; innovative schemes peripheries and informal settlements, “street” children, to serve lower or less predictable demand destinations and children with disabilities; and gender norms that through on-demand services; and the improvement of prioritize boys’ education over girls’ and impose heavi- the transport planning process to ensure that the voic- er household chore duties on women and girls. The es or the more marginalized transport users are equal- interviews also highlighted sexual harassment and ly heard. Longer-term but potentially higher payoff gender-based violence in public transport and while interventions include improvements in the metropoli- walking to or from school as key constraints for girls’ tan-scale transport and land use planning coordination, education in particular. including to ensure transit-oriented development and transit access to essential services facilities; reforms of The appropriateness of mobility systems for peo- the existing – often informal – public transport services; ple with disabilities was noted as a barrier for and addressing the supply-side gaps in health and accessing healthcare in several countries. For education, most notably the quality of service issues in example, blind people are reportedly not able to move public facilities. 1. Introduction 14 MOBILITY AND TRANSPORT CONNECTIVITY SERIES CONNECTIVITY FOR HUMAN CAPITAL Over the past three decades, the number of children liv- the context of low-quality primary education, being in ing in urban settings has increased by nearly a quarter, school matters: in Sierra Leone, for instance, a Multiple leading to concerns about available opportunities and Indicator Cluster Survey (MICS) literacy and numeracy services in cities. Globally, 43 percent of children lived in module showed that children between the ages of 7 cities in 1989, compared with nearly 55 percent today. and 14 still had better foundational skills than their out- The increase has been among the fastest in Africa, of-school peers even if they were receiving low-quality where nearly one half of children now live in cities, com- instruction. Reaching the remaining primary-school-age pared with less than one third in 1989 (UNICEF, 2019). children who are out of school globally will require dif- ferent strategies than the international community has In general, urban dwellers are better off than their rural deployed in the past – and a keener focus on equity. peers. They enjoy higher incomes and levels of educa- The children who remain out of school today are typi- tion, have access to more and better job opportunities cally among the most marginalized, impoverished, dis- and markets, and benefit from better infrastructure and advantaged and hard to reach. In some cities, sprawling services. These benefits have long been understood as unplanned urbanization has reduced the proximity of conferring an ‘urban advantage’ on people who live in many impoverished and marginalized urban house- cities, including children. A closer look at the evidence holds to essential services. The quality of services on reveals fissures in the urban advantage narrative, the urban periphery is often poor; in some slum areas, however. In reality, a considerable share of children in services may not even exist. urban areas have been left behind, living in pockets of poverty and deprivation. Analysis by international The Right to Education is defined as one of the fun- development organizations has identified enormous damental human rights in the Universal Declaration inequalities in urban areas, with children from house- of Human Rights, as is the Right to Equality – a con- holds in the richest quintile enjoying a large advantage cept that is multi-faceted and encompasses equality in on every indicator – such as education, immunization, access to all life quality enhancing opportunities such and overall mortality – over children from households in as education and healthcare. The right of everyone to the poorest quintile. The large advantage of wealthier enjoy the highest attainable standard of health and urban households pulls up the averages for all children the right of everyone to education are also recognized who live in cities, giving the impression that they are in the International Covenant on Economic, Social and better off than their rural peers. This effect is especially Cultural Rights. Interpreted in practice, the realization pronounced in cities and towns with large slums and of these rights requires that conditions are put in place many children living in the streets. that assure to all members of society that medical ser- vices can be accessed in the event of sickness; and that Over the next 50 years, Africa will be the continent primary and secondary education are made both avail- with the largest cohort of primary and lower-second- able and accessible to all. ary-school-age children in the world – 40 percent of the global total. Already today, the populations of most Agenda 2030 for Sustainable Development, similarly, is African countries are overwhelmingly young, with half grounded in the commitment to leave no one behind or more of the residents aged 15 or less (e.g., SSATP, and recognizes that there is a need to operationalize 2018a). There is preliminary evidence that even in human rights in development work. Universal access 15 REALIZING THE RIGHT TO EDUCATION AND HEALTHCARE THROUGH IMPROVED PUBLIC TRANSPORT IN AFRICAN CITIES in urban areas is embodied in two targets of the Sus- The stark human development gaps contribute to tainable Development Goals (SDG): 9.1 and 11.2. The SSA remaining the world’s poorest and most unequal first of these aims to develop infrastructure to support region in terms of income: it is home to 8 of the 10 economic development and human well-being, while most unequal countries in the world, as measured by the second aspires to provide sustainable transport the Gini coefficient. Importantly, SSA is also the fastest systems for all, with a focus on public transport. Final- urbanizing region in the world, and most large cities in ly, the Habitat III New Urban Agenda underlines the SSA are growing at annual rates exceeding 5 percent. need for accessible cities, and focuses on equal access Importantly, urbanization in Africa is occurring at a low- to all services, including transport. It stresses “age and er level of income than other regions, with implications gender-responsive planning and investment for sus- on the region’s ability to develop efficient and sustain- tainable, safe, and accessible urban mobility for all”, and able urban systems. With rapid urbanization, also pov- supports a focus on the needs of marginalized groups erty and unequal access to schooling and healthcare (Mason et al., 2017). are becoming increasingly urban issues; solving them requires robust evidence on the full set of constraints The Sub-Saharan Africa (SSA) region has made tremen- that prevent the poor and the marginalized from realiz- dous progress in ensuring equal access to education ing their rights to education and healthcare and ensur- and healthcare for its people. Schooling has expanded ing decent quality of life. almost universally in the past decade, with the gross primary enrollment rate rising from 68% in the 1970s to With Africa’s rapid urbanization, urban transport con- above 100% in 2010. Moreover, as noted by the recent nectivity is becoming central to equal physical access World Development Report on learning, previously mar- to education and healthcare. Public transport serves ginalized groups, especially girls, are now much more most motorized travel in SSA cities today but is often likely to start primary school (World Bank, 2018). inefficient or not reachable for certain socioeconomic groups such as women and the poor. Transport con- Nevertheless, the region continues to lag behind other sumes around 40 percent of income of the poorest parts of the world. Most African countries rank in the urban households, leaving less for education, health, bottom of the World Bank’s Human Capital Index and and other basic needs. In individual countries, expen- the United Nations (UN) Human Development Index. ditures on travel to schools have been found to be on The existing data also suggests that women are being par with those on school fees, while travel to medical overlooked in the drive to develop human capital. Only centers costs double the medical cost. The existing 55 percent of primary school students remain until last evidence points to stark inequalities in the coverage of grade, and only 79 percent of young (15-24 y/o) males public transport services within the cities, with people and 72 percent of young females in SSA are literate. in the poorer neighborhoods depending on walking for Africa has the largest return on education of any con- most of their trips. tinent, with each additional year of schooling raising earnings by 11% for boys and 14% for girls. But issues National and city governments in SSA are starting to of access loom large; about 50 million children are not recognize the importance of ensuring urban mobility in school at all. Differences in access to schooling lead for all by improving the existing public transport sys- to impacts that persist for several generations. tems and have called for World Bank’s assistance to 16 MOBILITY AND TRANSPORT CONNECTIVITY SERIES CONNECTIVITY FOR HUMAN CAPITAL do so. Over the past few years, Bus Rapid Transit (BRT) The World Bank’s twin goals of reducing poverty and projects have been put in place or are starting to be boosting shared prosperity imply the need to better planned with World Bank financing in Dar es Salaam, target development interventions to ensure that the Dakar, Abidjan, and Douala, with several other cities, most marginalized groups of the population have an such as Ouagadougou and Kigali, considering simi- opportunity to equally participate in economic develop- lar solutions. A departure from past practice is also ment. The Human Capital Project is an effort to acceler- the growing aspiration of the World Bank’s Transport ate the accumulation of human capital by encouraging Global Practice to help the client governments design more effective policies and investments. Progress on public transport systems in a way that measurably con- the ground, however, requires political leadership and tributes to human capital objectives and allows reduc- action in key areas, such as committing to equity and ing spatial and socio-demographic divides in accessibili- inclusiveness. Generating empirical, cross-sectoral evi- ty to opportunity. dence and disaggregated data on the existing inequal- ities and on who is being left behind and why is a step Transport connectivity and human capital indicators towards boosting such leadership. in SSA are highly correlated at the country level; for example, there are strong correlations between a The current study aims to contribute to this import- country’s Rural Access Index – or the share of the rural ant agenda by generating knowledge on the state of population living within 2 km of an all-season road – inequality – across space and across urban citizens and adult literacy, primary school completion rates, characterized by different types of marginalization – in and maternal mortality ratios. Comparatively much less accessibility to health and education services in ten complete is our knowledge of the level of accessibili- large African cities. The analytical outputs aim to ulti- ty – and the inequality in accessibility across space and mately inform the design of urban transport opera- across socio-demographic groups – that exists within tions that are sufficiently tailored to realize the rights to SSA’s rapidly growing cities. A more fine-grained under- education and healthcare by marginalized groups, with standing of gaps in physical accessibility to schools the intended long-term outcomes of improved develop- and health centers and their linkages to gaps in actual ment effectiveness and overall more streamlined reflec- health and education outcomes is needed to better tion of the equal rights to education and healthcare in plan and target physical connectivity investments and the international development organizations’ transport policies, including public transport improvements and sector country engagements. fare subsidy programs. With the growing pipeline of BRT and similar projects in the region, each requiring upfront financing of between US$150 and US$300 mil- lion, such an understanding is imperative for maximiz- ing the World Bank’s impact in terms of human capital outcomes and the realization of the equal rights to education and healthcare. 17 REALIZING THE RIGHT TO EDUCATION AND HEALTHCARE THROUGH IMPROVED PUBLIC TRANSPORT IN AFRICAN CITIES 2. Study Scope and Methodological Approach Photo credits: Dominic Chavez 18 MOBILITY AND TRANSPORT CONNECTIVITY SERIES CONNECTIVITY FOR HUMAN CAPITAL The study adopts an inherently cross-disciplinary and Accessibility-Human Capital linkages: The study sets mixed-methods approach to start to build a knowledge out by providing an overview of the importance of base on the spatial and socio-economic group specif- improved physical accessibility to education and health- ic accessibility inequalities in the selected cities. These care facilities, as revealed by a comprehensive review of include several from each African sub-region: Kigali, the existing published literature. Nairobi, Dar es Salaam, and Kampala in East Africa; Harare and Maputo in Southern Africa; and Douala, Human rights commitments & transport policy goals: Bamako, Conakry, and Ouagadougou in West and Next, we review the commitments the countries in Central Africa. scope of the study have made with respect to providing universal access to health and education. In addition, The study addresses the following key questions: we summarize the city-specific and national policy goals – to the extent that such goals have been defined at all 1. How well do the existing public transport systems in – in the urban transport sector with respect to physical SSA’s cities connect people to education and health- accessibility to health and education opportunities for care opportunities? What are the drivers of inequal- all, and the strategic goals regarding health and educa- ity in accessibility across the cities – is inequality tion outcomes defined in the country and city specific mostly explained by the characteristics of the public health and education sector plans. transport systems, or, rather, other factors such as degree of transit-oriented development or mixed- Data assembly and mapping: The study geo-located use planning? health and education facilities (hospitals, clinics, primary and secondary schools) in each of the cities, through 2. Who is being left behind? Are there spatial and assembly of existing spatial datasets via collaboration socio-demographic (gender or income-based) with the World Bank’s Health and Education Global inequalities in accessibility within each city? Practices. Characteristics of interest include the level of care or education provided (for instance, availabili- 3. What are the constraints to accessibility specific to ty of emergency obstetric care) and the private versus women and girls, the poor, or to people who expe- public status. For each city, population distribution rience multiple grounds of marginalization? What data were mapped at a fine spatial resolution, overlay- other barriers besides transport connectivity – such ing the locations of health facilities and schools and as cultural norms, lack of security in public transport the public transport network geo-spatial data. Poverty – prevent certain groups in the society from access- data at various spatial resolutions, depending on the ing health and education services, and how import- city, was obtained with technical input from the World ant are these compared to transport connectivity Bank’s Poverty Global Practice. Original poverty analy- challenges? sis and mapping using existing Census and nighttime lights data was undertaken for several cities where such 4. What are the linkages between inequality in the maps did not yet exist. physical accessibility to schools and health centers and actual education and health behaviors and intermediate outcomes, as revealed by the global evidence to date? 19 REALIZING THE RIGHT TO EDUCATION AND HEALTHCARE THROUGH IMPROVED PUBLIC TRANSPORT IN AFRICAN CITIES Accessibility analysis: Using the mapped spatial data A broader perspective on access constraints: A lim- of schools and health facilities, the study used spatial itation of the transport system accessibility approach modeling tools to estimate physical accessibility to is its aggregate nature, which can establish general schools and health facilities, by type, comparing across spatial patterns of access but does not provide detailed the cities. The analysis also disaggregated results for information on how specific segments of the popula- the overall city population versus the poor population, tion have experienced the system (Delmelle & Casas, where possible, and analyzed the within-city inequali- 2012). To complement the “spatial lens” on accessibility ty in accessibility. To better understand the drivers of inequality, the study adopts a complementary “cate- varying accessibility across the cities, the study derived gories lens”: through analysis of existing household a number of different transport and land use plan- travel survey data and semi-structured interviews with ning indicators, such as the degree to which each city’s international human rights and development organi- development can be characterized as “transit-oriented” zations working in the countries covered by the study, and the presence of schools and healthcare facilities the study uncovers the transport-related barriers to directly within residentially dense neighborhoods (i.e., education and health access faced by specific margin- land use that is “mixed” rather than segregated). alized groups, such as women, girls, the poor, and the disabled, and presents them in the broader suite of Modeling public transport accessibility has a long his- challenges these groups have to overcome to be able tory with a trend towards increasingly sophisticated to realize their Rights to Health and Education. measurements; several types of indicators of public transport accessibility can be identified (Fransen et al., 2015). The first type measures the physical accessibility to the public transport system in terms of the proximity of people to transit. A second type of indicator addi- tionally accounts for the technical characteristics of the public transport systems. Third, in addition to physi- cal accessibility to the transit system and the level of service offered by the system, some indicators account for the time or cost associated with the journey to the considered destinations. In this approach, a routable transportation network is constructed, increasingly rely- ing on General Transit Feed Specification (GTFS) data,1 whereby travel time analysis to destinations such as schools and hospitals can be conducted by considering published timetables based on average travel speeds of public transport vehicles. The current study applies all these metrics to gain a better understanding of the drivers of accessibility inequality across cities. 1 Other recent studies that have applied GTFS data to estimate transit travel times at different times of the day include Farber et al. (2014) for accessibility to supermarkets, Peralta-Quiros et al. (2019), Ma & Jan-Knaap (2014), and Owen & Levinson (2014) for accessibility to employment, and Fransen et al. (2015) to hospitals, supermarkets, and daycare centers. 20 MOBILITY AND TRANSPORT CONNECTIVITY SERIES CONNECTIVITY FOR HUMAN CAPITAL 3. Linkages Between Accessibility and Education & Health Outcomes: The Existing Evidence Photo credits: Hendri Lombard 21 REALIZING THE RIGHT TO EDUCATION AND HEALTHCARE THROUGH IMPROVED PUBLIC TRANSPORT IN AFRICAN CITIES Good transportation allows people to reach a high transit system rather than by the transit system. There number of destinations within a certain threshold, or are exceptions, however, such as the comprehensive reduce their travel time to preferred destinations (Foth study of the Bay Area, California, by the Transportation et al., 2013). “Spatial accessibility” is one of the most for Healthy Communities Collaborative (2002, p.22), commonly used terms in the transportation geography which measured accessibility to healthcare facilities by literature (Delmelle & Casas, 2012), being a measure of public transport, defining “Transit-Accessible” facilities the ease of traveling from an origin to a destination via as those which can be reached by a 30-minute tran- a given mode of transport (Guagliardo, 2004). Authors sit trip or a half mile walk. While indicators such as the such as Martens (2012) and Martens et al. (2012), spatial coverage of walk catchments around public among others, have argued that access or accessibility transport stops are insightful in identifying socio-spa- is the most appropriate measure of benefits from trans- tial differences in access to the public transport system portation plans and investments, and thus should be (thus revealing how well transport planning is coor- the focus of any effort to understand and measure the dinated with land-use planning), they do not provide impacts of transportation investment programs. In the much insight into whether the system brings people same way, Kevin Lynch (1981), one of the top thinkers to desired activity locations within an acceptable travel on cities and urbanism, considers access to be both the time (i.e., the quality of the transport system itself), and reason cities have flourished and the metric by which they ignore that inadequate proximity to public trans- they are judged. In planning vernacular, access is gen- port provision can be compensated by local availability erally taken to be a function of the number and quality of amenities (i.e., mixed use neighborhoods). In other of activities that can be reached given a set of temporal, words, providing access to the transport system itself is monetary, social, cultural, technological and physical an important first step; however, if the system does not constraints (see Hanson & Schwab, 1995). Such con- enable residents to reach essential activities or oppor- straints can include poor knowledge of opportunities, tunities throughout the city, its objectives will not have limited financial means, and physical separation from been met (Delmelle & Casas, 2012). Similarly, mea- opportunities and a lack of the transportation resourc- sures such as the supply of healthcare options within a es that enable people to overcome that physical sepa- certain geographic area can lose validity in congested ration (Morris, 2011). However, despite a prolific litera- urban areas (Guagliardo, 2004) where getting to even ture on accessibility studies, focus on cities in develop- nearby located facilities may be difficult. ing countries has been limited (Kneeling, 2008). The concept of spatial accessibility in health and educa- The past two decades have witnessed a large and tion matters because schooling and health outcomes growing academic and policy interest in the social impli- are determined by more than just the availability and cations of transport planning alongside the traditionally quality of healthcare and schooling. They also directly well-studied economic and environmental outcomes depend on factors such as whether teachers report (Lucas, 2012). Accessibility may be measured in many for work (Filmer, 2003). On the so-called “demand side” ways (see Geurs & van Wee, 2004, for a thorough of education and healthcare, benefits and costs deter- review of accessibility measures). However, much of the mine how much an individual invests in education or empirical work to date has explored these connections health. Costs include both direct and indirect; among by examining social disparities in access to the public the former, user fees, textbook fees, drug costs but 22 MOBILITY AND TRANSPORT CONNECTIVITY SERIES CONNECTIVITY FOR HUMAN CAPITAL also transport costs are likely to be the most import- determinants of health and health inequalities through ant. There is a wide range of downstream outcomes the implementation of appropriate interventions. of good physical accessibility to health and education What is needed is evidence about which interventions facilities, among others, on the demand side, student are effective and for whom (Bambra et al., 2009). Evi- school enrollment and attendance, patient usage of dence-based and replicable spatial indicators relevant medical centers, regularity of anti-natal visits; and, on to transport policy are needed to monitor pathways for the supply side, provision of medical and school sup- health behaviors and outcomes and inform planning in plies and retention of medical professionals and teach- this field (Badland et al., 2015). ers (lower staff turnover). Morris (2011) posits that inadequate access will lead to suboptimal life outcomes Penchansky & Thomas (1981) described access in five in a large number of spheres. These include, in health, dimensions: availability, accessibility, accommodation, poor knowledge of healthcare options, a constrained affordability, and acceptability, where the latter three health care facility choice set (substandard care might do not relate to spatial relationships but rather reflect have to be accepted), and needed appointments may healthcare financing arrangements and cultural factors. be foregone; and, in education, less opportunity to Guagliardo (2004) proposed two main spatial dimen- access educational facilities, trips to desired educational sions of access – spatial accessibility (availability and opportunities must be foregone, travel time crowds out accessibility in a geographic sense) and aspatial accessi- education time, and education trips are more oner- bility (dependent on social class, income, ethnicity, age, ous, physically and temporally. Inaccessible services sex, etc.) – and delineated four categories of spatial raise the effective price of healthcare and schooling, accessibility measurements: provider-to-population which results in higher mortality and lower educational ratios (the so-called regional availability approach), dis- achievement (Filmer, 2003). tances to the nearest provider, average travel imped- ance to a provider, and gravity models. Similarly, Khan (1992) classified access to healthcare according to two Health dichotomous dimensions: potential versus revealed, and spatial versus aspatial. Badland et al. (2015) pro- Transportation is linked to health through the concept posed a conceptual model from a public health per- of access. It is generally accepted that access to health spective to demonstrate how multiple pathways of care is an important determinant of health status transport impact health behaviors and outcomes in (Probst et al., 2007). Primary care is recognized as the Victoria, Australia; and identified spatial indicators poli- most important form of healthcare for maintaining cy-makers and planners could apply over a given region population health because it is relatively inexpensive, to determine how measures of transport support or can be more easily delivered than specialty and inpa- hinder health behaviors and outcomes. tient care, and if properly distributed it is most effec- tive in preventing disease progression on a large scale Intuitively, transportation barriers lead to rescheduled (Guagliardo, 2004). or missed appointments, delayed care, and missed or delayed medication use; these consequences may In health policy, including in developing countries, lead to poorer management of chronic illness and thus there is increasing pressure to tackle the wider social poorer health outcomes. Syed et al. (2013) synthesize 23 REALIZING THE RIGHT TO EDUCATION AND HEALTHCARE THROUGH IMPROVED PUBLIC TRANSPORT IN AFRICAN CITIES the literature on the prevalence of transportation bar- setting in the U.S. Logistic regression models found riers to healthcare access, reviewing 61 peer-reviewed that some of the key characteristic predicting inability studies. Overall, the evidence supports that transpor- to keep an appointment included not using a car to the tation barriers are an important barrier to healthcare last kept appointment and not keeping an appointment access, particularly for those with lower incomes or the in the past due to transportation problems. Buchmuel- under/uninsured. ler et al.’s (2006) studied hospital closures in Los Ange- les County between 1997 and 2003 and their effect Jones & Lucas (2012) sought to highlight the impor- on distance to the nearest hospital; they found that tance of understanding the social impacts and con- increased distance to the closest hospital increased sequences, and the distributional effects of transport deaths from heart attacks and unintentional injuries. decision-making. They point out that different kinds of For residents with health insurance, increased distance social impacts are manifest over different time periods. was found to shift regular care towards doctor’s offic- Some have primarily short-run outcomes, where the es, and seniors in particular perceived more difficulty impacts are directly associated with a transport sys- accessing care. Arcury et al. (2005) analyzed the asso- tem or policy intervention (e.g. travel time savings, or ciation of transportation and healthcare utilization in a collision reductions), while others occur over the lon- rural region in the U.S. They found that, controlling for ger term and are less direct; they may be cumulative personal characteristics, health characteristics, and dis- in nature and result from interactions among several tance, those who had a driver’s license had 2.29 times short-run outcomes. These long-run consequences are more healthcare visits for chronic care and 1.92 times likely to include health condition, social exclusion/inclu- more visits for regular checkup care than those who did sion, social capital, etc. not. Fortney et al. (1999) showed that travel distance affected the probability of utilization of mental health Many studies have assessed the link between transpor- and alcoholic treatment services. Athas et al. (2000) and tation access and health outcomes in the U.S. When Nattinger et al. (2001) found increasing travel distance getting to healthcare services is a barrier, patients often to be associated with decreased utilization of breast end up not seeking care, missing appointments, or cancer treatment. Basu & Friedman (2001) found that delaying care until a condition deteriorates and requires children living in areas with lower primary care avail- emergency attention (Transportation for Healthy Com- ability were more likely to travel greater distances for munities Collaborative, 2002). Guidry et al.’s (1997) ambulatory care sensitive conditions (ACSC) inpatient study of cancer patients in Texas found that patients, services, the implication being that disease rates were particularly minorities, opt to forgo needed care in the higher in these areas. Pesata et al. (1999) developed absence of available and affordable means of transpor- a descriptive study to analyze families’ perceptions of tation. Inadequate transportation to pediatric facilities barriers to attending clinic appointments, surveying in Boston was found to be the largest barrier identified 200 participants with a history of missed appointments, by Latinos when asked why they did not bring their mostly families headed by single mothers. Their analysis children in for treatment or checkups (see Flores et found that families identified transportation problems al., 1998). Yang et al. (2006) investigated the impact of as one of the key barriers. Welty et al. (2010) sought to transportation problems on households’ ability to keep determine whether limited transportation affects medi- healthcare appointments for their children in an urban cation adherence in patients with epilepsy. 24 MOBILITY AND TRANSPORT CONNECTIVITY SERIES CONNECTIVITY FOR HUMAN CAPITAL Health sector policymakers have cited transportation learning and training opportunities in a rural area of barriers as key obstacles to providing health care to eastern England. They conclude that transport and low-income populations in particular. Silver et al. (2012), travel play a crucial role in exacerbating poor skills and in a study of low-income, largely immigrant clients in low productivity. four public clinics in a New York City suburb, found that nearly one-quarter reported having transportation prob- lems, such as limited local bus service, that had caused Developing country evidence them to miss or reschedule a clinic appointment in the past. Rask et al. (1994) surveyed disadvantaged and Poor physical access to health facilities also in devel- minority patients at an urban public hospital presenting oping countries has been identified as an important for ambulatory care. Their analysis found that lack of contributor to reduced uptake of preventive health transportation was one of the statistically significant pre- services, likely more so in low-income settings. Variable dictors of delaying care for a new medical problem. uptake of available health interventions in SSA has been found to undermine healthcare programs and to play an important role in child and maternal mortality (Ruth- Education erford et al., 2010). Empirical evidence is not conclusive about the main fac- Based on a systematic review of 34 studies, Lankowski tors affecting student achievement (Asahi, 2014), and et al. (2014) concluded that geographic and transporta- researchers in the education field have typically focused tion-related barriers are associated with poor outcomes in traditional schooling inputs such as teaching quality across the continuum of human immunodeficiency virus (see, e.g., Rockoff, 2004) or class size (Krueger & Whit- (HIV) care in SSA. Difficulty obtaining reliable transpor- more, 2001). tation to clinics is frequently cited as a barrier to HIV care in the region, and the cost of transportation for Two studies, set in Britain and Norway, respectively, monthly clinic visits has been identified as a potential have explored the impact of school accessibility on barrier to antiretroviral (ARV) adherence. Tuller et al. intermediate education outcomes, namely, post-com- (2009) conducted interviews to understand structural pulsory education enrolment and graduation from barriers to ARV adherence and clinical care in Uganda. upper-secondary schools. Dickerson & McIntosh (2013) Almost all respondents cited the need to locate funds found that shorter Euclidian distance between the for the monthly clinic visit as a constant source of stress students’ home and their closest school is positively and anxiety, and lack of money for transportation was a related with the probability that mediocre students con- key factor in cases of missed doses and missed medical tinue into post-compulsory education. Similarly, Falch appointments. Several other studies, too, have found et al. (2013) concluded that reduced commuting time transportation costs to be a potential barrier to sus- has a positive effect on graduation from upper second- tained ARV treatment in SSA countries (see, e.g., Hardon ary schools, and this effect is larger for students with et al. 2007; Mshana et al. 2006). Wesolowski et al. (2015) low academic achievement. Owen et al. (2012) explore quantified the impact of accessibility on preventative the impact of low population density and transport healthcare in Kenya using mobile phone data to under- constraints on skills development and the take-up of stand how estimated travel times to health facilities are 25 REALIZING THE RIGHT TO EDUCATION AND HEALTHCARE THROUGH IMPROVED PUBLIC TRANSPORT IN AFRICAN CITIES related to individuals’ uptake of childhood immuniza- health services and reduce neonatal mortality. Mucun- tions and antenatal care. They combined an analysis of guzi et al. (2014) evaluated a free-of-charge 24-hour the geographic variation in mobility patterns of nearly ambulance and communication services intervention 15 million anonymous mobile phone subscribers with in a district in Uganda and compared the outcomes modeled estimates of travel times to health facilities, with those in a neighboring non-intervention district. generated through standard cost–distance-based They found that hospital deliveries increased by over 50 spatial analysis methods. The authors then compared percent per year in the intervention district with a slight these with direct, geocoded measures of childhood reduction in the average hospital stillbirths per 1,000 immunization and antenatal care uptake, measured by hospital births in the intervention district. Reliable com- household surveys during a home-based HIV counsel- munication and transport services increased access to ing and testing program. Their findings were consistent and utilization of maternal health services, particularly with the hypothesis that remote communities experi- caesarean delivery services. A study in western Uganda ence an increased burden of travel; however, the travel established that the distance and availability of quality patterns were also found to be locally heterogeneous. transport were more important factors in the choice In sublocations of similar physical access to health facil- of place of delivery compared to cost and quality of ities, increased mobility was associated with a higher health services in the health facility (see Parkhurst & percentage of households accessing preventive health- Ssengooba, 2009). A similar intervention in Mali showed care. Thus, mobility can help explain heterogeneities in that reducing transport time and eliminating finan- accessing care for populations with comparable physi- cial barriers doubled the utilization of major obstetric cal travel times to health facilities. interventions, mainly caesarean sections, and was also correlated with increased utilization of health centers Despite progress in the last decades, nearly 18,000 for deliveries (see Fournier et al., 2009). children under the age of 5 years continue to die every day in low- and middle-income countries (LMICs), many Asahi (2014) is among the few studies exploring the of these deaths due to lack of access to high-quali- effect of school accessibility on student performance ty obstetric and neonatal care (Bhutta et al., 2014). A in a developing country setting, as measured by math- multi-country study, covering 21 LMICs, including Burki- ematics test scores in Santiago, Chile. He posits that na Faso, Cameroon, Zimbabwe, Kenya, Uganda, Guinea, school accessibility could affect test scores through and Mali, estimated the relationship between distance several potential mechanisms. First, increased trans- to health facilities, service utilization, and child mortali- port accessibility could lead to an upturn in school ty (see Karra et al., 2017). Its results were unequivocal: enrolment, implying greater class sizes, which in turn compared with children who live within 1 km of a facili- could decrease student performance. Second, better ty, children living within 2 km, 3 km, and 5 km of a facili- transport accessibility could affect test scores through ty had 7.7-percent, 16.3-percent, and 25-percent higher school competition, whereby better connected schools odds of neonatal mortality. The authors conclude that face more competition from other schools. Third, better even relatively small distances from health facilities transport accessibility may affect student performance are associated with substantial mortality penalties for through increased pupil turnover or changes in neigh- children, and that policies that reduce travel distanc- bors’ characteristics. The author’s own study found that es and travel times are likely to increase utilization of schools that experienced large distance reductions to 26 MOBILITY AND TRANSPORT CONNECTIVITY SERIES CONNECTIVITY FOR HUMAN CAPITAL the subway network also experienced an increase in poor public transportation infrastructure or coverage, their enrolled students, and that increased proximity or the person’s physical limitations such as a disability to the subway network was associated with statistically that prevents access to the transportation system. significantly lower test scores, thus lending evidence to the plausibility of the first potential causal mechanism. Policy interest in social exclusion originated in the Unit- ed Kingdom in the late 1990s as part of a broader social A World Bank team led by Barrett et al. (2019) reviewed welfare reform under the New Labor government. A current research studies on how school infrastructure Social Exclusion Unit set up in 1997 has sparked off affects children’s learning outcomes and identified key a series of policy documents, including a widely dis- parameters that can inform the design, implementa- seminated report that focused on the interactions tion, and supervision of future educational infrastruc- between social disadvantages and transport disadvan- ture projects. The report describes the key conditions tages (Fransen et al., 2015). Since the publication of the for maximizing effective access to school places, which, report, researchers from around the world have built among others, involves schools that are locally distrib- up empirical evidence of social exclusion as an outcome uted to maintain reasonable travel-to-school distances. of transport problems, including, to a limited extent, in It also cites robust evidence, for example from South African countries (see Lucas, 2011; Porter et al., 2012). Asia, that “school building programs rank among the most effective educational interventions” (Asim et al. Equity has been a major concern of public transport 2015; Petrosino et al. 2012). provision and is required by legislation in many coun- tries. A range of legislation now requires that govern- ment agencies consider fair treatment of all population Equity of accessibility groups in the provision of services (see, e.g., American Public Transport Association, 2005). In the U.S., metro- Accessibility to transportation systems from population politan planning organizations typically undertake an centers has also been explored in relation to the broad- analysis of regional transportation plan equity to com- er concept of “spatial equity” (Delmelle & Casas, 2012). ply with federal anti-discrimination law, such as Title VI Early discussions of transport equity in the literature of the 1964 Civil Rights Act, and federal agencies, both revolved around a more economic basis, considering the United States Department of Transportation and how public transit changed consumer welfare and prof- the Federal Transit Authority are required to conform it maximization. Later, the focus turned towards a more to equity standards in terms of vehicle loads, vehicle socially oriented consideration of equity, with attention assignment, vehicle headway, distribution of transit to how public transportation access was distributed amenities, and transit access (Welch & Mishra, 2013). amongst captive or low-income riders (Welch & Mishra, However, in the absence of detailed guidance, prac- 2013). Transport-related social exclusion refers to the tice has become dominated by a single method that notion that individuals are physically unable to partici- has foundations in the spatial analysis of environmen- pate in everyday activities, including necessary services tal exposures and the neighborhood effects literature and employment (e.g., Church et al., 2000). The exclu- (Karner & Niemeier, 2013). There is no standard defini- sion itself, however, may be due to a variety of reasons, tion of distributional equity for transportation benefits such as lack of affordability of transportation services, (Martens et al., 2012). In turn, different definitions of 27 REALIZING THE RIGHT TO EDUCATION AND HEALTHCARE THROUGH IMPROVED PUBLIC TRANSPORT IN AFRICAN CITIES equity can point to very different priorities for route and access to benefits (Foth et al., 2013). On the other hand, service allocation (Litman, 2007). vertical equity (or social inclusion) is concerned with distributing resources between individuals of different One approach to defining equity, proposed by Martens abilities and needs; it favors groups based on social et al. (2012), relies on theories of justice to support a class or specific needs in order to make up for over- ‘‘maximax’’ criterion to guide investments that would all societal inequalities. These two frameworks reflect maximize average access while limiting the maximum two contrasting perspectives in public transport plan- gap in accessibility between the lowest- and highest-ac- ning. One emphasizes the need to efficiently move the cessibility groups. Drawing on philosophies of social largest numbers of people (Hay, 1993), while the other justice and following a similar approach proposed by been called the ‘‘social transit’’ perspective (Betts, 2007), Wachs & Kumagai in 1973, Golub & Martens (2014) whose goal is to provide transit access to those with explore how distributional measures of benefits can be greatest need, such as those without private transport incorporated into the evaluation process for regional or specific demographic groups such as the low-in- transportation plans. They present an equity assess- come, youth or ethnic minorities (Deakin, 2007). ment of the distribution of accessibility in San Francisco Bay Area in order to define the rate of ‘‘access pover- Delbosc & Currie (2011b) proposed a simple measure of ty’’ – akin to income poverty – among the population. transit system equity performance in the form of Lorenz Fransen et al.’s study (2014) set in Flanders, Belgium,2 curves that measure the relative supply of transit to the proposes a methodology for identifying a mismatch population and compares public transport supply for between the socially driven demand for transit and the different social groups. In economics, Lorenz curves are supply provided by transit agencies. The obtained index a graphical representation of the cumulative distribution of public transport provision is compared to a public function of wealth across the population (Lorenz, 1905). transport needs index based on the spatial distribution The most common measure for this inequity is the Gini of various socio-demographics. index, which has traditionally been used to calculate the distribution of wealth among a population. The Lorenz Another approach to defining transport equity has curve is a visual representation of equality whereas been proposed by Litman (2007), who distinguishes the Gini coefficient is a single mathematical metric to between “horizontal equity” and “vertical equity.” Hor- represent the overall degree of inequality, represented izontal equity (or fairness) distributes benefits even- by the ratio of the area between the perfect equity line ly to all groups; equity here is essentially defined as (a straight line where 50 percent of total income is held equality in terms of uniform spatial distribution in a by 50 percent of the population) and the Lorenz curve. geographical region or the same distance from each When there is no difference between the perfect equity resident to public facilities (e.g., Chang & Liao, 2011). line and the Lorenz curve, the index value is 1, repre- Yet measuring uniform distribution or distance ignores senting perfect equity. Following a similar approach, varying population densities in regions and fails to Welch & Mishra (2013) propose a methodology to esti- assess whether all residents require the same level of mate transit equity using a stylized connectivity measure 2 Flanders is one of the only regions in the world where the right to basic provision to public transport, formulated as having spatial access to a minimum level of public transport service irrespective of the location of residence, is granted by law. 28 MOBILITY AND TRANSPORT CONNECTIVITY SERIES CONNECTIVITY FOR HUMAN CAPITAL with a Gini index for equity estimation at different levels public spaces varies distinctly with social characteris- such as stop, line, zone and area. Murray & Davis (2001) tics, especially gender, and strongly influences how evaluate equity by comparing the need (primarily an public spaces – including transport facilities – are used. index dominated by income) and access (the availability Delmelle & Casas (2012) explore the spatial accessibility of transit in a particular location). In a study set in Perth, landscape created by newly implemented BRT system Australia, Ricciardi et al. (2015) found that the public in Cali, Colombia, in terms of both access to the system transport distribution3 for socially disadvantaged groups itself and access to three distinct activities around the is less equitable when compared to the population as city, and explore the equitable distribution of accessibil- a whole and that, overall, Perth’s population exhibits a ity patterns in relation to neighborhood socio-economic 0.52 Gini coefficient suggesting a relatively unequal spa- strata. They find that accessibility is the least equitable tial distribution of services to the population yet more for hospitals which tend to be spatially clustered. equal than that of Melbourne (0.68). Peralta-Quiros et al. (2019) used GTFS data for the same SSA cities as Of course, particular social groups may not be homog- the current study to estimate the extent to which the enous in terms of their perceptions or activity patterns, existing public transport systems ensure accessibility to which will affect transport needs and accessibility pref- employment opportunities. erences; there may also be multi-dimensional reasons why individuals are disadvantaged in relation to trans- Kaplan et al. (2014) propose the assessment of equity in port (e.g., not only their income but also physical disabil- transit provision in Copenhagen by considering in-ve- ity). Still, it is clear that the differences and connections hicle time, access/egress times, waiting time, service between the `category’ and the `spatial’ approach lie reliability, frequency, and ‘seamless’ transfers along at the heart of questions over how transport resources multi-modal paths, as well as by weighing the imped- are used to tackle social exclusion and to what extent ance components according to their relative importance resources should be allocated to benefit particular to travelers. social groups, or to specific geographical areas. Finally, for the current study, perhaps the most useful Delbosc & Currie (2011a) explore the hypothesis that conceptual framework for thinking about transport transport disadvantage will have a greater impact on equity is that proposed by Church et al. (2000), among social exclusion and well-being in remote areas than it others, which distinguishes between the category will in accessible urban areas, as has been theorized in approach and the spatial approach. While the spatial the literature (e.g. Pucher & Renne, 2005). Probst et al. approach focuses on the equity of transport access (2007) aimed to quantify geographic and race-based across the urban space, the category approach focuses differences in distance traveled and time spent in travel on the travel patterns, attitudes and needs of particu- for medical/dental care using representative national lar social groups, for example, women, the poor, or the data in the U.S. They found that rural residents experi- elderly. For example, research by the Department of ence higher travel burdens than urban residents when Environment, Transport and the Regions (2000), among seeking medical/dental care. others, has shown how perceived lack of security in 3 As measured by the “public transport supply index” initially proposed by Delbosc & Currie (2011a), that is based on proximity to the transit stops and the service level (number of bus and train arrivals per week). 29 REALIZING THE RIGHT TO EDUCATION AND HEALTHCARE THROUGH IMPROVED PUBLIC TRANSPORT IN AFRICAN CITIES 4. Overview of Health and Education Indicators, Commitments, and National and City-Level Policy Goals Photo credits: Vincent Tremeau 30 MOBILITY AND TRANSPORT CONNECTIVITY SERIES CONNECTIVITY FOR HUMAN CAPITAL 4.1. Basic health and education indicators In the three decades following the adoption of the Con- recent decade and are also characteristically superior vention on the Rights of the Child, despite an exploding to the averages in the countries overall. Table 1 sum- global population, it has been possible to reduce the marizes the key indicators at the country level based number of children missing out on primary school by on the most recent data available from UNICEF. The almost 40 percent. Gains in child survival and health are purpose of this summary is not a direct comparison matched by leaps in access to schooling and enhanced across countries but rather the setting of the stage for protection of children from harmful practices. In 1990, the later discussion on spatial and population groups- almost 20 per cent of children of primary-school age based inequalities. were not in school; now this ratio is below 10 per cent globally. Gender disparity in access to primary Among the health indicators, some of the greatest education has largely disappeared in most countries, variability across the countries in scope of this study is although Africa remains an exception. Despite these in terms of maternal and infant care and directly relates and many other successes, in terms of both influence to the persons’ ability to physically reach healthcare and tangible results, the Convention stands at a cross- services (or be reached by health professionals). For roads, as its realization – translating rights into results example, the share of infants who have received three for children – has been mixed and uneven. Progress on doses of the DTP vaccine, a combined vaccine against realizing children’s right to education is also a cause for diphtheria, pertussis (whooping cough) and tetanus, concern. Globally, the number of out-of-school children ranges from just 45% in Guinea to more than double at the primary level has remained largely static since that in Burkina Faso, Rwanda, and Tanzania. Similarly, 2007, as increased access to primary education has the proportion of births attended by skilled medical barely kept pace with global child population growth – personnel is less than half in Mali but over three-quar- particularly in Africa. Gender gaps, while diminishing in ters in Burkina Faso, Rwanda, and Zimbabwe. some cases, persist in many areas of child rights that have seen strong gains, including access to secondary As noted, these averages are not directly relevant to education. While the global number of out-of-school the countries’ largest cities, where health facility cov- children of primary-school age dropped from 100 mil- erage is much better and so are the average incomes. lion in 2000 to 59 million in 2018, in percentage terms, For example, in Bamako, the vast majority of deliveries the reduction in the number of out-of-school children (97%) take place in a health facility – a much higher has just about kept pace with the expansion in the total share than in Mali overall (67%) (Republique du Mali, population of primary-school-age children, particular- 2019). In individual countries, also the progress over ly in Africa (UNICEF, 2019). SSA also contributes more time in closing human development gaps has been than a half of the world’s maternal mortality and has more significant in urban areas. For example, as noted had the slowest annual reduction rate of maternal mor- in Cameroon’s National Development Strategy 2020- tality from 1990 (Mucunguzi et al., 2014). 2030, despite some progress reached in the past, the country’s Human Capital Development Index slightly Across the cities in scope of the study, basic health and between 2012 and 2017, which can be attributed to education indicators – such as primary school enroll- infant malnutrition and education and health poli- ment rates, infant and maternal mortality, and pre- cies that focused the resources in urban areas at the ventative healthcare access – have improved over the expense of the rural ones. 31 REALIZING THE RIGHT TO EDUCATION AND HEALTHCARE THROUGH IMPROVED PUBLIC TRANSPORT IN AFRICAN CITIES Table 1: Key indicators of current health and education status Burkina Cameroon Rwanda Zimbabwe Kenya Tanzania Mali Guinea Mozambique Uganda Faso Population, million (2018) 18.1 23.3 11.6 15.6 46.1 53.5 17.6 12.6 28 39 HEALTH Child mortality (<5) per 1,000 live births 81 84 38 50 46 54 106 86 72 49 Infant mortality per 1,000 live births 51 55 29 36 34 38 66 56 53 35 <5 children with suspected pneumonia 52 28 54 51 66 55 23 30 50 80 taken to health provider (%) Infants who receive 3 doses of DTP vaccine 91 86 98 89 82 97 66 45 80 85 Children who received the 2nd dose of 50 NA 95 78 35 79 NA NA 45 NA measles containing vaccine Antenatal care coverage for at least 47 59 44 76 58 51 38 51 51 60 4 visits (%) Proportion of births attended by skilled 80 65 91 78 62 63 44 63 54 74 medical personnel (%) Births who had their first postnatal check- 33 68 19 73 36 42 63 63 NA 11 up within the first 2 days after birth (%) EDUCATION Attendance in early childhood 3 28 13 22 NA NA 5 NA NA NA education (%) Adjusted net attendance rate, primary 52 85 94 95 85 81 53 60 71 85 education Adjusted net attendance rate, lower 18 50 30 55 42 28 30 29 16 19 secondary education Adjusted net attendance rate, upper 5 30 15 24 36 3 13 12 3 8 secondary education Completion rate, primary education 31 65 54 88 79 80 43 42 40 36 Youth (15-24) literacy rate 50 81 85 90 87 86 49 46 71 84 Adult literacy rate, male 37 78 71 88 78 75 43 37 67 83 Adult literacy rate, female 22 65 62 80 67 61 20 12 36 65 Source: UNICEF (https://data.unicef.org/country/) 32 MOBILITY AND TRANSPORT CONNECTIVITY SERIES CONNECTIVITY FOR HUMAN CAPITAL Under-5 mortality has declined across the region; for attendance. In Conakry, and Guinea overall, there are example, over the last 25 years, better access to public notable gender inequalities in school enrollment and healthcare in Tanzania has saved many young lives and attendance, in particular at the secondary level. The the under-5 mortality has been nearly halved. Never- ratio of female to male enrolment rates drops 20 per- theless, children’s use of potentially life-saving health- centage points from primary to secondary education, care services remains limited in some countries, at least reaching only 60% in the case of the latter (World Bank partly due to inability or unwillingness of families to Group, 2018b). Attendance rate in Conakry is 84% for physically travel to health facilities that could provide boys and 81% for girls at the primary level but decreas- the care needed. For example, only half or less of all es to 58% and 48%, respectively, at secondary level. In children under 5 with suspected pneumonia are taken Mozambique, the education sector has been report- to a health provider in Cameroon, Mali, Guinea, and ed to suffer from absenteeism and low primary and Mozambique. secondary completion rates, and even while there has been progress in gender parity, enrollment rates and School attendance rates – similarly at least partly a educational attainment at higher levels of education function of the children’s ability to physically reach have large gender gaps (World Bank, 2016c). In Dar es school facilities – decline markedly as one moves from Salaam, primary net enrollment ratios in 2011-125 were primary to upper secondary education levels. In all 91% for boys and 89% for girls but the gap was wid- countries in scope of this study, the difference between er at the secondary level, where the respective shares primary and upper secondary attendance rates is were 62% and 48% (The United Republic of Tanzania, above 40 percentage points; in all countries except 2013b). In Kampala, despite a high school attendance Kenya, the net attendance rate at the upper secondary rate among 6-12 year old children (97%), there is a level is less than one-third. Zimbabwe’s Interim Pover- slight disparity against females (UBOS, 2016). In Mali, ty Reduction Strategy Paper 2016-2018 highlights the while girls are slightly more likely to attend school in the high rates of literacy and enrolment in primary level youngest age group, enrollment rates among boys are but less than optimal transition rates to secondary higher in all older age groups, and the gap between education. Similarly, many Tanzanian children continue male and female enrollment rates widens to 5 percent- to miss out on education: about 23% of children aged age points at ages 16–18 (Kuépié, 2016). 7-13 years are not in school, and, while 80% of children complete primary school, only 31% – lower secondary A notable exception is Zimbabwe, which, according to school. Less than half of all 5-year-olds have access to MICS 2019, had somewhat higher effective transition pre-primary education.4 rates to lower secondary school for girls than for boys (75% and 66%, respectively); the overall effective transi- Gender gaps in adult literacy rates remain significant tion rate in Harare specifically was 84% (ZIMSTAT, 2019). across the region, exceeding 20 percentage points in Mali, Guinea, and Mozambique, which are at least partly explained by gender gaps in school enrollment and 4 Basic Education Statistics in Tanzania (BEST) 2017; Final Findings Report, Tanzania National Early Grade Reading Assessment (EGRA), 2016; Out of School Children: Tanzania Country Report 5 These indicators were not available in the 2017/18 Household Budget Survey. 33 REALIZING THE RIGHT TO EDUCATION AND HEALTHCARE THROUGH IMPROVED PUBLIC TRANSPORT IN AFRICAN CITIES 4.2. National laws and commitments to relevant international human rights treaties on education and health access International and regional human rights law provides Charter on the Rights and Welfare of the Child provides for the right to education and healthcare for all. The for the right to education in Article 14. This right is also Rights to Education and Healthcare are defined as included in the Maputo Protocol (on the Rights of Wom- fundamental human rights in the Universal Declaration en in Africa) in Article 12. of Human Rights, as is the Right to Equality – a con- cept that is multi-faceted and encompasses equality in Underlying disparities mean that, regardless of the access to all life quality enhancing opportunities such efficiency of the a city’s transport system, educa- as education and healthcare. This concept in further tion and health may not be accessible for the entire enshrined in the International Covenant on Civil and population. This section outlines the implementation Political Rights (ICCPR). The International Covenant on of the international and regional human rights treaties Economic, Social, and Cultural Rights (ICESR) further which the ten targeted countries have ratified. It does recognizes the right to education (Articles 13 and 14), so by summarizing findings from key human rights as does the Convention on the Rights of the Child (CRC) reports, submitted during the Universal Periodic Review (Articles 28 and 29). The Convention on the Elimination (UPR) to the Office of the United Nations High Commis- of Discrimination Against Women (CEDAW) recogniz- sioner for Human Rights (OHCHR), as well as reports es the right to education for women (Article 10). The from the African Commission on Human and People’s Convention on the Rights of Persons with Disabilities Rights (ACPHR) over the past decade as related to the (CRPD) recognizes the right to education for persons rights to education and healthcare. Particular attention with disabilities in Article 24, and this is also recognized is given to access by women and children. for children in the CRC (Art. 23). The African Charter on Human and People’s Rights (ACHPR) defines the right All of the countries whose cities are covered in this to education in Article 17. The African Charter on the report have ratified most, if not all of the relevant Rights and Welfare of the Child provides for the right human rights treaties. Individual exceptions include to education in Article 11. This right for women is also Cameroon, which has signet, but not yet ratified, the included in the Maputo Protocol (on the Rights of Wom- Convention on the Rights of Persons with Disabilities, en in Africa) in Article 14. and Mozambique, which has yet to ratify the Internation- al Covenant on Economic, Social, and Cultural Rights. Likewise, the Right to Health is part of the right to an adequate standard of living (Universal Declaration of Despite the formal commitments, challenges Human Rights, Art. 25) and was again recognized as a remain in ensuring access to education for all, and human right in the ICESR (Art. 12). The CRC recognizes gender disparities are reported to persist in most the right for children (Article 24), and CEDAW recog- countries. In Cameroon, school attendance is free and nizes the right to health for women (Art. 12). The CRPD compulsory. Still, financial constraints are reported to recognizes the right to health for persons with disabil- be a barrier, particularly for women, to access educa- ities in Article 25, also recognized in the CRC (Art. 23). tion due to the indirect costs of attendance.6 Other bar- The ACHPR defines the right in Article 16. The African riers include “lack of infrastructure, lack of educational 6 Consideration of reports submitted by States parties under article 18 of the Convention, Seventh to ninth periodic reports of States parties due in 2014, para. 29, 13 July 2015. 34 MOBILITY AND TRANSPORT CONNECTIVITY SERIES CONNECTIVITY FOR HUMAN CAPITAL materials and the shortage of qualified teachers.”7 In particular helped to increase attendance. The country some locations, armed groups have called for boycot- no longer penalizes girls for their pregnancies, allow- ting schools, and have used schools as bases. While ing them to stay in school.10 However, the CRPD Com- this has not been reported in Douala, as it occurs in mittee expressed concerns about ongoing barriers to English-speaking parts of the country, it has an impact accessing education, in part due to long distances and on the education system generally (Human Rights accessibility accommodation, though this is more pro- Watch, 2020c). nounced in rural areas.11 Children in Rwanda reported that teachers’ conduct and punishments may pose a In Burkina Faso, similarly, the Education Policy Act barrier to student’s attendance in school. provides for free schooling and mandatory attendance for students, reducing gender gaps and increasing Barriers to women’s education in Zimbabwe are report- enrolment.8 However, several attacks on schools by ed to include cultural attitudes, early marriage, and armed groups have affected access to education. challenges of returning to school after pregnancy.12 Armed groups have also reportedly threatened teach- In part, this is reportedly due to religious beliefs that ers, children, and families, causing fear about attending girls cannot continue education after marriage.13 The school, and in some cases, resulting in school closures. Government is working to eliminate negative attitudes In March 2020, the Ministry of Education reported that and has provided for girls with children to return to 2,500 schools had been closed due to attacks or inse- school.14 However, practices persist that preclude girl curity. Some children began to attend schools further mothers from being readmitted.15 Likewise, travel to from their homes in order to access education, but school includes risks, particularly for girls, of harass- they are exposed to other dangers during long transits ment and violence, though most often in rural loca- (Human Rights Watch, 2020a). This violence interferes tions. The Government is working to minimize distances with children’s right to education. to school and increasing accountability for perpetrators of sexual harassment and abuse.16 In Rwanda, primary education is compulsory and free, and the Government provides additional, targeted Guinea has prioritized gender equality policies, includ- support to low-income families to support indirect ing to repeal measures banning pregnant girls from costs.9 Work to improve school environments for girls in schools. Primary education in Guinea is compulsory, 7 CRPD/C/RWA/CO/1, para. 43. 8 Committee on the Rights of the Child Seventy-first session, 11-29 January 2015, List of issues in relation to the second periodic report of Zimbabwe, Replies of Zimbabwe to the list of issues, 15 October 2015. 9 Human Rights Watch Submission to the Committee on the Elimination of Discrimination against Women (CEDAW) of Zimbabwe’s periodic report for the 75th CEDAW Session, December 2019. 10 CEDAW Sixth periodic report submitted by Zimbabwe under article 18 of the Convention, para. 60, 6 December 2018. 11 Committee on the Rights of the Child Seventy-first session, 11-29 January 2015, List of issues in relation to the second periodic report of Zimbabwe, Replies of Zimbabwe to the list of issues, 15 October 2015. 12 Id., para. 68. 13 Committee on Economic, Social and Cultural Rights, Initial report submitted by Guinea pursuant to articles 16 and 17 of the Covenant,, E/C.12/GIN/1, para. 270, 29 March 2019. 14 Committee on the Elimination of Discrimination against Women, Consideration of reports submitted by States parties under article 18 of the Convention on the Elimination of All Forms of Discrimination against Women, Combined seventh and eighth periodic reports of States parties, CEDAW/C/GIN/7-8, para. 84. 15 Amnesty International, GUINEA: SUBMISSION TO THE HUMAN RIGHTS COMMITTEE, LIST OF ISSUES, AI Index: AFR 29/7600/2017, 13 December 2017. 16 FIDH, et. al., Comité CEDEF, Examen de la Guinée Rapport alternatif conjoint, FIDH-OGDH-MDT-AVIPA- CODDH. October 2014. 35 REALIZING THE RIGHT TO EDUCATION AND HEALTHCARE THROUGH IMPROVED PUBLIC TRANSPORT IN AFRICAN CITIES but difficult learning conditions are thought to drive possibly being expelled subsequently.23 Further, girls up dropout rates:17 an estimated 72% of girls are out may not access school due to risks of sexual violence of school, compared to 55% of boys.18 Guinea recently while traveling to or from school. In urban areas, there modified its criminal code to criminalize forced mar- are reports that children must use commuter buses riage, having had a high rate of child marriage: three in to access schools, which are reported to be unsafe for five girls were married before 18 according to the Unit- them, possibly affecting access to education.24 There ed Nations Population Fund (UNFPA), impeding girls’ have also been reports that schools are the second access to education.19 There are reports of sexual abuse most common context for sexual violence.25 and sexual harassment in schools, particularly affecting girls, likely impacting girls’ enrolment and attendance, Public education is provided for in Mali’s Constitution, and relatedly, literacy.20 The country’s National Habitat but low school attendance persists, in part due to the III report notes the need to increase citizen participa- lack of school infrastructure. Early marriage and high tion and to improve the consideration of human rights rates of child labor may also affect school enrolment.26 in urban development, in particular, by putting in place Mali has worked to improve girls’ enrolment and devel- initiatives to protect and promote the rights of women op non-formal education options.27 and girls (see Republique de Guinee, 2016). Kenya has free primary education; however, other bar- Tanzania provides free and compulsory primary edu- riers include shortage of teachers, insufficient facilities, cation, but there are reports that additional fees and indirect costs, and poor learning environments.28 The geographic disparities limit access for all children.21 Government has worked on equipping schools to be The Government has reportedly agreed not to pursue more inclusive for girls to improve access, including discriminatory actions against pregnant girls’ access to through provision of sanitary towels.29 school.22 However, even where girls may not be banned from attending, there are concerns that they may Mozambique has removed barriers to pregnant girls stop accessing education for fear of the stigma and of from attending class, banned child marriage to improve 17 Convention on the Rights of the Child, final recommendations, 3 March 2015. 18 United Republic of Tanzania United Nation’s Convention on the Rights of the Child (UNCRC) NGO REPORT. 19 Human Rights Watch, Q & A on Ban on Pregnant Girls and World Bank Education Loan 20 United Republic of Tanzania United Nation’s Convention on the Rights of the Child (UNCRC) NGO REPORT. 21 Center for Reproductive Rights, Re: Supplementary information on Tanzania scheduled for review by the Committee on Elimination of Discrimination against Women during its 63rd Pre-sessional Working Group, June 2, 2015 22 CEDAW/C/MLI/Q/6-7/Add.1, 7 March 2016. 23 Committee on Economic, Social and Cultural Rights, Initial report submitted by Mali under articles 16 and 17 of the Covenant, para. 368. 8 February 2018. 24 Ministry of Education, Science and Technology Strategic Plan 2013-2016, Education under Threat: The Commercialization of Education in Kenya, Supplemen- tary report submitted by the Economic and Social Rights Centre, January 2016. 25 E/C.12/KEN/2-5, para. 9. 26 Combined third to fifth periodic reports submitted by Mozambique under article 18 of the Convention, CEDAW, 22 March 2018. 27 Supplementary Information on the Status of Women’s Economic Social and Cultural Rights in Uganda to the Committee on Economic, Social, and Cultural Rights during its 55th session prepared and submitted by the Women NGOS on ESCRs in Uganda, June 10, 2015. 28 Consideration of reports submitted by States parties in accordance with articles 16 and 17 of the International Covenant on Economic, Social and Cultural Rights, Burkina Faso, E/C.12/BFA/1, para. 230 (received February 25, 2015). 29 Center for Reproductive Rights CEDAW Submission, Rwanda. 36 MOBILITY AND TRANSPORT CONNECTIVITY SERIES CONNECTIVITY FOR HUMAN CAPITAL girls’ access to education (Human Rights Watch, 2020e), in part due to social stigma.33 Rwandan women and and there are measures in place to limit sexual harass- girls reportedly walk an hour to reach the nearest ment in schools.30 health facility in some locations, though more so in rural areas. This distance poses a barrier to accessing these Uganda has increased access to primary schools and services. Rwanda is investing in additional health cen- provides universal primary education free of charge. ters within an hour walking distance to improve access; However, teacher absenteeism, in part due to lack of universal insurance has also helped improve access.34 transport and low pay, continues to inhibit access to education in practice.31 Guinea has suffered from conflicts, internally and in neighboring countries, which has affected health out- Access to health for all is still impeded by many comes. In addition, the Ebola virus negatively impact- challenges, including accessibility related ones, ed health outcomes, including maternal mortality.35 although affordability and quality appear to be Maternal mortality remains high, while access to quality more constraining issues. Free primary healthcare in obstetric care is low.36 Burkina Faso is guaranteed, but not all medical pro- cedures are free of charge,32 and there continues to While maternal and child health care is provided for free be high infant and child mortality. Cameroon has the in Tanzania, stockouts and other fees reportedly contin- third highest cost of healthcare in SSA, resulting in 64% ue to limit access to care.37 Adolescents have reported of households not seeking healthcare due to the cost discrimination in accessing reproductive health services, (Human Rights Watch, 2020d). To address this issue, as have survivors of sexual violence.38 Access to repro- the country has provided vouchers to expand access ductive health is also reportedly a challenge following for mothers and children to maternal care. government policies discouraging usage.39 Adolescents and low-income women in Rwanda report- In Kenya, there is free maternity care in public hospitals, edly face obstacles accessing family planning services, and for children under five.40 Kenya piloted universal 30 Consideration of reports submitted by States parties under article 40 of the Covenant, Fourth periodic reports of States parties due in 2013, Rwanda, para. 134, 11 July 2014] 31 CRC/C/GIN/3-6, Combined third to sixth periodic reports submitted by Guinea under article 44 of the Convention, para.79, 28 August 2018. 32 Committee on the Elimination of Discrimination against Women, Consideration of reports submitted by States parties under article 18 of the Convention on the Elimination of All Forms of Discrimination against Women, Combined seventh and eighth periodic reports of States parties, CEDAW/C/GIN/7-8, para. 126-127. 33 Center for Reproductive Rights, Re: Supplementary information on Tanzania scheduled for review by the Committee on Elimination of Discrimination against Women during its 63rd Pre-sessional Working Group, June 2, 2015. 34 Center for Reproductive Rights, Re: Supplementary information on Tanzania scheduled for review by the Committee on Elimination of Discrimination against Women during its 63rd Pre-sessional Working Group, June 2, 2015 35 Id.; Convention on the Rights of the Child, final recommendations, 36 Consideration of reports submitted by States parties under articles 16 and 17 of the International Covenant on Economic, Social and Cultural Rights, Combined second to fifth periodic reports of States parties due in 2013, E/C.12/KEN/2-5, para. 1. 1 July 2013. 37 Center for Reproductive Rights, CRC Submission. 38 Committee on the Elimination of Discrimination against Women, Consideration of reports submitted by States parties under article 18 of the Convention, Eighth periodic report of States parties due in 2015, CEDAW/C/KEN/8, para. 168, 3 March 2016. 39 Center for Reproductive Rights, letter January 13, 2019 to The Human Rights Committee RE: Supplementary information for list of issues for Kenya, scheduled for adoption by the Human Rights Committee during its 128th session (2 to 27 March 2020). 40 Committee on the Rights of the Child, Combined third and fourth periodic reports submitted by Mozambique under article 44 of the Convention, para. 242, 28 March 2018. 37 REALIZING THE RIGHT TO EDUCATION AND HEALTHCARE THROUGH IMPROVED PUBLIC TRANSPORT IN AFRICAN CITIES health care and continues to expand maternal care. The countries have made progress in ensuring However, challenges to access are reported to include education and healthcare access for people with poor quality, long distances to facilities, cost, and disabilities, but disparities remain. In Burkina Faso, risk of detention for any unpaid bills.41 Women with children with disabilities who have a disability card have lower incomes and lower education levels have addi- the right to education based on Act No. 012-2010/ tional challenges in accessing healthcare, according AN of 1 April 2010.46 School fees and costs of supplies to reports:42 they are reportedly unaware of how to are covered by the Government. The Act requires that register for free maternal care services, and those who schools themselves be “adequately equipped to accom- do register report that post-delivery services are not modate pupils with disabilities,” and also provides that covered. Unsafe abortion is another contributor to high transport companies must make transport accessible to maternal mortality due to women’s inability to access persons with disabilities.47 Persons with disabilities also safe abortions.43 have the right to health care benefits, including free consultations and treatment.48 Nonetheless, human Expanding the number of healthcare centers has rights reports state that difficulties to access public reduced the transport time for the population in services continue, particularly affecting girls’ school Mozambique, resulting in increased access of health attendance.49 services.44 However, while public health facilities are legally obligated to provide free healthcare services to Cameroon has taken action to make education accessi- pregnant women, this is being inconsistently applied in ble for persons with disabilities. Still, some human rights practice (World Bank, 2016c). actors have reported that discrimination continues to be an impediment to access, particularly for girls.50 In Uganda, women continue to experience challeng- es in accessing healthcare, in particular reproductive Despite attention provided to persons with disabilities care, due to reports that their partners make decisions in Rwanda, and an inclusive education plan, there are regarding healthcare.45 concerns about neglect and abuse of persons with disabilities.51 Affordable and accessible public transport 41 November 2015, Banjul, The Gambia Concluding Observations and Recommendations on the 5th Periodic State Report of the Republic of Uganda (2010 – 2012), para. 77; Center for Reproductive Rights, CEDAW Committee Submission, 15 September 2010. 42 Consideration of reports submitted by States parties in accordance with articles 16 and 17 of the International Covenant on Economic, Social and Cultural Rights, Burkina Faso, E/C.12/BFA/1, para. 141 (received February 25, 2015). 43 Initial report submitted by Burkina Faso under article 35 of the Convention, due in 2011, CRPD/C/BFA/1, para. 37, 108. 44 Initial report submitted by Burkina Faso under article 35 of the Convention, due in 2011, CRPD/C/BFA/1, para. 37, 117 (received November 30, 2018). 45 CNDH, Rapport Alternatif De La Commission Nationale Des Droits Humains Sur La Mise Eb Œuvre De La Convention Relative Aux Droits Des Personnes Handicapees, para. 1, 2. July 2020. 46 International Disability Alliance, Suggestions for disability-relevant questions to be included in the List of Issues prior to reporting, Country report task force, Human Rights Committee, 103rd Session. 47 CRPD/C/RWA/CO/1, para. 29. 48 CRPD/C/RWA/CO/1, para. 43(c). 49 Combined fifth and sixth periodic reports submitted by Rwanda under article 44 of the Convention, para. 61, 10 July 2018. 50 Our views on how Children’s Rights are respected in Rwanda- Report by Children, CRC Submission, August 2018. 51 Convention on the Rights of the Child, final recommendations, 3 March 2015. 38 MOBILITY AND TRANSPORT CONNECTIVITY SERIES CONNECTIVITY FOR HUMAN CAPITAL is one challenge.52 The Government’s education plan Mali has worked to improve infrastructure, to make ensures that schools are disability friendly.53 However, public services more accessible for persons with disabil- children report that sign language and other disability ities. However, limitations on transport are reported to accommodation remains inadequate.54 continue to be problematic, possibly impeding access to healthcare and education.61 The country has also In Tanzania, there are reports that children with dis- developed special education for children with disabil- abilities continue to face stigma, possibly affecting their ities is provided in some parts of the country. Due to access to education, though mostly in rural areas.55 Due limited financing, the services available do not yet meet to risk of attacks on children with albinism, there are the needs of children with disabilities.62 Regulations Government-established boarding schools. While these protect persons with disabilities from discrimination protect against violence, they separate children from when accessing healthcare.63 However, healthcare their families.56 access remains challenging, in particular, reproductive and sexual health services are reportedly not universal- Although Guinea has ratified the CRPD, inclusive poli- ly accessible.64 cies and practices have yet to be implemented.57 Chil- dren with disabilities are reported to not have adequate Kenya’s Constitution grants the right to the highest support services, impeding their access to education.58 attainable standard of health, and the country provides free treatment to children with disabilities whenever In Zimbabwe, discrimination on the grounds of disabili- possible.65 Kenya has strong disability inclusion poli- ty is forbidden in the Constitution and the Disabled Per- cies and requires all Ministries to mainstream disability sons Act.59 Healthcare facilities in Zimbabwe are being inclusion.66 Kenya’s Persons with Disabilities Act (2003), made accessible for children with disabilities, including and its Constitution provide access to free, compulso- by teaching sign language to professionals.60 ry, and inclusive educational and reasonable access 52 Id. 53 CRC/C/GIN/3-6, Combined third to sixth periodic reports submitted by Guinea under article 44 of the Convention, para.76, 28 August 2018. 54 Committee on Economic, Social and Cultural Rights, Initial report submitted by Guinea pursuant to articles 16 and 17 of the Covenant,, E/C.12/GIN/1, para. 287, 29 March 2019. 55 Human Rights Watch Submission to the Committee on the Elimination of Discrimination against Women (CEDAW) of Zimbabwe’s periodic report for the 75th CEDAW Session, December 2019. 56 Committee on the Rights of the Child Seventy-first session, 11-29 January 2015, List of issues in relation to the second periodic report of Zimbabwe, Replies of Zimbabwe to the list of issues, 15 October 2015. 57 Initial report submitted by Mali under article 35 of the Convention, CRPD/C/MLI/1, para. 128, June 24, 2019. 58 Initial report submitted by Mali under article 35 of the Convention, CRPD/C/MLI/1, para. 129, June 24, 2019. 59 Initial report submitted by Mali under article 35 of the Convention, CRPD/C/MLI/1, para. 108, June 24, 2019. 60 L’application de la Convention sur l’Elimination de toutes les forms de Discrimination à l’Egard des Femmes, RAPPORT ALTERNATIF AUX 6ème et 7ème RAPPORTS PERIODIQUES DU GOUVERNEMENT DU MALI. 61 Consideration of reports submitted by States parties under article 35 of the Convention Initial reports of State parties due in 2010, CRPD /C/KEN/1, para. 116. 3 April 2012. 62 Consideration of reports submitted by States parties under article 35 of the Convention Initial reports of State parties due in 2010, CRPD /C/KEN/1, para. 49, 69-70. 3 April 2012. 63 Consideration of reports submitted by States parties under article 35 of the Convention Initial reports of State parties due in 2010, CRPD /C/KEN/1, para. 178. 3 April 2012. 64 Consideration of reports submitted by States parties under article 35 of the Convention Initial reports of State parties due in 2010, CRPD /C/KEN/1, para. 105. 3 April 2012. 65 Center for Reproductive Rights, CEDAW Submission. 66 Id. 39 REALIZING THE RIGHT TO EDUCATION AND HEALTHCARE THROUGH IMPROVED PUBLIC TRANSPORT IN AFRICAN CITIES to public transport for children with disabilities.67 The (LGBTI) continue to face implicit or explicit discrimi- Kenyan government supports students with disabilities nation in accessing education and healthcare; this is to attend university, and the country’s Ministry of Edu- often also the case for people living with HIV/AIDS. cation and Ministry of Health work to identify children’s In Burkina Faso, there are reports that LGBTI individuals needs early on.68 Still, very few children with disabilities are unable to access healthcare due to discrimination. attend school after primary school. Advocates report Due to fear of harassment and stigma, LGBTI persons that girls with disabilities are particularly prone to may not seek healthcare. Likewise, HIV-positive individ- sexual abuse and that they may be discouraged from uals reportedly fear accessing medical services due to accessing education for fear of potential harassment.69 fear of harassment (U.S. Department of State, 2019). There are also reports that individuals with disabilities face stigma, discrimination, and other challenges in Cameroon’s penal code criminalizes same sex relations, accessing family planning services.70 and LGBTI persons have also reportedly been attacked physically, with impunity (Human Rights Watch, 2020b). The Persons with Disabilities Act of Uganda provides Due to the law criminalizing homosexuality, LGBTI indi- the right to access medical care. While being imple- viduals may be less likely to access healthcare for fear mented, there are reports of inadequate access to of repercussions if their sexual orientation is exposed.74 health facilities for persons with disabilities, finding The UN has found that, although HIV prevalence in that, in 2012, only 2-25% had access to rehabilitation Douala was 24% in 2011, members of the LGBTI com- services.71 Challenges also remain in terms of access to munity were unable to obtain HIV services.75 education for children with disabilities.72 There are reports of ongoing stigma and discrimina- Mozambique is reported to monitor transport and tion against LGBTI people in Zimbabwe (Human Rights public infrastructure for accessibility for people with Watch, 2019a), and local groups report that LGBTI disabilities.73 populations face discrimination in healthcare settings in particular; many LGBTI persons do not seek services In most of the countries, persons identifying as out of fear of stigma.76 lesbian, gay, bisexual, transgender, and intersex 67 November 2015, Banjul, The Gambia Concluding Observations and Recommendations on the 5th Periodic State Report of the Republic of Uganda (2010 – 2012), para. 118; Consideration of reports submitted by States parties under articles 16 and 17 of the International Covenant on Economic Social and Cultural Rights, Initial reports submitted by States parties due in 1990, 6 December 2012. 68 Consideration of reports submitted by States parties under articles 16 and 17 of the International Covenant on Economic Social and Cultural Rights, Initial reports submitted by States parties due in 1990, para. 74, 6 December 2012. 69 Committee on the Rights of Persons with Disabilities, Initial report submitted by Mozambique under article 35 of the Convention, para. 1, 3 January 2020. 70 Submission by Human Rights Watch to the Committee on Economic, Social and Cultural Rights on Cameroon 65th session, 2019. 71 Id. 72 Submission to the UN Committee on the Elimination of Discrimination Against Women, 75th Session (10-28 February 2020), Review of Zimbabwe. 73 United Republic of Tanzania United Nation’s Convention on the Rights of the Child (UNCRC) NGO REPORT. 74 Human Rights Watch 2019 Annual report, Tanzania; Human Rights Watch, Obstructions to LGBTI Health Rights. 75 Convention on the Rights of the Child, final recommendations, 3 March 2015. 76 List of Issues Relating to the Violence and Discrimination against Lesbian, Bisexual, Transgender, Intersex and Queer Women in Kenya, Submitted for the consideration of the 8th periodic report by Republic of Kenya for the 68th Session of the Committee on the Elimination of all forms of discrimination Against Women, Minority Women in Action, AFRA-Kenya, Kenya Campus Lasses Association and the National Gay and Lesbian Human Rights Commission. 40 MOBILITY AND TRANSPORT CONNECTIVITY SERIES CONNECTIVITY FOR HUMAN CAPITAL In Tanzania, the Government has reportedly agreed not healthcare for HIV positive individuals, access to repro- to pursue discriminatory actions with regard to LGBTI ductive health and family planning remains limited.83 populations,77 but reported arrests have taken place of LGBTI individuals (Human Rights Watch, 2019b). Discrimination is reported to persist for sexual minori- Tanzania makes adult same sex conduct punishable, ties in Uganda, as same sex relationships remain ille- and drop-in centers for health care for LGBTI patients gal.84 There are reports that sexual minorities and sex have been closed, impeding LGBTI individuals’ access workers are unable to access healthcare due to stigma to health.78 Children with HIV and AIDS have reportedly and punitive laws on same sex relationships (Human been unable to access proper health services, particu- Rights Watch, 2014). Recent policies seek to eliminate larly for adolescents and due to sexual orientation.79 discrimination in accessing HIV/AIDS and reproductive health services for persons with disabilities.85 In Kenya, and non-cis women reportedly face discrim- ination at health facilities and have reported to have Rwanda’s healthcare policies take into consideration been refused services.80 needs of children affected by HIV.86 However, there remain gaps in availability of accessible health facilities, In Mozambique, homosexuality has been decriminal- particularly with regard to HIV/AIDS services and sexual ized; nonetheless, reports that LGBTI women are dis- and reproductive health services. criminated against persist and may affect their access to services.81 Similarly, individuals with albinism report- edly continue to face discrimination and stigma, and are unable to access services (Human Rights Watch, 2019c), and children with albinism are reported to have limited accommodations in schools (Human Rights Watch, 2019d). Children living with disabilities and HIV/ AIDS are guaranteed education assistance.82 On the other hand, while the country’s laws provide rights to 77 Contribution to the Committee on the Elimination of All Forms of Discrimination against Women in relation to the consideration of the State report of Mozam- bique (73 Session (01 -19 Jul 2019) Presented by ODRI “Intersectional rights” - Office for the Defense of Rights and Intersectionality, June 10, 2019. 78 Committee on the Rights of the Child, Combined third and fourth periodic reports submitted by Mozambique under article 44 of the Convention, para. 279, 28 March 2018 79 Consideration of Reports Submitted by States Parties under Article 62 of the African Charter on Human and Peoples’ Rights, Concluding Observations and Recommendations on the Second and Combined Periodic Report of the Republic of Mozambique on the Implementation of the African Charter on Human and Peoples’ Rights (1999 – 2010). 80 Consideration of reports submitted by States parties under articles 16 and 17 of the International Covenant on Economic Social and Cultural Rights, Initial reports submitted by States parties due in 1990, para. 74, 6 December 2012. 81 Consideration of reports submitted by States parties under article 35 of the Convention, Initial report of State party. Uganda, 22 January 2013. 82 Combined fifth and sixth periodic reports submitted by Rwanda under article 44 of the Convention, para. 63, 10 July 2018. 83 Consideration of reports submitted by States parties under article 35 of the Convention Initial reports of State parties due in 2010, CRPD /C/KEN/1, para. 103. 3 April 2012. 84 Consideration of reports submitted by States parties under article 35 of the Convention Initial reports of State parties due in 2010, CRPD /C/KEN/1, para. 105. 3 April 2012. 85 Child Poverty in Tanzania report, 2016 86 Combined fifth and sixth periodic reports submitted by Rwanda under article 44 of the Convention, para. 63, 10 July 2018. 41 REALIZING THE RIGHT TO EDUCATION AND HEALTHCARE THROUGH IMPROVED PUBLIC TRANSPORT IN AFRICAN CITIES 4.3. National and city-level transport and urban development policies to improve accessibility to education and healthcare opportunities Awareness of the role of transport connectivity and within a 10-km radius; in urban/dense areas, one CSPS improved transport and land use planning coordination should be available for 10,000 people. is noted in nearly all of the Government-level – both national and city-specific, where available – policy doc- The National Plan for Economic and Social Develop- uments and future strategies. Similarly, human capital ment 2016-2020 (Government of Burkina Faso, 2016) development, to be achieved through better access to has three strategic axes, including development of schooling and healthcare opportunities, is nearly unan- human capital. Specific strategic objectives include the imously part of national level Vision documents and promotion of population health and acceleration of the metropolitan master plans. At the same time, the dif- demographic transition, which is expected to guarantee ferential education and healthcare access needs of the access to quality health services for all. Another objec- more vulnerable society groups – and hands-on strat- tive is to increase the supply and quality of education, egies on how to serve them – receive more variable including access to quality higher education. Burkina attention, and analysis of the existing spatial patterns of Faso’s Basic Education Strategic Development Program exclusion is not commonly reflected. 2012-2021 proposes providing universal, free and obligatory access to ten years of education (Ministère The National Study for “Burkina 2025” (Conseil National de l’Enseignement de Base et de l’Alphabétisation, de Prospective et de Planification Strategique, 2005) 2012). The Sectoral Program for Education and Training was developed to analyze the past and current eco- 2012-2021 (Ministères en Charge de l’Education, 2013) nomic, social, political and cultural situation of Burkina goes further in recognizing the role of transport acces- Faso, and to determine the future development mecha- sibility in reaching education goals: under the theme of nisms. The Vision 2025 for Burkina Faso is a nation that access to formal education and training, the document is inclusive of all groups, especially the most vulnerable, notes the need to improve the study conditions for and that ensures access for all to quality education and students, including transport to schools; with respect to health services. The National Health Policy (Ministère de higher education, it proposes acquiring dedicated bus la Santé, 2011) presents a vision that is aligned with the transport. National Study for “Burkina 2025”; moreover, it notes that its goal is to support Burkina Faso in achieving The National Housing and Urban Development Pol- its international commitments, including those envi- icy (Ministère de l’Habitat et de l’Urbanisme, 2008) sioned in the Universal Declaration of Human Rights, envisions that urban planning should provide people such as by ensuring universal access to healthcare and with access to transport infrastructure, education and improving health services for vulnerable groups. The health facilities, while recognizing the lack of sufficient earlier National Health Development Plan 2001-2010 human resources to implement urban planning poli- (Ministère de la Santé, 2001) specifically acknowledged cies, the lack of coordination among urban stakehold- the limited financial and geographic access to health ers, and the poor implementation of urban planning services and defined specific targets with respect to guidelines. In 2014, the Ministry of Housing and Urban the most basic healthcare facilities: in rural areas, there Planning hired a consultant with funding from UN-Hab- should be a Health and Social Promotion Center (CSPS) itat to work on the “Preparation of the National Habitat 42 MOBILITY AND TRANSPORT CONNECTIVITY SERIES CONNECTIVITY FOR HUMAN CAPITAL III Report” of Burkina Faso (2015). Among the issues National Development Strategy 2020-2030 (Republic addressed by the report were the need to respond to of Cameroon, 2020) provides guidance for the sec- the needs of the youth in the urban environment, the ond phase of Vision 2035, defining the development needs of the elderly, and the need to integrate gender of human capital as one of its pillars and recognizing equality in urban development, including by removing the continued issues with mobility and access in urban barriers for girls to enroll in- and complete- school. areas, despite the efforts of the past decade. While Finally, the National Urban Mobility Policy 2030, which mostly focusing on improving access to basic services is part of the current National Economic and Social in rural areas, to reduce the existing disparities among Development Plan (2016–2020), intends to improve regions, the Strategy sets targets that also apply to access to not only economic opportunities but also cities, specifically, a 100-percent rate of achievement in health and education services for as many people as primary education and ensuring the functioning of 80% possible. To this end, the Commune of Ouagadougou of intermediate and peripheral health facilities. has developed an Observatory for Urban Movement, a mechanism of coordination and collaboration that aims The country’s Health Sector Strategy 2016-2027 (Minis- to centralize information regarding the mobility prac- try of Public Health, 2016a) states the vision of universal tices of the city’s residents and brings together various access to quality health services ensured for all social transport stakeholders. strata by 2035, with the full participation of commu- nities, with its first guiding principle being equity in Vision 2035 for Cameroon (Ministry of Economy, Plan- geographical, financial and cultural access to health ning and Regional Development, 2009) aims to, among services. In its assessment of the 2001-2015 Health other things, improve and expand the provision of Sector Strategy, it mentions the failure in some indica- social services, including education and health. The tors including the large spatial gaps in the share of dis- Vision recognizes that population growth puts pressure tricts serviced by health centers and the continued high on the provision of social services and this pressure is maternal mortality, which was aimed to be reduced but more evident in the urban context. Key identified needs in fact increased between 2004 and 2011 from 669 per include the improvement of the quality and quantity 100,000 live births to 782. The Strategy acknowledges of the education services and in particular to facilitate the importance of the spatial distribution of care and access to primary education for the poorest sectors the difficulty of physically access. Similarly, the National of the population. Other goals include expanding the Health Development Plan 2016-2020 (Ministry of Public availability of health services and strengthening the Health, 2016b) recognizes that inadequate physical role and financial independence of women and other access to services contributes to the poor performance groups living in vulnerability. Covering the first decade of some of health indicators, for example, delivery of the Vision’s timeline, the Government of Camer- assisted by professionals. Similarly, Cameroon’s Edu- oon developed the Growth and Employment Strategy cation and Training Strategy 2013-2020 (Republic of 2010-2020 to serve as a integral framework of devel- Cameroon, 2013) defines “access and equity” as one opment, among others, noting the poor state of the of its guiding principles, specifically, the objective of roads. The Strategy’s human development objectives improving access and equity at all levels of education. include the provision of universal access to healthcare Specifically, it defines measures to ensure attendance and improved access to basic education. Further, the to school of vulnerable populations considering their 43 REALIZING THE RIGHT TO EDUCATION AND HEALTHCARE THROUGH IMPROVED PUBLIC TRANSPORT IN AFRICAN CITIES levels of poverty, their place of residence and their gen- Policy 2030 that it is closely aligned with CREDD and der (among others, proposing to study the possibilities aims to improve urban living conditions and mobility. of providing dedicated transport or boarding options); This policy is targeting the problem from a multimod- increase rates of pre-primary enrollment; construct and al approach in which urban planning and mobility are rehabilitate educational facilities, etc. done in coordination. It acknowledges the gaps in con- sidering non-motorized modes in urban planning and The Strategy for the Development of Douala and its seeks to rectify this by giving importance to creating Metropolitan Area (Republic of Cameroon, 2009) builds secure pedestrian routes. The National Transport and on ten strategic axes, including among them the need Road Infrastructure Policy (NTP) acknowledges that the to improve accessibility of and to neighborhoods and enabling role the transport sector plays in Mali’s devel- public services. However, the document does not go opment, through promoting people’s access to social further into the topic of physical access to schools services, among others (Republique du Mali, 2015). or health centers. The Agenda Douala 2021 (Douala The NTP’s strategic objectives includes the provision of Urban Council, 2010) document, which is intended to access to health centres and the improvement of public be continuously updated, sets as objectives the pro- transportation via increasing its capacity, the coordi- motion of clean transport and sustainable mobility, nation of the different systems, and attracting more including cycling and the use of public transportation; people (i.e. through differentiated tariffs catering to development of support systems for vulnerable groups; different population groups). and improvement of access to municipal buildings and other services to people living with disabilities. Another The National City Policy of Mali notes the role of the guiding document for the city is the Development of a lack of basic infrastructure and education and health Transport Plan and Urban Travel For Douala (Ville de facilities in the use of residential facilities as education/ Douala, 2009); however, for accessing social services health centers and the streets as playgrounds, which specifically, it only notes the need for traffic calming affects not only the health and safety of children but measures around schools. also the mobility of the populations (see Republique du Mali, 2014). The Policy also points to the inadequate Mali’s Strategic Framework for Economic Recovery and roads and public transportation as a general problem Sustainable Development 2019-2023 (CREDD) defines in urban centers. For people with disabilities, the Policy the country’s vision of “inclusive growth and a struc- acknowledges the lack of guidance in facilitating their tural transformation of the economy”, recognizing the easy access to public places and transport services. importance of mobility issues in urban areas (see Min- As its General Objective number one, the Policy notes istry of Economy and Finance, 2019). CREDD aims for a improving access to education and health services process of wealth creation that is inclusive and respect- and to transport, including by identifying and adopting ful of the environment and values human capital, espe- modes of public transport that are adequate for Bama- cially benefiting the youth and women. CREDD acknowl- ko and by creating road spaces (lanes) for the circula- edges the current situation in the country as unequal tion of motorcyclists and cyclists. and characterized by difficult access to health and education services, partly due to the prevailing secu- Mali’s Ten Year Health Plan 2014-2023 notes as among rity situation. Mali also has a National Urban Mobility the main issues affecting the sector the spatial gaps in 44 MOBILITY AND TRANSPORT CONNECTIVITY SERIES CONNECTIVITY FOR HUMAN CAPITAL access, as only 42% of the population has access to a infrastructure and enforcing its protection for pedes- health facility within 5 km radius, and only one in three trian use, such as by not permitting informal vendors people seek medical consultations. To promote the use to occupy sidewalks or the sidewalks to be used as of health services, the Plan proposes increasing the parking spots. These policy document notwithstanding, coverage of health care and looking for alternatives to there is a need for mechanisms to align and delimitate cover more women and more of women-related issues responsibilities and coordination among the Minis- (see Republique du Mali, 2014b). tries and institutions in charge of the different themes (SSATP, 2018a). Strategic initiatives have also seen a Human capital is among the six pillars of Guinea’s mixed record of implementation, are not always well Vision 2040 (see Republique de Guinee, 2017) as a known to the authorities, and sometimes lack the sup- necessary driving force of the country’s development, porting policies in place to be executed (World Bank with intermediate objectives including equitable access Group, 2019). to a quality education for all and a healthy life for every Guinean. The National Health Policy (Republique de Tanzania’s Vision 2025 aims to guide the nation to a Guinee, 2014) has a Vision of a Guinea with “universal middle-income country that is educated and highly pro- access to high-quality, fully inclusive health care and ductive and that brings opportunities for all, including service,” with specific priority areas including the need people with disabilities. Among the targets, the Vision to increase availability, access, quality and coverage of 2025 aims to realize universal education, gender equali- maternal care; and to strengthen community based ty and empowerment, access to quality primary health initiatives and multi-sectorial interventions to reduce care and quality reproductive health services, and an the exclusion of certain population groups. Similar- adequate level of physical infrastructure. Tanzania’s Five ly, the Government’s 10-Year Education Program for Year Development Plan II (FYDP-II 2017/18-2020/21) 2020-2029 puts emphasis on inclusive development is aligned with the Vision 2025 and contains several of human capital. The Program stresses the need to objectives for enhancing the country’s human capital, increase the coverage of education services to reduce through diverse mechanisms such as matching of skills inequalities of all types (gender, spatial, etc.); however, and market needs, high quality of life, and quality of it does not explicitly mention the role of physical acces- education, and with specific targets for enrolment and sibility, instead, suggesting school meals as an effective students passing exams (The United Republic of Tan- tool for increasing enrolment and retention of chil- zania, 2016a). To achieve this, Tanzania recognizes it dren, and the need for improvement of classrooms and needs to improve the teacher-student ratios and the toilets to accommodate children with disabilities (see learning and teaching environment. In the health sec- Republique de Guinee, 2019b). tor, FYDP-II aims to improve service delivery and reduce the share of people traveling long distances to health Guidance documents at the city level include the Urban facilities from 36% in 2014/15 to 15% in 2025/26. Mobility Plan for Conakry (Republique de Guinee, 2019a) and Grand Conakry Vision 2040. While the Plan Tanzania’s National Transport Policy (see The United does not explicitly mention access to schools or health Republic of Tanzania, 2013a) sets the direction for the centers, it places emphasis on planning for pedestri- management of transport in urban areas, with strong ans and their travel needs, by providing the necessary focus on reducing congestion around the business 45 REALIZING THE RIGHT TO EDUCATION AND HEALTHCARE THROUGH IMPROVED PUBLIC TRANSPORT IN AFRICAN CITIES district, and recognizes the role that transport plays in Social Transformation Pillar provides the framework to enabling access to education and healthcare. The 2017 enable Rwandan citizens to develop their capacities and update acknowledges that, regardless of the introduc- skills, including by ensuring access to quality health for tion of the BRT in Dar es Salaam, the characteristics of all; specifically, this goal is expected to be achieved by commuting in Dar es Salaam are still poor, with conges- constructing and upgrading health facilities. The same tion, pollution, poor road safety, and lacking of provi- Pillar also includes an education goal, specifically focus- sions to accommodate pedestrians and cyclists (see ing on increasing pre-primary enrollment and decreas- United Republic of Tanzania, 2017). Regarding land use ing drop-out rates. While it does not mention tackling planning, the Policy recommends to allocate facilities barriers related to traveling to school, the document such as schools and other amenities close to residen- notes that special attention will be paid to people with tial areas. It also specifically speaks about transport for disabilities to be able to access education and that the disadvantaged groups in urban areas, such as students, education facilities have adequate infrastructure (i.e. the elderly, and people living with disabilities, recom- sanitation facilities). The United Nations Children’s Fund mending that the Government, communities and oper- (UNICEF) is working closely with the Government to ators contribute to solving the mobility issues for these implement its Education Sector Strategic Plan 2018/19– groups without jeopardizing the commercial aspects 2023/24, with a focus on three key areas: (1) increasing of the service. The guidance for public vehicle design, access to education for vulnerable groups; (2) qual- moreover, specifies that public transport should be ity of education; and (3) increasing access to quality able to accommodate safely and with comfort all users, pre-primary education. There is also a consistent focus including those belonging to disadvantaged groups. on ensuring gender equity and inclusion in all efforts. Participation of education has improved, as evidenced The Dar es Salaam Transport Policy and System Devel- by an increase in access to pre-primary education and a opment Master Plan, now over a decade old, focuses reduction in dropout rates. In 2017, more than 20,000 mostly in large-scale infrastructure interventions, while refugee children, children with disabilities, and out- also recognizing the dependence of many of the city’s of-school children had opportunities to access quality residents on walking and public transportation. It pro- education in an inclusive environment. poses several policies, such as “Pedestrian and Non-Mo- torized focus development and Urban Road Develop- Rwanda’s National Urbanization Policy (NUP) (Republic ment”, “Public Transport Oriented Development’, and of Rwanda, 2015a) provides a framework to that aims “Accessibility and Mobility to all” (see JICA, 2008). to guide urbanization in the country based on princi- ples of sustainability, resilience, inclusivity, participa- Among the priorities defined under the social trans- tion, and flexibility. Its four pillars, namely coordination, formation pillar of the Rwandan Government’s Nation- densification, conviviality and economic growth, are also al Strategy for Transformation (NST) 2017-2024 are embedded in the Master Plan for Kigali of 2018 (Sur- ensuring access to quality health for all, and increasing bana Jurong Consultants Private Limited, 2018). The access to and improving the quality of education (see NUP does not directly speak to the connection between Republic of Rwanda, 2017a). NST 2017-2024 focuses on transport and access to services; however, its Convivi- Economic Transformation, Social Transformation, and ality Pillar states that as part of the urban quality of life, Transformational Governance as its three pillars. The the residents should have easy access to education and 46 MOBILITY AND TRANSPORT CONNECTIVITY SERIES CONNECTIVITY FOR HUMAN CAPITAL health facilities. It also brings a strong angle of inclusiv- the accessibility of centers of social and economic ity and women’s empowerment by bringing the diverse importance through the development of the road net- urban groups into the planning discussion to address work, with the participation of road users, including the their needs. civil society (see Parliament of Zimbabwe, 2002). The Kigali Master Plan, updated in 2018, builds on three The United Nations, The World Bank and the African components: green and efficient city, inclusive city, and Development Bank, responding to a request from the vibrant and productive city. Among the issues identified Government of Zimbabwe, in 2019 conducted an exer- in the Plan is also the need to reduce existing dispar- cise to assess the needs to be addressed over time. In ities in live quality and the lack of physical and social terms of specific policy needs, This Joint Needs Assess- infrastructure, with the envisioned approach based ment for Zimbabwe (JNA) points to the finalization and on inclusive development and consultations reaching implementation of the Education Act and the develop- all members of the city’s diverse community, including ment of a Strategy for Post-Secondary Education. In the vulnerable populations. It estimated that approximately health sector, the JNA highlights the need to revise the 60% of Kigali’s urban households live in substandard country’s Health Financing Strategy, specifically the user conditions, with poor access to health and education fee policy for vulnerable population groups. No poli- services and infrastructure, mainly derived from their cy documents regarding health and education access location in unplanned settlements. It also acknowl- and/or the role of transportation are available specifi- edged the disproportional burden of road accidents on cally for Harare. the most vulnerable road users, with 71% of accidents in Kigali involving a pedestrian, cyclist or a motorbike. Kenya’s Vision 2030 is to become a ‘globally competi- The Vision 2050 for Kigali, described in the Master tive and prosperous nation with a high quality of life’, Plan, proposes Kigali’s living standards to be increased in part, by investing in people (see Government of the through “faster, inclusive urbanization and greater Republic of Kenya, 2007). Vision 2030 sets goals of agglomeration”, emphasizing the importance of urban increasing enrollment rates and transition rates to tech- mobility and public transport. nical schools and universities, to reform the curricu- lum for secondary education, to develop key programs In the education sector, the Vision 2030 for Zimbabwe for learners with special needs, among others, and to “towards a prosperous and empowered upper mid- strengthen education infrastructure. In the health sec- dle income society by 2030, with job opportunities tor, it envisions the revitalization of community health and a high quality of life for its citizens” focuses on the centers to promote preventative healthcare and to improvement of curricula, STEM, and facilities for ter- support disadvantage groups (youth and economically tiary education, also noting the need to develop special vulnerable households). The Vision also notes that it is needs education and adult training (see Republic of imperative to provide convenient and efficient transpor- Zimbabwe, 2018). In the health sector, priority is giv- tation that cuts commuting times and transport costs, en to preventative care and bringing services closer to and to provide for the specific needs of women in the communities by decentralizing services from Referral working class, such as by expanding the availability of to Provincial, and from there to District Hospitals. The childcare facilities. The National Urban Development country’s Roads Act establishes as an important goal Policy, formally endorsed in 2016, envisions Kenya to 47 REALIZING THE RIGHT TO EDUCATION AND HEALTHCARE THROUGH IMPROVED PUBLIC TRANSPORT IN AFRICAN CITIES have well-governed, competitive, and sustainable cit- that ensures affordability and cost effective modes of ies that contribute to the achievement of the broader transport. The Integrated Urban Development Mas- national development goals articulated in the Constitu- ter Plan for the City of Nairobi (JICA, 2014a), similarly, tion and Vision 2030. The Policy aims to facilitate sus- presents a vision for the city’s CBD as a compact urban tainable urbanization through good governance and center that is bot efficient but also inclusive. Finally, in delivery of accessible and efficient infrastructure and 2015, the Non-Motorized Transport Policy for Nairobi services, based on the principles of inclusivity, connec- was launched, which, among others, acknowledges the tivity, and livability (adequate quality services and infra- data gap on the importance of NMT modes for different structure). The National Spatial Plan (2015-2045) guides users (see Nairobi City County Government, 2015). The Kenya’s spatial development and is aligned with Vision Africa Transport Policy Program’s assessment recogniz- 2030. The NSP recognizes the need to improve accessi- es the steps Kenya has already taken towards improv- bility and recognizes the role of transport as a catalyzer ing urban mobility and access (see SSATP, 2018b). As an for other sectors. The National Integrated Transport example, in 2017, the Nairobi Metropolitan Area Trans- Policy has identified challenges for users and a plan for port Authority was established with the mandate to more accessible infrastructure.87 Additional regulations “regulate and oversee the establishment of an integrat- from 2009 require various modifications to traffic sig- ed, efficient, effective and sustainable public transport nals and on the pavement for improved access.88 system within the Nairobi Metropolitan Area”. Nairobi Metro 2030 (Government of the Republic of As part of Uganda Vision 2040, the country has plans Kenya, 2008) is the Nairobi Metropolitan Region’s to develop five regional cities: Kampala, Gulu, Mbale, guideline to achieving high quality of life and sustain- Mbarara, and Arua (see The Republic of Uganda, 2010). able wealth; its building blocks also include optimizing For the Greater Kampala Metropolitan Area (GKMA), mobility and connectivity through effective transporta- Uganda envisions that by 2040 it will be providing high tion and enhancing inclusiveness. The document recog- quality public transport and a complementary non-mo- nizes the challenges in the region, such as poor mobil- torized transport network. Urbanization in the GKMA ity and connectivity, which translates into poor and has been characterized by uncoordinated planning and expensive transport services and, therefore, poor quali- developments leading to sprawl. Therefore, the Govern- ty of life and access to basic services, such as education ment aims to develop and ensure implementation of and health care. Nairobi Metro 2030 sets the goal of physical Master Plans that drive the development of the a transit-oriented development structure for the city, GKMA, which will take into account considerations of aiming to fully integrate mobility planning into the land provision of social amenities, including education and use planning and development processes, and consid- health. The Vision 2040 recognizes that previous efforts ering the social profile of the residents. The document to promote gender equality and women’s empower- also notes the objective of developing an integrated ment have yield positive results, but are still insufficient. institutional framework for transport management Therefore, it puts a stronger focus on targeted policies, 87 Consideration of reports submitted by States parties under article 35 of the Convention Initial reports of State parties due in 2010, CRPD /C/KEN/1, para. 103. 3 April 2012. 88 Consideration of reports submitted by States parties under article 35 of the Convention Initial reports of State parties due in 2010, CRPD /C/KEN/1, para. 105. 3 April 2012. 48 MOBILITY AND TRANSPORT CONNECTIVITY SERIES CONNECTIVITY FOR HUMAN CAPITAL strategies and programs that facilitate the participa- and improving quality of, and access to health services, tion of women in the development process, including although physical access is not mentioned explicitly. flexible working conditions. With respect to Education, Transport issues are addressed under a different Pillar Uganda’s Second National Development Plan (2015/16- of the Plan, namely “City Economic Growth,” where the 2019/20) identifies several sector constraints, including Plan aims for the implementation of multi-modal urban shortage of critical infrastructure and overcrowding but transport solutions to address congestion, a key chal- does not to mention distance or access to education lenge mentioned during the stakeholder engagement centers as a key issue (The Republic of Uganda, 2015). undertaken during the preparation of the Plan. The Kampala Physical Development Plan, similarly, empha- The Ugandan Ministry of Works and Transport’s Nation- sizes the need to infrastructure planning to deliver a al Transport Master Plan 2008-2023 for the country and highly connected transport network and accessible the GKMA identified several challenges, some of them social services. associated with the lack of regulation in the sectors linked to transport, such as land and governance (see In terms of access of education, according to the KCCA, The Republic of Uganda, 2008). For example, it recog- 65% of the traffic congestion in Kampala is caused by nizes that the lack of structural planning is one of the school-related traffic, due to the location of the top per- causes of the rapid increase of urban sprawl along the forming schools in City Centre. To respond to this issue, main radial routes, that city dwellers walk long distanc- the KCCA, under the Kampala Model School Project, is es to access public transportation and that pedestrians, considering to support the relocation of some of the non-motorized transport (NMT) and trips made through City Centre schools to residential areas to ensure easier these modes were not taken into account when design- access. This is aligned with the Kampala Physical Devel- ing roads and infrastructure. opment Plan, were a goal of creating a new hierarchy of organized and accessible services is envisioned, among Kampala Capital City Strategic Plan 2020/21-2024/25 other objectives. (KCCA, 2020), which includes “enhanced quality of life” as one of its core pillars, envisions access to all basic Human capital is extensively emphasized in Mozam- services; this also entails that accessible and afford- bique’s Agenda 2025, the country’s strategic vision able transportation systems, either roads or pedestrian prepared in 2003 (see Comité de Conselheiros, 2003), infrastructure, are accessible to everyone, allowing to of which health and education are noted as fundamen- ”to move around the city quickly and comfortably”. The tal components. In this regard, the document acknowl- strategic objectives of the Plan include (1) improving edges the importance of extending the coverage of the lives of vulnerable groups, (2) improving the quality health and education services and of having an efficient of educational opportunities, and (3) improving pub- patient transport system among health facilities. The lic health and environmental management. Specific document provides strategic options for the provision commitments under the second objective include the of schools providing Upper Primary Education, not- identification of the barriers for completion of second- ing that at least 50% of the spaces available for stu- ary education (including gender-related) and imple- dents should be for girls and that incentives need to menting mitigating solutions. Activities defined as nec- be put in place for families to continue sending girls to essary to reach the third objective include expanding school. The Agenda also envisions creating schools for 49 REALIZING THE RIGHT TO EDUCATION AND HEALTHCARE THROUGH IMPROVED PUBLIC TRANSPORT IN AFRICAN CITIES children with a physical or mental disabilities. The role The country’s Action Plan for Poverty Reduction 2011- of transport services is acknowledged in the document 2014 (Government of Mozambique, 2011) establishes with respect to providing access to jobs and facilitat- as a strategic objective guaranteeing access to trans- ing the satisfaction of basic need, specifically encour- port for urban users, minimizing distances and travel aging NMT. Development of human capital is also and wait times, through the liberalization of transport among the pillars of the National Development Strategy rates and putting in place protections for students for (END 2015-2035, Government of Mozambique, 2014), traveling to school and for other vulnerable groups. emphasizing the need to adopt land-use management plans that ensure access to quality services. While it As part of the Comprehensive Urban Transport Master does not mention lower levels of education, the END Plan for the Greater Maputo (JICA, 2014), the shared refers to the importance of promoting access, equity vision for Greater Maputo was defined as “socially and and expansion of coverage of technical and vocation- environmentally sustainable urban transport systems al education. Also the Government’s current Five Year facilitating the international gateway capital”; howev- Program (Government of Mozambique, 2020) defines er, access or affordability are not explicitly mentioned. as its first priority the Development of Human Capital The Plan notes the role of public transport in increas- and Social Justice, recognizing the current gaps and the ing mobility and accessibility, along with the need to need to, among others, promote an inclusive education improve the use of road space and the pedestrian envi- system; increase access to health services; and pro- ronment. However, the Master Plan has been criticized mote gender equality, social inclusion and protection for paying little attention to chapas (minibuses) whose of the most vulnerable populations. This is consistent recent mapping provides an opportunity to better plan with the National Strategy for Basic Social Security and integrate the various parts of the transport system 2016-2024 (Government of Mozambique, 2015), which in terms of access and equity (Klopp and Cavoli, 2019). aims to contribute to the development of human capital through improving access to education and health for the poor and the most vulnerable and defines priorities in the health sector of particular importance to women, such as increasing the quality of the so-called Casas de Espera para Mulheres Grávidas.89 It is also consistent with the vision of the Health Sector Strategic Plan 2014-2019 (Ministry of Health, 2013) which aims to “progressively achieve Universal Health coverage enabling all Mozam- bicans, especially the most vulnerable groups”, through reforms and more and better services. The Plan delves into limited physical access and financial barriers (such as cost of transport) as determinants of the use of health services. 89 Waiting Homes for Pregnant Women: accommodations where pregnant women can wait and be closer to health centers to deliver safely. 50 MOBILITY AND TRANSPORT CONNECTIVITY SERIES CONNECTIVITY FOR HUMAN CAPITAL 5. Barriers to Health and Education Accessibility: The Categories Lens Photo credits: Trevor Samson 51 REALIZING THE RIGHT TO EDUCATION AND HEALTHCARE THROUGH IMPROVED PUBLIC TRANSPORT IN AFRICAN CITIES 5.1. Evidence from household travel surveys, and policy documents primary or secondary school, ability to access education 5.1.1. Transport distance as a bar- facilities. The vast majority of respondents (71%) typical- rier for some groups ly use a motorcycle or a scooter to reach health facili- ties. Only a slightly greater share of women than men Across the cities where detailed survey data is avail- rely on walking and biking (10% vs. 8%); however, modal able, albeit sometimes not directly comparable due to shares differ more significantly across the household its variable recently, distance to facilities represents a income spectrum, with walking and biking dominating major obstacle to schooling and to seeking care. How- in the low-income groups but being entirely absent in ever, it is one of several challenges households face, the upper ones. with affordability – of transport but, more so, of the health and education services themselves – playing an equally important role. Over one in five respondents report distance/ availabil- ity of transport as either the most important constraint To better understand the connectivity constraints faced or one of the main constraints in accessing healthcare: by Ouagadougou residents for accessing key social 19% of men and 22% of women. As a comparison, the services and facilities, a field survey as part of this study share of women aged 15-49 in Ouagadougou report- was conducted in the city in June, 2020, altogether ing distance to health facilities as a barrier to seeking surveying 2,086 individuals. The survey asked a number healthcare was 34% according to the most recent avail- of questions regarding the general role of transport able Demographic and Health Survey for Burkina Faso constraints in the individuals’ ability to access health- (now a decade old) (see Burkina Faso, 2010). care opportunities and, for those who have children in Figure 1: Travel by children to school, by mode, in Ouagadougou (by parent gender and household income) 100% 100% 90% 90% 80% 80% 70% 70% 60% 60% 50% 50% 40% 40% 30% 30% 20% 20% 10% 10% 0% 0% Men Women < 50,000 50,000-100,000 100,000-150,000 150,000-200,000 200,000-300,000 > 300,000 Household monthly income (CFA) Walking/biking Moto Bus/comm. taxi Taxi (yellow) Car Source: Survey in Ouagadougou by SATREC, 2020 52 MOBILITY AND TRANSPORT CONNECTIVITY SERIES CONNECTIVITY FOR HUMAN CAPITAL Transport availability/ distance presents a much more the fact that it is more commonly the households’ wom- common constraint to accessing healthcare services en who are responsible for bringing the children to for the poor compared to the better off, with 38% of school. In contrast to travel for regular medical needs, respondents in the lowest-income group saying it is the the availability of transportation as a constraint for chil- most important or one of the main constraints. How- dren to frequent school is not clearly related to house- ever, it represents a constraint even for many of the hold income, possibly again due to the wider availability upper income respondent and is more concerning for of schools in the respondents’ immediate neighbor- older respondents compared to younger ones. hood, regardless of income. About one-third of Ouagadougou residents report In Douala, residents perceive travel time as the main using a motorcycle or scooter to transport their chil- issue of traveling in the city (15%), approximately the dren to school, slightly less than those who bike. same as the share of those who are worried about road Walking is also a common mode, reported by 27% of safety issues, difficulties to find a vehicle, and transport the respondents. Looking at differences by gender in cost. For about 9% of the residents the main issue is this case is not as meaningful, as the survey does not the access to a transport service by walking, which is record the child’s gender but only the parent’s. Never- more prevalent among the low-income residents (likely theless, some differences in modal shares emerge, with because they have to walk further to find any public women reporting their children using a bike or walk- transport options). Low-income residents of Douala are ing more commonly than men (65% vs. 54%). As with also disproportionately more concerned about long attending to regular medical needs, also with regard to travel times and ability to find a transport vehicle (Doua- children’s travel to school the poorer households rely la Household Survey, 2018). on walking and biking much more than the upper-in- come ones. In the lowest-income group, children walk A study by SSATP (2004a) estimated that most trips to or bike to school in 92% of the cases, compared to 24% school are made on foot, also identifying the barriers in the upper-income group. Still, unlike in the case of for this mode: obstruction of sidewalks, poor condition travel for regular medical needs, walking and biking are of roads, and bad smells. In discussing the reasons for important modes for children to get to school even for gaps in school enrollment between the poor house- the better-off households, which may be explained by holds and the non-poor, which are more manifest in the fact that households send their children to schools the 6-9 and the 14-21 age groups, the study suggests relatively nearby, given the relatively dense distribution that the inadequate supply of public schools implies of primary and secondary schools in Ouagadougou, but that distances to public schools are longer than to this is not always possible with medical facilities. private ones (more widely available); however, the cost of private schools can be a deterrent for the poor to Nearly one in four respondents say that distance/avail- enroll their children. The study found that almost all ability of transportation is the main constraint or among children in primary school get to school by walking; the main constraints affecting the frequency of their 22% of children of poor households in who are in public children’s schooling. Female parents are more likely schools and 13% of those who are in private schools than male ones to perceive transport availability as an have to walk more than half hour each way. At the sec- important constraint (26% vs. 22%), perhaps reflecting ondary school level, while walking is still the main mode 53 REALIZING THE RIGHT TO EDUCATION AND HEALTHCARE THROUGH IMPROVED PUBLIC TRANSPORT IN AFRICAN CITIES of transport used to reach schools, children from poor the populations in need. In Douala, over 22% of women households are more likely to walk than from non-poor aged 15-49 report distance as the constraint for seek- households, especially so among the poor children who ing care at health facilities, while in the country’s other attend private secondary schools: 84% of children in major city, Yaoundé, the share is 26% (Republique du poor households enrolled in private secondary schools Cameroun, 2018). walk versus 56% of children in private schools from non-poor households. The difference is not as wide Because of lack of supply of the public healthcare when comparing poor and non-poor children enrolled services, about three-quarters of all households visit in public secondary schools (71% vs. 65%). private facilities and less than half visit public facilities. When accessing the services by public transportation, According to baseline analysis underlying Cameroon’s 9% of Douala’s poor households were estimated to ride Growth and Employment Strategy 2010-2020, in the for more than half hour to access either a public or a health sector, there is wide availability of informal private center (SSATP, 2004). When accessing the next health services and other structures that offer cheap- level of care, hospitals and clinics, walking is not preva- er services. While the problematic of accessing health lent; about one-third of the poor households reported services is mentioned more in relation to rural areas, riding public transportation for more than half hour also for the urban areas the document expresses the when accessing public facilities, and 48% when access- need of having ‘mobile health teams’ that can access ing private facilities; for the non-poor households the Figure 2: Distance to health facility as a barrier for seeking treatment at health facility in past 5 years among 15-49 year old women: in largest cities vs. among lowest-wealth quintile in country overall (%) 80 70 60 50 40 30 20 10 0 Dj e s Na r li c ra a ey Co s Ga a sS u Ka ou Mo ek re k ry ala Ba a K i ko ng Br aam le Bu asa W ura ia Lib lle bi n Co la to an da ka ga i go m en r e go k tow d iro ov ua vil pu ra ho Ou Niam vi ma sa ton ute idj an Ad na mp Ac Lo Da b Ki La h am Da dou re za Ha nr Do al Ma jum ee Lu Ab ind ns Lu az Fr ag N' City Lowest-quintile Source: Countries’ most recent available Demographic and Health Surveys (DHS) 54 MOBILITY AND TRANSPORT CONNECTIVITY SERIES CONNECTIVITY FOR HUMAN CAPITAL respective shares were lower – 26% and 25%. While travel alone; the burden exceeds 30% of income for access is not commonly cited as a concern in seeking one-quarter of poor households, and expenditure on more advanced healthcare services given that the cost public transport is 20% higher if they live in the outer of the actual care is what concerns dwellers the most, it suburbs (see SSATP, 2004b). The same study reports does feature more frequently among the poor. that the city’s pedestrians face numerous issues, includ- ing bad smells, garbage, and filth; poor road conditions; In Bamako, walking is the mode of transport for more and obstruction of sidewalks. An overwhelming share of than half of all trips (SSATP, 2020b). The average num- the poor household students in Conakry rely on walking ber daily trips per person (3) is among the lowest in to get to school: 96% among primary school students, West Africa, and over half of all trips that do take place 61% and 75% of secondary school students enrolled are short distance. Most trips (57%) in the city are made in public and private schools, respectively. About a fifth on foot, 17% by bus, and 9% by car, although data is of children from poor households enrolled in public not available on the differences by gender. For access- school walk half hour or more to reach school. Among ing healthcare, distance to the facilities is mentioned children from non-poor households, a much smaller as a major constraint by 17.4% of women aged 15-49 share, though still very large, depends on walking to in the city, behind getting the money to pay for the reach school – about 45% of those in public schools services and getting the permission to seek treatment and 56% of those in private ones. This is explained by (Republique du Mali, 2019). While disaggregated data the fact that, because they are more abundant, private was not available for Bamako, in Mali overall distance schools are more likely to be in the same district as the to school is named as a reason for never attending residence than public schools. According to this same a formal school by about 10% of children and young study, albeit now over 15 years old, half of the children adults aged 7-24. Among children ages 5–10, girls are in Conakry have to go to city center to attend school, but less likely than boys to visit a clinic or other health facil- the location is directly correlated with the grade. Among ity when they experience an illness (42% versus 49%), primary school children, 59% attend a school in their which may reflect a lower priority being given to girls’ district and another 29% in an adjacent district, and the health (World Bank, 2020). share of the trips to primary school made by foot is as high as 94%. To attend secondary school, 60% of chil- The mobility of Conakry residents is low, at only 1.8 trips dren have to travel beyond even any adjacent district, per person per day, and traveling on foot is common, and the share reaches 88% among high-school stu- accounting for about 70% of trips in urban areas. At dents. At the secondary school level, even children from the same time, despite the importance of walking as an non-poor households travel longer if they are in public access mode in Conakry, the provision of infrastructure school (31 minutes one way) than if they are in private and policies have been lagging that would make travel school (22 minutes). Finally, the same study also found on foot safe (SSATP, 2018a). that, while both male and female primary and secondary school students cited bad smells, garbage, and filth as Based on data from 2012, approximately 10% of the main problem when walking, the second most men- Guinea’s urban poor spend between 30 and 44 minutes tioned issue among girls was risk of assault, while it was to even reach public transport (Republique de Guinee, mentioned by less than a third of the male pupils. 2016). Poor households spend 19% of income on urban 55 REALIZING THE RIGHT TO EDUCATION AND HEALTHCARE THROUGH IMPROVED PUBLIC TRANSPORT IN AFRICAN CITIES Dissatisfaction with schooling in Conakry mostly relates At the national level, 24% of Ugandan households have to excessive fees, crowding, and lack of books/furniture, a bicycle, 8% a motorcycle and 3% a vehicle. However, and regarding the reasons for not attending school, male ownership of bicycles is almost 5 times higher only 0.7% of children aged 7-19 mention distance, than women’s and ownership of motorcycles – as much according to a 2012 Government survey. Similarly, as 18 times higher (UBOS, 2018). Nearly three-quar- distance to health centers was named only by 0.1% of ters of households in Uganda live within 5 km of a respondents as a reason for not seeking healthcare, health facility; in Kampala specifically, the first point of while a considerably larger share (4.9%) named cost entry for seeking healthcare is about 2.4 km to a Gov- (Republique de Guinee, 2012). However, these findings ernment Health Facility and less than a kilometer to a are in contrast to those of the most recent Demograph- non-government facility (UBOS, 2016). Nevertheless, ic and Health Survey for Guinea (2018), which found 41% of Ugandan women mention distance as a chal- that nearly a quarter of women aged 15-49 in the city lenge to seeking medical services. In the education find distance to be the barrier for not seeking treat- sector, the Ugandan Government considers an accept- ment at a health facility. able distance to travel to school to be 3 km; however, in Kampala, about 16% of school-attending children are The share of the poor in Conakry who walk to seek reported to travel over 3 km. Between 9% and11% of primary healthcare – at least according to the 2004 communities cite long distance as a barrier to access- data – is high in the case of lower-level health facilities ing health services, either private or public, and about such as health centers and dispensaries that are more 6% cite lack of transport (UBOS, 2018). Approximately widely distributed: among poor households, 72% walk 13% of Kampala’s female residents aged 15-49 perceive to public facilities and 79% walk to private ones (SSATP, distance to health facility as a problem to accessing 2004b). These types of facilities appear to be accessible, healthcare (UBOS and ICF, 2018). In contrast, only about given that the average time spent by poor households 3% of Ugandan children reported not attending school to reach the health facility by any mode of transport is because of distance, and transport was not mentioned between 22 and 25 minutes, depending on whether among the reasons for children to leave school. the facility is public or private. However, about one-third of poor households and 17% of non-poor ones do not In its analysis of the determinants of housing demand use any healthcare services in either public or private in Kigali, the Kigali Master Plan (2018) notes the impor- hospitals, which there are much fewer. Of those who do tance of access to schools, with 60% of the children in use hospital care, the vast majority choose public facil- Kigali traveling 1 km or less to reach their schools. Walk ities and tend to travel by magbanas. Across all modes time to a primary school in the Nyarugenge and Kicukiro of transport, poor households spend an hour travel- districts in 2013 was reported to be up to 29 minutes for ing to a public hospital, and 44% have to ride public about 80% of the children, but in Gasabo about 40% of transport over an hour to reach it. The travel time to a the children have to walk half hour or more (see Rwan- public hospital for poor households was estimated to da Environment Management Authority, 2013). Also increase progressively as their residence moves spatial- regarding access to health services, most residents of ly outward – from an average of 28 minutes for those Nyarugenge and Kicukiro walk about 30 min to a health who live in the city center to 113 minutes for dwellers of center, while most Gasabo residents spend between outer suburbs. 30 and 60 minutes. Only one-fourth of transport users 56 MOBILITY AND TRANSPORT CONNECTIVITY SERIES CONNECTIVITY FOR HUMAN CAPITAL report reaching a transportation hub within 20 min- Data on average distances traveled to school and the utes, which explains why the vast majority of commuters modal shares – in Zimbabwe or Harare specifically – is (70%) either walk or use motorcycle transport. not available in recent Government surveys (for exam- ple, this information is not captured in the Educational The Road and Public Transport Accessibility Study in Management Information System 2019). Regarding Rwanda (Esri Rwanda Ltd, 2019) mapped public trans- healthcare services access, the distance is perceived as portation stops across the country and estimated the a constraint by 12% of women aged 15-49 years old in number of schools and healthcare facilities located in Harare (Republic of Zimbabwe, 2016b); in Zimbabwe close walking distance from the stops. Nation-wide, only overall, female respondents have noted ‘distance to a quarter of health facilities and only about one in twen- health facility’ as the second main obstacle to access- ty primary schools were estimated to be within 500 m ing healthcare after ‘getting money to pay for health of a bus stop. However, the study points out that prima- care’, according to the Data Collection Survey on Health ry schools are intended to serve a specific community Sector (JICA, 2012). Similarly to Kigali, the rate of deliver- and the need of public transportation to access primary ies in healthcare facilities is relatively high – in Harare, schools is not be as relevant as it is for other levels of about 78% are performed in a public hospital and 12% education. For Rwanda’s secondary schools, the study in a private one, and only 8% - at home. found a slightly higher share (13% of Level A and 5% of Level O) to be within 500 m of a bus stop. In the country The Kenya Urbanization Review of 2016 estimates that overall, the study estimated 4.2 million people (37% of an average trip related to schooling in Nairobi takes the population) to live within 45-minute walk of a public 38 minutes, which, although high, is less than for other transport stop, with Kigali outperforming the rest of needs (World Bank, 2016a). Extensive surveys by Salon the country. Distance presents a problem to accessing & Gulyani (2019) found that 74% of school children in healthcare for about 8% of women aged 15-49 living Nairobi walk for most of their commutes and report in the country’s urbanized areas, and for over10% of walk times of between 10 and 20 minutes, while those women in this age group in Kigali specifically (Repub- who do not walk use matatus and incur longer travel lic of Rwanda, 2015b). Within Kigali, while only 3% of times. According to an earlier travel survey conducted women aged 15-49 report this as a problem in Kicukiro, in 2013 (JICA, 2014a), even among children from house- in Nyarugenge and Gasabo the respective figures are holds who own a private car, one fifth walk. About 7% 12-13%. As a result of the overall high share of women of women aged 15-49 in Nairobi perceive distance as a who do not perceive distance to be an issue, delivery problem for seeking healthcare (Kenya National Bureau in health facilities across Rwanda is comparatively very of Statistics, 2015). high, ranging from 88% in the East of the country to nearly 91% in Kigali. Recent studies have also looked Gap analysis conducted in Nairobi by JICA (2014a), at the actual use of different health facility types for based on the guidance that for every 25,000 peo- different purposes. These have found that, for example, ple there should be a health center, found there to most Rwandan children under the age of 5 are treated be a shortage of 47 facilities. With respect to primary at a health center, and less than 2% - at a provincial or schools, where it suggests the need for a school for district hospital (Republic of Rwanda, 2017b). every 5,000 people and availability of a school with- in a 500-meter walk, the study identified a shortage 57 REALIZING THE RIGHT TO EDUCATION AND HEALTHCARE THROUGH IMPROVED PUBLIC TRANSPORT IN AFRICAN CITIES of more than 400 schools, especially in areas such as school. For example, in Dakar, 94% of children who Mukuru Kwa Njenga and Kayole. For secondary schools, attend daara (religious school) or a public primary it proposed that a school should be available for every school reach school by walking, which is explained 25,000 people, with a walking distance of no more than by the fact that the vast majority of children attend a 1 km, finding a shortage of 77 schools. school that is located within their residential neighbor- hood (see Republique du Senegal, 2015). Reliance on In the case of Dar es Salaam, distance does not figure walking is lower among Dakar’s private primary school among the reasons why children aged 7-13 do not pupils, of whom three-quarters walk to school. Among attend school (The United Republic of Tanzania, 2013b). all the children attending daara, 12% report transport The same survey data, albeit now nearly a decade old, as a constraint for attending school, while the respec- suggests reliance on walking to access school in the city tive share among public or private primary school (78% of children), followed by public transport (12%), pupils is 4-5%. The average trip to primary school in private vehicles (4%), and biking (<1%). Among the Dakar takes about 14 minutes. At the secondary school primary school children who walk to school, the time level, less than half of students attend school within required in Dar es Salaam is less than 15 minutes for their own residential neighborhood; however, most of about 90%. In contrast, children in O-Level secondary them (about three-quarters among public secondary schools walk about 28 minutes; among those children school students and 56% among private school ones) who arrive to school by private vehicle or public vehicle, nevertheless rely on walking to reach school. Across all the average travel times are 49 and 46 minutes, respec- secondary school students, the average trip to school tively. Distance to the healthcare provider was not takes between 17 and 22 minutes, depending on the cited as a reason for not seeking care. However, about type of school. Issues with transport as a constraint 37% of women in Dar es Salaam aged 15-49 perceive for attending school are reported by about 6% of all distance to health facility as an issue (see The United secondary school students, both public and private. Republic of Tanzania, 2016b). Among all students under the age of 19, a very small share rely on public transport modes – buses, informal Mozambique’s Agenda 2025 (Comité de Conselheiros, minibuses, communal taxis – to get to school; the figure 2003) notes distance to school as a barrier to school- is somewhat higher among girls than boys, with over ing, specifically interfering with the transition of stu- 5% versus 3%, respectively. dents from EP1 (grades 1-5) toEP2 (grades 6-7). Almost half of all trips (45.9%) in the city are made by walking Transport (including congestion) in Dakar does not or bicycle, and trip to school represent the send most appear to be a common constraint – at least relative to important trip purpose (JICA, 2014). Distance to health others – for accessing healthcare facilities, either. Here, facility is a constraint to seeking healthcare for 16.5% of the various modes of public transport, including formal women aged 15-49 in Maputo City (Instituto Nacional buses, informal minibuses, and communal taxis, repre- de Estatística, 2013). sent at least 10% of all trips (and over one-third of trips for accessing public hospitals specifically); however, less In other SSA cities where detailed household survey than 5% of respondents consider transport access to data is available, similarly, children appear to be over- the health facility an issue. However, this figure is not whelmingly dependent on walking to reach primary fully consistent with the comparatively high share of all 58 MOBILITY AND TRANSPORT CONNECTIVITY SERIES CONNECTIVITY FOR HUMAN CAPITAL Dakar residents – 10% - who say that they have fore- children to attend school, relative to other constraints, gone health-related needs due to transport constraints. and also somewhat more important than transport availability/distance, with 26% of the respondents say- In Abidjan, the average trip to primary school lasts 16 ing it is either the most important constraint or one of minutes and is nearly the same across different house- the main ones. Female parents are more likely to report hold income brackets. About 94% of trips are under- transport cost as an important constraint compared taken on foot, and the share is the same for girls and to male parents (30% vs. 22%) and also more likely to boys but reaches 96% among children from the lowest report it as a constraint compared to transport avail- income group (Republic of Cote d’Ivoire, 2013). Among ability/ distance. The number of respondents in each secondary school students, about 63% walk, and household income bracket is relatively small, and a also among the lowest-income households the share large share of those respondents who reported trans- increases only slightly, to 67%. The average trip lasts port cost to be an important constraint either declined about 21 minutes one way but ranges from 17 min- to report their household income or did not know it. utes for pupils from households in the highest income Nevertheless, some differences can be observed across bracket to 23 minutes for pupils from the lowest-in- the household income spectrum, with the respondents come households. in the lower-income groups much more likely than those in the upper-income ones to report transport cost as an important constraint for their children to 5.1.2. Transport costs as a barrier to access- attend to school. ing schools and healthcare facilities For 16% of the respondents, transport cost is among According to the surveys conducted in Ouagadougou the main constraints affecting access to healthcare, and in June 2020, on average, the one-way cost of traveling it is equally so among women as among men. Trans- to a medical facility was reported at about US$2.54; port cost is a more common constraint for the older however, the average was as high as US$5.71 for those respondents and, as expected, among the respon- who had traveled by car but was only US$0.36 for the dents belonging to lower-income households. Across person who had traveled by bus. For travel to schools, all household income categories except the very upper the average one-way cost of transport was reported at one, however, transport availability/ distance represents about US$1.61, but ranged from zero monetary cost a more important constraint than transport cost, while incurred by those who walked to US$17.81 for the for the highest income household individuals both person who traveled by car. Nearly all those respon- factors are reported as important by equal shares of dents who on the day of the interview had traveled respondents. Within the lowest-income group, both to a school by bus did not report a per-trip cost but transport availability and cost in fact appear to be said that their transport costs for travel to the school constraining for a larger share of men than women; in amount to about US$5.30 per month, quite a significant other words, a higher share of low-income women than sum for many households. men consider other constraints to be more important in their ability to access healthcare services. In fact, compared to travel for medical needs, transport cost appears to be a more important constraint for 59 REALIZING THE RIGHT TO EDUCATION AND HEALTHCARE THROUGH IMPROVED PUBLIC TRANSPORT IN AFRICAN CITIES Figure 3: Availability/distance of transportation vs. transport cost as “the most important constraint” or “one of the main constraints” in accessing health services, by household income in Ouagadougou (% of respondents) 38% 30% 27% 19% 15% 14% 14% 13% 12% 9% 9% 9% < 50,000 50,000-100,000 100,000-150,000 150,000-200,000 200,000-300,000 > 300,000 Household monthly income (CFA) Transport availability/distance Transport cost Source: Survey in Ouagadougou by SATREC, 2020 Ugandans living in urban areas use 6.9% of total higher in Harare specifically, reaching 12.4% (ZIMSTAT, monthly expenditure on transportation; in Kampala, 2013). No breakdown, however, is available on the this figure is 7.9% (UBOS, 2018). Expenditure on trans- spending burdens faced by different population groups. port to and from school in urban areas differs by the level of education: children in primary education pay 1.6 In Douala, about 15% of the city’s residents perceive times more than children in secondary education. transport cost as the main constraint for travel; howev- er, among the low-income residents the share is nearly According to the Kigali Master Plan of 2018, depending 20% (Household Travel Survey, 2018). on the Kigali district, children spend between RWF 790 (Gasabo district) and RWF 1,285 (Kicukiro), on aver- Data from a 2015 survey in Dakar suggests that the age, to travel to school, equivalent to US$0.81-1.31, average reported expenses for students to reach school although for some children the expense reaches RWF range from US$0.25 among elementary school students 6,500-7,000. However, these averages are in light of the to about US$0.31 among secondary school students. overwhelming dependence of children on walking to Thus, the overall daily expenses on transport amount to get to and from school, with only a small share relying US$0.5-0.6 per student, which is high considering the on public or private transport. average household budgets in the city and also consid- ering the fact that the vast majority of students reach According to 2011 data, households in Zimbabwe’s school by walking and therefore do not incur transport Urban Council Areas spend, on average, 9.6% of their expenses at all (see Republique du Senegal, 2015). budget on transport, although the share is slightly 60 MOBILITY AND TRANSPORT CONNECTIVITY SERIES CONNECTIVITY FOR HUMAN CAPITAL 5.2. Evidence from interviews with human rights practitioners factors. More variation in access to public education 5.2.1. Transport and physical acces- was noted in comparison to health access, which was sibility related barriers generally considered poor. Inequalities in education access were reported to result from inequality in physi- To provide a richer perspective on the variety of con- cal access and transport gaps; inequality in quality (due straints faced by specific marginalized groups in access- to the issue of “dual systems”, similarly to healthcare); ing needed care and schooling, the study team con- affordability; and the exclusion of specific groups, such ducted a series of semi-structured interviews with key as children living in city peripheries and informal settle- staff at international and locally-based human rights ments, “street” children, and children with disabilities; and development organizations working in the coun- and gender norms that prioritize boys’ education over tries in scope of the study, including the OHCHR local girls’ and impose heavier household chore duties on and regional offices, the UN and UNFPA local offices, women and girls. The COVID-19 pandemic was again and FATE (based locally in Kigali). noted as having had a magnifying impact on these already sizable constraints. As suggested by the interviews, in all countries, trans- port infrastructure and services appear as a critical barrier to accessing health services, and it is yet more The poor intensified for women due to a combination of con- As noted by the human rights professionals working straints related to gender norms, economic depen- in Rwanda and Senegal, for example, only the middle dence, and transport availability. However, another class, the affluent, and foreigners can easily access reason for the marginalization of specific population quality health services, with the access gaps faced by groups is also the spatially varying quality of the health- the poor mostly attributed to the widespread job infor- care services available. Similarly, even in areas where mality and income insecurity. A recurrent theme in the physical access appears to exist, some groups have lim- interviews is a divergence between legal provisions and ited access to health services in practice, such as due practice: how health is supposed to be “universal”, with to limited affordability of the health service itself and many countries having legal provisions that establish the time costs associated with the long wait times to that health (and primary education) are free; however, receive care. The COVID-19 crisis was noted by several in practice, the poor populations cannot access care. to have impacted access to healthcare, especially affect- Even in areas with where some healthcare physical facil- ing maternal health. ities are present, health services or medicine may not be available, reliable, affordable, or of sufficient quality, While not as much highlighted as in the case of health- especially for higher complexity treatment. Given these care access, transport gaps represent a barrier for constraints, the poor in practice end up not accessing schooling not only because public transport is report- nearby health services but, instead, have to refer to edly not organized to reach schools but also because private services that are costly and more distant. This in some locations even the private transport services same issue was pointed out in interviews across Burki- (taxis) are limited. The interviewed experts noted that na Faso, Senegal, Uganda, and Zimbabwe and, to some access to education is generally better than access extent, is likely present in all countries. to health; however, it is still unequal due to various 61 REALIZING THE RIGHT TO EDUCATION AND HEALTHCARE THROUGH IMPROVED PUBLIC TRANSPORT IN AFRICAN CITIES “Maybe one other issue, that goes back to the issue of transport, is that reaching the health centers requires a cost, and [Name] correct me, but that has an impact on whether, when or not people access health services. And of course, there is a huge difference between the poor and the rest of the population.” — Uganda “In terms of geographical location, for some people to go to the central hospital, it takes money and time, and that’s another type of barrier. It can also be noted that in the capital Ouagadougou, public transportation doesn’t really exist like that, and people use private transportation.” — Burkina Faso “The middle class and the affluent, they can easily access the health services, but you will find the people who are living, even at 10 km radius from the city center, they are living in, the slum areas and poor high densities, their access to health service is completely compro- mised. Especially now with the COVID crisis, if you don’t have your personal transport and you are relying on public transport, it means automatically you are cut off from major health service. […] The other issue is also accessibil- ity because, with the lockdown restrictions, many clients don’t have letters to go and seek the services. Those are added transport costs because much of the public transport has been suspended. The few cars applying the rules they will be like overcharging because they are taking a risk, so the transport cost has also become very high in the country.” — Harare Photo credits: Sarah Farhat 62 MOBILITY AND TRANSPORT CONNECTIVITY SERIES CONNECTIVITY FOR HUMAN CAPITAL non-poor, with 87% and 92%, respectively. However, secondary education enrollment rates are low and the “No, it’s not accessible to many of these, in gap between poor and non-poor increases to more Ethiopia, especially the street children, they than 20 percentage points (34% for the extreme poor don’t have access to education, even if it is vs. 58% for the non-poor). free, primary education is free, they don’t have access to education because their parents can’t afford, it’s not school fees, it is about feeding, it Women and girls is about transport to get to these schools.” The transport infrastructure and services related bar- — Ethiopia riers for accessing health services are intensified for women – especially older women, due to a combina- tion of constraints related to gender norms, economic dependence, and transport availability. In all countries, transport infrastructure and services appear as a critical barrier to accessing health services; Women and the youth were reported to be significantly however, the accessibility disadvantages for those affected by affordability constraints that are interrelat- population groups – such as the lower income ones – ed with cultural norms. As reported by the interviewed who are dependent on public transport to travel longer human rights experts in the countries in scope of the distances have been yet more magnified during the analysis, it is the households’ men who usually own context of the COVID-19 pandemic. On the other hand, any private means of transport. For example, in Zimba- a positive example is Rwanda, which delivered some bwe, women were said to depend on men to pay both medicines (e.g., antiretroviral) to communities to ensure for transportation and health services. In Uganda and people would not physically move. Ethiopia, some women were reported to need their husbands’ approval and depend on their husbands’ Affordability is reportedly a significant issue for access- willingness to pay to reach the hospital. Prenatal care, ing education for children from poorer families and similarly, was suggested to depend to a certain extent families living in informal settlements. In many coun- on the husband’s willingness to pay, while access to tries, even those such as Kenya, Rwanda, Uganda, and pre-natal and post-natal care specifically is reportedly Zimbabwe where primary education is free “on paper”, limited in some cities due to a mix of constraints that families reportedly pay sometimes considerable addi- include not only poor accessibility, but also direct and tional costs related to transport, food, and in terms of indirect costs, women’s economic dependence, and lost earnings. Due to affordability issues, children from cultural norms that generate a preference for tradi- poor households sometimes have to walk long distanc- tional medicine and traditional birth attendants, among es to reach schools they can afford, as was noted in the others (noted to be the case in Zimbabwe, Uganda, and case of Uganda. Many children drop out due to school Ethiopia). Access to maternal health is reported to be fees in families with fewer resources, especially com- notably worse for women with disabilities and young mon among children living on the street. girls; however, this is due to a host of reasons besides transportation, such as lack of appropriate beds and Providing a complementary view, the World Bank’s equipment at health facilities. However, also for elderly recent Joint Needs Assessment for Zimbabwe pointed women the transport infrastructure and services relat- out that while extreme poverty is associated with hav- ed barriers for accessing health services were reported ing limited access to quality social services, Zimbabwe’s to be intensified (such as in Senegal), due to a combina- extremely poor in fact have net primary enrollment tion of constraints related to gender norms, economic rates (different from attendance) nearly as high as the dependence, and transport availability. 63 REALIZING THE RIGHT TO EDUCATION AND HEALTHCARE THROUGH IMPROVED PUBLIC TRANSPORT IN AFRICAN CITIES “I am African myself but not most women have their own cars, it is the husbands in the household. even a bicycle, women, girls, not really, you rely on your husband to take you and if there is a health need that you do not need your husband to know because they are certain things you don’t tell your husband, so having [breaking] reliability on public transport, it is quite not easy.” — Ethiopia “I can give an example of when a woman conceives, she needs transport, she needs resources to buy other medicine, to go for antenatal but she has to ask her husband unless she is employed or she has a source of income, if she doesn’t, then it becomes a problem, so she has to consult her husband, if her husband doesn’t give money, of course, that affects the whole system, she will not access her maternal services, she will not go to the hospital, she will not take her child for immunization, and that becomes a problem.” —Uganda “One of the things that we have picked up during monitoring from one of the monitoring com- munities, with the COVID period, was that there were single mothers who was HIV+ were large- ly employed in the informal sector doing washing and cleaning and people weren’t getting them to clean anymore and therefore had no income and they had, for reason of stigma, registered to receive their Antiretroviral treatment not within the com- munities, further away from the communities and therefore with no income, they couldn’t travel any- more to receive their treatment, and that was the issue and also because the prices of transport had gone up because public transport here is actually privately run; I mean public transport are run pri- vately by groups and the prices hacked with COVID because of distancing measures.” — Kenya Photo credits: Peter Kapuscinski 64 MOBILITY AND TRANSPORT CONNECTIVITY SERIES CONNECTIVITY FOR HUMAN CAPITAL In individual countries, HIV positive women were report- Other marginalized and vulnerable groups ed to face stigma and therefore choose to register for treatment outside their communities – i.e., in facilities Age is an element that contributes to discrimination that are not necessarily nearest to their home and eas- in various ways. In Ethiopia, women past child-rearing iest to physically get to. Similarly to the earliest obser- age reportedly have limited access to health services. In vation made in relation to the poor city residents, the Zimbabwe, the youth face challenges in accessing their accessibility challenges these women already face on a desired health care due to a lack of financial indepen- daily basis were further exacerbated by the COVID pan- dence. In Kenya, access to health by the elderly pop- demic and the associated decline in public transport ulation in urban areas is reportedly restricted due to affordability. mobility constraints related to transport affordability and lack of social support. At the same time, the interviewed experts highlight- ed the positive example of Rwanda which has utilized Appropriateness of mobility systems for people with the pandemic period not only to improve the physical disabilities was noted as a barrier for accessing health- school infrastructure but also took advantage of the care in several countries. For example, blind people forced break in in-person schooling to train teachers in Uganda were noted not to be able to move inde- with a focus on inclusive education. pendently because of the lack of appropriate trans- port; this, in turn, was noted to particularly exclude Several of the interviewed experts highlighted sexu- blind people with lower incomes who cannot afford a al harassment and gender-based violence in public guide. However, in individual cases, such as Rwanda, transport and while walking to or from school as key the interviewed experts highlighted the existence of constraints for girls’ education in particular (noted in policies aimed to make health facilities suitable for the case of Burkina Faso, Kenya, Rwanda, Ethiopia, people with disabilities. Similarly, children with disabili- Zimbabwe, Uganda). Cases of harassment are report- ties are reported to not have adequate transportation edly common not only in public buses but also while to schools or school facilities in several countries, and waiting for transportation. Some experts pointed to while there are many special needs schools (such as transport design gaps as an enabler of harassment, for in Rwanda and Zimbabwe), getting admission to them example, noting the poor lighting near bus stops and is not possible for everyone in need. Poor pedestri- the need to walk long distances to reach a stop. The an infrastructure – which is the main infrastructure exposure of these types of risks is reportedly directly children rely on to reach schools across all the cities linked to affordability issues and, essentially, the great in scope of this study – reportedly limits walkability, extent to which women and girls from certain income disproportionately affecting children with disabilities, groups are entirely dependent on public transport, especially during peak hours, as noted in the case of including poorly regulated informal paratransit (e.g., Kampala and Nairobi. Moreover, children with dis- noted in the case of Kampala and Harare). As a result abilities are reportedly excluded from schooling also of these risks, parents reportedly refrain from sending due to other factors besides inadequate transport their daughters to school due to fear of harassment or access; these mostly include inadequate staff training violence (noted in the case of Ethiopia and Kenya). and school infrastructure, as mentioned in the case of Kenya, Senegal, and Ethiopia. 65 REALIZING THE RIGHT TO EDUCATION AND HEALTHCARE THROUGH IMPROVED PUBLIC TRANSPORT IN AFRICAN CITIES In individual cities, Internally Displaced Persons repre- 5.2.2. Beyond transport: constraints to fulfill- sent another marginalized group in terms of access: ing the right to health and education due as reported by the human rights experts, in Ethiopia, to social norms, cultural beliefs, lack of women in refugee camps face many challenges for appropriate information provision accessing health services; similarly, in Burkina Faso, people who have been displaced and live in the capital Health do not have access to services due to lack of formal rec- ognition and registration. Social norms limit women’s access to information and health services related to contraception and repro- Certain population groups characterized by overlap- ductive healthcare and affect the appropriate service ping types of marginalization are reported to experi- provision. Access to information on this health topic ence particular access difficulties. People with disabil- remains limited, and cultural barriers lead to some insti- ities, women with disabilities, single mothers, people tutions that work on these issues to close. Many hos- with albinism, LGBTI, and HIV positive women were all pitals are attached to family planning clinics; however, mentioned in the interviews as disadvantaged in their because they have different entrances, and the person access to health. For these populations, poverty over- can be seen entering, so many are reluctant to do that laps with other issues related to social norms, stigma, (e.g., in Ethiopia). Cultural factors threaten prenatal and economic dependence. The lack of preparedness care for girls specifically: many services are not “ado- of health systems in terms of adequate infrastructure lescent-friendly”, especially in reproductive health (e.g., and staff training also contributes to these groups’ noted in the case of Zimbabwe). discrimination. Several examples of such issues were mentioned in interviews covering Uganda, Ethiopia, and Lack of childcare options was reported to be anoth- Burkina Faso. Inadequate transport infrastructure was er barrier for women to access medical treatment. noted to represent a barrier for gender-based violence Because of the household organization and cultural fac- survivors to access care services. tors, women need to address the logistics and the extra costs when she or one of their children is in the hospital. In several countries, a common additional barrier to accessing healthcare services relates to the inappropri- “Another aspect that emerged as a barrier is ate formats in which health information is provided – be because of the nature of the infrastructure as it it limited to the main spoken language in the specific has been put, it makes it very difficult when law country (e.g., mentioned in the case of Kenya and Ethi- enforcement agencies want to enforce contain- opia) or the lack of appropriate communication formats ment, for example to allow safe passage of survi- for people with disabilities such as hearing impairment vors if they want to go for health facilities.” (e.g., in Kenya, Zimbabwe) or the youth. Social norms — Kenya and taboos limit access to reproductive health informa- tion to LGBTI groups and women in several countries. 66 MOBILITY AND TRANSPORT CONNECTIVITY SERIES CONNECTIVITY FOR HUMAN CAPITAL The ability of people to rely on the service actually being Education available is another issue affecting the real accessibil- ity to care. For example, in the case of Zimbabwe, the The ability of girls to fulfill their right to education – interviewed human rights experts noted that, even if especially at the higher levels – was noted by several of accessibility challenges are overcome, people may find the interviewed human rights experts to be inevitably the service unavailable due to other factors impacting hindered by gender norms and cultural practices, most provision, such as strikes. In Burkina Faso, where the notably early marriage and pregnancy (noted in the situation differs from most of the other countries cov- case of Rwanda, Kenya, Ethiopia, Zimbabwe). In sever- ered in this study due to high levels of fragility, armed al countries, household organization was reported to conflict, especially in combination with the COVID-19 affect girls’ education, especially when they are teen- pandemic, impedes with people’s ability to fulfill their agers. They have to help in doing household chores, right to health, although reportedly more so in the which impacts day scholars, as they have to balance Northern region than in Ouagadougou. school work and chores at home. These norms and their impact on education have reportedly intensified during the COVID-19 epidemic, “I think the most important thing, in the case of further widening learning inequalities. Many coun- Burkina is that the existing challenges that are tries established distance learning in response to the really high, are being accelerated by first, armed pandemic, which has disproportionately negatively conflict rising and in the second place COVID-19, affected children from households that do not own which is affecting people’s access, like move- a computer and internet access (noted in Zimbabwe, ment of people etc. that has been limiting the Rwanda) or radio that can be used for radio classes (in rights, in particular economic and social rights.” Burkina Faso). The homeschooling based approach that was adopted during the pandemic reportedly further — Burkina Faso worsened girls’ ability to learn specifically: staying at home has, instead, been associated with increased care burden and, in some cases, worsened the issue of early marriage and pregnancy. Affordability is a universal and significant issue in access- ing health. First, there is limited affordability of health- There were no examples mentioned in the interviews of care services and medicine. Even in locations where civil society participation in the planning of where new there is some type of public health insurance, the cov- schools should be built to better serve the communi- erage can be limited, or the payments required are still ties better. The interviews noted the overall presence of high for poor groups, as was noted in the case of Zim- participation mechanisms for parents in private schools babwe and Rwanda. Second, the bureaucracy (e.g., veri- but not in public ones (e.g., in Ethiopia), and the lack of fying insurance information) and waiting times to access adequate communication and access to information, health are associated with overall high time costs. which hinders public participation, despite formal laws 67 REALIZING THE RIGHT TO EDUCATION AND HEALTHCARE THROUGH IMPROVED PUBLIC TRANSPORT IN AFRICAN CITIES prescribing mechanisms of public participation in edu- cation (e.g., in Kenya). On the other hand, informants also highlighted positive examples, such as the ability of parent committees in Rwanda to decide on the costs associated with education in both public and private schools, and the involvement of parents in school man- agement in Uganda – including the decisions regarding new roads (not in Kampala). “The other one is social norms, I believe it is not only tied to Kenya but world-wide where it is expected that girls and women take the large burden of domestic household chores and you find out that it affects their ability to give devot- ed time to their education and this has been magnified during COVID period, for those that are being home schooled, you find that they have to attend to house chores before they attend to the studies. This will attend to be a challenge especially now as we are talking about home-based care approach to COVID and wom- en and girls will be burdened with that and that will affect their access to education.” — Kenya Photo credits: Flore de Preneuf 68 MOBILITY AND TRANSPORT CONNECTIVITY SERIES CONNECTIVITY FOR HUMAN CAPITAL 6. Barriers to Health and Education Accessibility: The Spatial Lens Photo credits: Hendri Lombard 69 REALIZING THE RIGHT TO EDUCATION AND HEALTHCARE THROUGH IMPROVED PUBLIC TRANSPORT IN AFRICAN CITIES 6.1. The spatial reach of the public transport systems Providing a complementary perspective on the con- not in outlying areas themselves. Data on job locations straints to accessing health and education opportunities used to define the boundaries in the case of each city in the ten cities, the following sections assess – through was sometimes available directly, such as in the case of a spatial lens – the current state of public transport Kigali, Bamako, and Dar es Salaam, and in the case of based physical accessibility to schools and health facil- others an extrapolation of job locations was created by ities as a necessary, if not sufficient, condition for the generating a relative index of “job-likeliness” through- rights to education and health to be realized. out each metropolitan area by identifying Employment Opportunity Areas of different intensity. These The public transport data is based on available GTFS were determined by scoring different indicators on data, the standard data used for planning routes, or 500-meter cells in a grid covering each city, with scores Geographic Information System shapefiles with the including the count of employment-related amenities information on public transportation travel speeds and – number of retail and financial establishments, proxim- frequencies. GTFS data of both formal and informal ity to major intersections, etc. – extracted from Google public transport services produced by private com- Maps and OSM, within each cell and its adjacent cells. panies and national agencies, sometimes with World This methodology for defining metropolitan boundaries Bank assistance, were available for all cities except was initially proposed by Peralta-Quiros et al. (2019). Ouagadougou, Kigali, and Conakry; for the latter cities GTFS was generated from the available transport net- The uniform approach to defining city boundaries based work shapefiles, integrating speed and headway infor- on how they truly function allows for a fairer and more mation. In most of the cities, public transport services direct comparison of the spatial indicators of accessibili- are ensured entirely by bus transport, and in many ty among them. An exception here is Kampala, for which cases these are paratransit operators driving minibus- the methodology could not be consistently applied due es that crisscross the urbanized area, providing vary- to more limited availability (only covering the formal city ing degrees of spatial coverage of the more densely limits) of geo-located health facility data. Kampala’s spa- populated areas. The public transport network data is tial planning and accessibility metrics presented later in combined with data from Open Street Maps (OSM) on the paper are therefore not directly comparable to the the road networks in each city. other cities, and are likely somewhat inflated compared to what they would be if the true – much wider – defini- The ten cities would be difficult to compare if based on tion of the “functional city” were applied. their formal administrative boundaries, which in some cases capture the true “functional city” better than in The average population densities of the cities, based others. To have a comparable frame of analysis between on this consistent definition of boundaries, ranges metropolitan areas, the study defines a uniform bound- from only about 1,500-2,000 people per square-kilo- ary for the metropolitan area in the case of each city, meter in Harare, Maputo, and Kigali, to 3,500-7,000 in including within it all areas from which at least some Dar es Salaam, Bamako, Nairobi, and Ouagadougou; jobs in the formal city can be accessed within an hour in Douala, Conakry, and Kampala (the latter defined by of travel. Thus, peri-urban areas are counted as part of the official city boundary) population densities exceed the “functional city” based only on access to employ- 8,000 per km2. ment opportunities identified within the urban area, and 70 MOBILITY AND TRANSPORT CONNECTIVITY SERIES CONNECTIVITY FOR HUMAN CAPITAL Using the “functional city” boundary and the spatial network, which is largely explained by the sparsity of coverage of the public transport networks, we calculate the networks themselves, as described later. Across the share of the population that live in direct vicinity of the ten cities, the relationship between average pop- public transport, as measured by a 1-km radius (repre- ulation density and the share of population concen- senting “walking distance”). This indicator provides an trated near the transit networks is not very distinct. In insight on the extent to which each city’s development Douala and Kampala, high density is combined with has been transit-oriented – i.e., whether or not higher high shares of population living near transit; in Harare, residential densities are concentrated near transit (or Kigali, and Maputo, despite much lower average den- whether public transport networks have expanded to sities, the public transport networks are nevertheless serve newly emerged residential poles. However, high directly accessible to a large share of the city residents. density per land area of the public transport networks In Conakry, despite a very high population density and themselves can to some extent compensate for devel- compact city form, the sparsity of the existing public opment that is characterized by more uniform and less transport network means that a low share of people articulated residential densities. have a convenient access to it. In Ouagadougou, rela- tively low average population densities combined with In the ten cities covered in this study, most have a low-density public bus network result in a very low upward of 85% of the population living within direct share of the city’s population able to reach a bus line proximity of a public transport route, reaching near- within a kilometer walk. Finally, Bamako and Nairobi ly 95% in Nairobi. Dar es Salaam and Maputo have stand out as having perhaps the most strategically somewhat lower shares of people living within walking articulated population densities and/or public trans- distance of transit, despite relatively well developed port networks that have effectively adapted to evolving public transport networks. Finally, Conakry and, espe- population growth in certain localities: despite moder- cially, Ouagadougou, stand out as having a large share ate average population densities, these cities have the of their populations – in the case of Ouagadougou, highest share of their populations within direct walking more than a half – living further away from the transit distance of public transport. Figure 4: Population within walkable distance (1 km) of public transport (%) and average population density (pop./km2) 100 14,000 90 12,000 80 70 10,000 60 8,000 50 40 6,000 30 4,000 20 2,000 10 0 0 Ouagadougou Conakry Dar es Maputo Kigali Harare Douala Kampala Bamako Nairobi Salaam % within walking distance Pop./sq-km Source: Estimates by study team 71 REALIZING THE RIGHT TO EDUCATION AND HEALTHCARE THROUGH IMPROVED PUBLIC TRANSPORT IN AFRICAN CITIES In Ouagadougou, bus transport services are provid- regarded as the more affordable, but the perception of ed by SOTRACO (Société de Transport en Commun de service depends on whether the user is in an accessible Ouagadougou) and, unlike in most other African cities, area. The poorly distributed service, the need to walk to there are no formal or informal public minibus services. the stop, and the risk of getting trapped in congestion Bus ridership represents less than 1% of all trips, which implies that people using this mode have to allow for a can be explained by the sparsity of the bus network, lot of time to reach their destination (SSATP, 2004b). If with only about 30 lines operating at a frequency of one also including moto-taxis, public transport is estimated bus every 20 or 30 minutes (every two hours on indi- to represent 40% of all trips in Conakry (Republique de vidual routes). Moreover, the buses are overloaded and Guinee, 2019a). unreliable (Commune of Ouagadougou, 2019). Douala’s public bus network operated by SOCATUR Mobility challenges in Conakry are at least partly due to (Société Camerounaise des Transports Urbains) consists of the geographical position and structure of the city, such a network of 30 lines, of which only 8 are in operation. as the city center being located in a peninsula. The pub- Although not very expensive, the buses currently serve lic transport system in this city is very sparse, consist- only about 1% of the trips made in the city. The bus ing of only about ten routes, although these are con- services are made unattractive by long waiting times, centrated in the most densely populated areas. Public irregular traffic headways that are difficult for users to transport, mostly provided by informal operators, does understand, uncomfortable buses, congestion, com- not efficiency serve mobility needs. Among public trans- petition from moto taxis, and poor road infrastructure. port modes, the magbanas (informal minibuses) are In addition to the formal network, the informal Yellow Figure 5: Examples of cities with public transport systems with relatively low coverage of populated areas Ouagadougou Conakry 72 MOBILITY AND TRANSPORT CONNECTIVITY SERIES CONNECTIVITY FOR HUMAN CAPITAL taxis run on organized routes during rush hours and In Dar es Salaam, the public transport system con- capture about 19% of motorized trips. Moto taxis are sists mostly of informal minibuses – or daladalas – that still the most common mode of transports, accounting ensure quite a dense network across the city, as well as for 61% of all motorized trips. However, given that moto the relatively new Dar es Salaam Bus Rapid Transit sys- taxis are a mode of transport that is widely regarded as tem that so far serves only one corridor but is planned unsafe and expensive, and that they do not travel on to be expanded six-fold. identified routes, we have chosen to not include them in the accessibility study. Waiting time for the Yellow Kigali’s public transport services are ensured by bus taxis are typically due to limited capacity compared to transport, which operates on approximately 250 routes the demand (queues at transfer points for entering a and is relatively well distributed across the “functional taxi), but reliable data on these could not be obtained. city” of Kigali. However, this is much less so the case of Despite the limitations, the public transport system the extent of the formal Kigali City, which extends signifi- in Douala appears to do relatively well in terms of its cantly beyond the area considered in the current analy- direct access to the city’s population. sis – the only city in the group for which this is the case. A recent study suggests that the physical form of In Harare, public transport services, similarly to most Bamako is one of the factors that increase congestion, cities in scope, are predominantly provided by para- given that most of the administration, higher educa- transit operators. The network is extensive and covers tion buildings, and the main market are in Rive Gauche the high-population-density areas relatively well, with (near city center) (World Bank, 2019b). It notes that approximately 88% of the city’s residents living within accessibility in Bamako is limited by the poor quality walking distance of the public transport network. of connective infrastructure, poor coverage of public transport, and a fragmented city, which makes it diffi- Kampala’s public transport system, consisting primarily cult and expensive to provide social services. of informal minibus – or boda boda – routes, covers the populated areas well. Considering the full extent of the As in many of the cities, the public transport system in functional city, about 90% of Kampala’s residents are Bamako is entirely dominated by minibus transport within 1 km of public transport, and this share increas- (Société des Transports du Mali, SOTRAMA), consisting es to nearly 98% if only considering the residents of the of about 200 routes. The system provides a relative- Kampala administrative area proper. ly good coverage of the city’s more populated areas. Approximately 92% of the residents of the “functional Maputo’s public transport system consists of approx- city” – which approximately corresponds to the extent of imately 240 bus, minibus, and rail lines that cover the the official Bamako Circle administrative boundary – live city’s most densely populated areas well but are much within walking distance to at least one minibus route. more sparse in the more peripheral areas of the “func- tional city.” 73 REALIZING THE RIGHT TO EDUCATION AND HEALTHCARE THROUGH IMPROVED PUBLIC TRANSPORT IN AFRICAN CITIES Figure 6: Examples of cities with public transport systems with relatively good coverage of densely populated areas Kigali Nairobi ) Nairobi’s public transport system is predominantly transport options in the city, and Nairobi also per- informal, consisting of six rail lines and just over 120 forms poorly in the provision of NMT infrastructure; as matatu – or informal minibus – routes, the latter of a result, children and women are disproportionately which effectively cover the city’s high-density areas. affected in terms of social inclusion and sustainable mobility (Salon & Gulyani, 2019). A survey conducted Nearly 95% of the residents of the “functional city” of along two corridors in Nairobi point out that the main Nairobi, whose boundaries also quite closely corre- reasons to use NMT is affordability and speed, while the spond to those of the administratively defined “Nairobi reasons against it are the lack of NMT infrastructure county”, live within walking distance of the public trans- and safety concerns (see Mitullah et al., 2013). Another port network. challenge, common in many developing cities, is that the roads and spaces intended for NMT are taken up by Despite the city appearing quite transit-oriented based kiosks. Finally, pollution, dust, and the presence of sew- on the spatial residential patterns, most of Nairobi’s erage on walkways all make NMT more difficult. slum residents cannot afford any of the motorized 74 MOBILITY AND TRANSPORT CONNECTIVITY SERIES CONNECTIVITY FOR HUMAN CAPITAL 6.2. Availability of dedicated transport to schools and health facilities Data on access to dedicated transport to schools is with no access at all. It is possible that there are some available for only some of the cities in scope. In Douala, issues with the representativeness of the data at the the recent household travel survey indicates that the zone level. availability of school transportation is very limited. Only 2% of students report having access to free dedicated In Kampala, the database available from the KCCA – school transport; another 2% have access to school which only covers the administrative area of Kampala transport that is partly paid for the educational estab- proper – information is provided for each medical facil- lishment. For 4% of the students, dedicated school ity on the availability of ambulance services. Among all transport is available but is entirely their own financial 420 medical facilities in the city that provide any surgi- responsibility. There is no clear pattern in the availabil- cal services, 61 are reported to provide an ambulance ity of dedicated school transportation across the city: service. Among the 26 hospitals specifically, ambulance in individual centrally located neighborhoods access is services are available for 23 (including for all of the nearly universal, but these border with neighborhoods public ones). Figure 7: Access to dedicated school transportation in Douala (% of students) Source: Douala Household Travel Survey 2018 75 REALIZING THE RIGHT TO EDUCATION AND HEALTHCARE THROUGH IMPROVED PUBLIC TRANSPORT IN AFRICAN CITIES Only a small share of the privately operated advanced health facilities in Conakry – which represent the large majority of all advanced healthcare facilities – have their own dedicated transport services that can be used to transport the patients in from around the city. Of the 89 clinics, 10 have an ambulance service available, while among the 27 polyclinics, eight do (see Abt Associates Inc., 2018). Evidence from other cities in SSA for which household travel survey data is available also suggest that trans- port organized/provided by schools themselves to ensure the daily travel needs of students is not com- monly available. In Dakar, school bus is used by just 1% of all elementary school students and about 2.5% of secondary school students. Among all students under the age of 18, a lightly higher share of girls than boys report relying on school pick-up, with 3% versus 2%, respectively (see Republique du Senegal, 2015). In Abidjan, only a fraction of a percent of either primary or secondary school students report using school bus to travel to school (see Republic of Cote d’Ivoire, 2013). Photo credits: Sarah Farhat 76 MOBILITY AND TRANSPORT CONNECTIVITY SERIES CONNECTIVITY FOR HUMAN CAPITAL 6.3. Distribution of education and healthcare facilities within the cities In the interviews with human rights organizations work- health and education facilities in each city, the extent to ing in the countries in scope of this study, inadequate which their planning appears to have been coordinated access to healthcare services and education was noted, with transport networks, and the degree to which land among others, to be a function of insufficient account- use in each city is mixed in the sense of having essen- ability and inter-sectoral coordination. The interviewed tial health and education facilities present locally within experts noted that users’ needs are not always taken residential communities. into account in the siting of health and education facili- ties vis-à-vis the road and the public transport network, Basic health and education facility data for nearly any indicative of a lack of consultation with the population city in the world is available from OSM; however, this and representatives of the education and health sectors. data is crowd-sourced and not always verified by insti- tutions working in the health and education sectors on the ground. In this analysis, only those cities were included where officially verified geo-locations of health and/or education facilities were available, most of them “Our transport sector has sort been ad-hoc, provided by the World Bank staff in Health and Educa- because in the early times, early 70s, it was only tion sectors working directly with the relevant country- being manage by the government, therefore it and city-level institutions. For a few cities, the facilities was easy for them to be managed, the routes; were geo-mapped using available official lists of facili- but by the time it was privatized like [R2] has said, ties provided by the relevant institutions on the ground. then therefore you find it is driven by the demand In several cities, only health facility geo-locations could in the market and not necessarily the need that’s be obtained. there. So it is not uncommon to find a health facility that is adequate, a private one most of Ouagadougou: Spatial locations of health facilities and the time, it is not at approximate place next to schools were made available to the study team by the the road and this is an indication that there was government Ministries, including information on the little consultation even with the people in the facilities’ public versus private status and care or school- health sector and also the education sector. So it ing level offered; these were mapped on the ground in is something that has been organic but not nec- February-March of 2020. The facilities are distinguished essarily practically run. There is exact recognition that there is need to reform that to ensure that by their role in the education or health sector hierarchy, the facilities are planned according to the infra- respectively, such as primary schools versus secondary structure and with participation of the public.” schools (separately, public and private), and community health and social centers (CSPS) and medical centers — Kenya providing only some services (centres medicaux, or CM/ CMU) versus medical centers with surgical capabilities (CMA) and hospitals providing highest available quality care in Burkina Faso. Only the latter two types – CMA The analysis presented in this section provides a spa- and hospitals – are categorized as “advanced health- tial-quantitative perspective to complement the inter- care facilities” in the current study. views, providing insights on the spatial distribution of 77 REALIZING THE RIGHT TO EDUCATION AND HEALTHCARE THROUGH IMPROVED PUBLIC TRANSPORT IN AFRICAN CITIES Douala: Data on the distribution of health and educa- in Abt Associated Inc, 2018). Among the private health tion facilities was provided by the Douala City Council, facilities, the analysis considers only polyclinics and clin- based on a detailed census of establishments carried ics, as these have hospital-like features like ambulance out in 2017. Among health facilities, only those that pro- services, laboratories, and inpatient treatment oppor- vide core services are considered (for example, a health tunities, etc. Most polyclinics also ensure maternity center that specializes in ophthalmology only would services and have specialized delivery rooms, although be excluded). A total of 11 hospitals and 145 clinics are only about half of all clinics do. Among public facilities, mapped across the city, with private institutions out- only medical centers and hospitals are included, while numbering public ones by more than 10 to 1. Hospitals basic health centers are not. Altogether, 140 advanced and clinics (“advanced healthcare facilities” providing healthcare facilities are geo-located, the vast major- surgical services, among which all hospitals are public ity of them privately operated. While the distribution and all clinics – private) are concentrated in the central of facilities is relatively even across the city, this is not parts of Douala, with much less facilities in the outlying the case for the few publicly operated ones, which are areas. The education facilities included in the data- concentrated entirely in the southern and central part set are high-schools, middle-schools, and elementary of Conakry. schools. Private education is predominant in Douala. Both health and education facilities in Conakry have in Conakry: School location data is available from the past studies been estimated to be more accessible in Ministry of Education’s Office for Strategy and Devel- denser and wealthier areas closer to the city center: opment, which also reports their public versus private because the road network in the city improves accessi- status both for primary schools and secondary schools. bility in a linear way, people living closer to a radial road The vast majority (about 90%) of both primary schools to city center experience an easier access. However, in the city are private. While the schools appear to be most roads are in poor condition, and, for those living well distributed across the city, there are vast differenc- outside the city center, the likelihood of living close to a es across the schools in terms of the student-to-teach- paved road decreases by half (World Bank Group, 2019). er ratios, which the Ministry’s dataset allows to calcu- late. For primary schools, these range from less than 3 Bamako: In Mali, the Referral Health Centers (CSREF for students per teacher to as many as 188, with the public short) are present in each District and in some cases primary schools generally having higher ratios com- have quite advanced facilities. Their role is to act as a pared to the private ones. For secondary schools, the link between the Community Health Centers (CSCOM) ratios range from about 1 teacher per student to about and the Hospitals. Most CSCOM are run by a Community 115; individual private schools have higher ratios com- Health Association. They provide basic preventative and pared to any public ones. curative services in maternal and child health. In the cur- rent analysis, CREF and hospitals are grouped together A map of the public health facilities in Conakry is avail- as “advanced healthcare facilities” (15). Education facili- able from the Ministry of Health; the geo-locations and ties are mapped based on a dataset assembled by the characteristics of private health facilities were collected World Bank as part of the Mali Urbanization Review. as part of a recent mapping activity (details available 78 MOBILITY AND TRANSPORT CONNECTIVITY SERIES CONNECTIVITY FOR HUMAN CAPITAL Dar es Salaam: Health facilities with coordinates are Figure 8: Hospitals and other advanced health facilities available from the Ministry of Health’s Facility Registry. providing maternal care in Kampala The facilities included in the analysis are limited to the health centers and hospitals, representing the subset of facilities providing advanced care, while excluding highly specialized facilities such as those dedicated to cancer or orthopedic treatment. We only consider health facilities that are “operating” rather than marked as “pending, under construction.” Verified school facility geo-data was not available. Kigali: Health facilities and schools, by type, were geo-located as part of a data mapping exercise man- aged by ESRI, a global Geospatial Information System company, commissioned by the Ministry of Infrastruc- ture in 2019. Within the “functional city” of Kigali, 109 primary schools and 111 secondary schools were geo-located. Rwanda’s healthcare system operates a range of dif- ferent facility types, among which health posts provide mainly outpatient services such as immunizations; similarly, clinics are equipped only with basic medical equipment. In Kigali, district and referral hospitals pro- vide more advanced care, including caesarean surger- ies, treatment of complicated cases, etc., and provide Source: Data from KCCA database care to patients referred by the primary health centers, while health centers and medical clinics offer complete and integrated services such as curative, preventive, Kampala: The KCCA provides detailed data on both promotional, and rehabilitation services (WHO, 2017). public health facilities and for-profit health facilities Based on this characterization of the care offered, all for the Kampala city administrative area, along with hospitals and health centers/medical clinics are catego- information on the available staff and services. For the rized as “advanced healthcare facilities” in the current analysis, medical facilities that are reported to provide study, although this may be overstating the level of care surgical services – i.e., “advanced” health facilities – were available at some specific health centers and medical sub-selected (420 in total), of which 26 are hospitals clinics. Altogether, four district hospitals, four referral and the rest are clinics and medical centers. Of the 420 hospitals, 28 health centers, and 48 medical clinics are facilities, the vast majority are private for-profit; the located within the “functional city” of Kigali. public/non-profit facilities tend to be somewhat more 79 REALIZING THE RIGHT TO EDUCATION AND HEALTHCARE THROUGH IMPROVED PUBLIC TRANSPORT IN AFRICAN CITIES concentrated in the central city. Among the 26 hospi- the Maputo Department of Urban Planning, and the tals, 15 are owned by private for-profit entities. Among Department of Health. Not all primary schools listed the 420 facilities, 398 provide laboratory services, 146 could be geo-located using the provided coordinates provide radiology services, and 360 provide maternal even after a thorough search, by school name, on Open care. Of the maternal care facilities, less than 10%, are Street Maps and Google Earth; therefore, the results government/non-profit owned. Because the dataset should be interpreted with some caution. Altogether does not cover the full area that would be considered 230 public and private primary schools were located to be the “functional city” as per our methodology, within the “functional city” of Maputo, which extends accessibility metrics are estimated only for the admin- quite significantly to the West and South-West com- istrative unit called “Kampala”, which is considerably pared to the official boundaries of the Maputo province smaller. Within this area, advanced health facilities, and and the Maputo City localities. While central Maputo especially hospitals, are lacking in large parts of the localities have a high density of primary schools, this is more peripheral neighborhoods, especially in the city’s not the case in the more outlying localities like Cidade North, extreme South, and Southeast, where population de Matola, Matola Rio, and Maputo 1. densities are lower. These areas also have a much lower density of advanced facilities that provide maternal care The Mozambican healthcare classification distinguishes services, which are particularly important for women. between primary healthcare and secondary healthcare, the latter including medical services related to obstetric Harare: The list of health facilities for Harare was care, surgery and the fight against AIDS. A comprehen- obtained from the Ministry of Health and Child Care; sive geo-location exercise in the public health sector this dataset also provides information on the spatial was undertaken in 2013, when each type of facility was coordinates of the public facilities. Based on the data- also characterized in terms of the available resources set, a total of 51 health facilities were located in Hara- and services offered (see Cidade de Maputo, 2013). The re; these include clinics, policlinics, health centers, and health facility network of the City of Maputo is described hospitals. In addition to the list above, the Parirenyatwa in terms of the basic typology consisting of special hos- Hospital was located using Google Earth. In the anal- pitals, general hospitals, urban health centers (type A, ysis, only hospitals and policlinics were retained, as B or C) and rural health centers (type I and II); however, these provide more advanced healthcare services. For this classification is of nominal character and does not education facilities, using a preliminary list, 159 primary necessarily respond to the services actually offered by schools and 177 secondary schools could be mapped each facility. The concept of the “Health Center” rang- in the city using Google Earth and OSM. es from only emergency consultations carried out by a basic nurse or medical agent in a rural health center at Maputo: Health facility and primary school geo-loca- his/her residence to a specialized gynecology consul- tions were identified based on datasets available from tation carried out by a gynecologist in a type A urban the Maputo municipality, the Department of Education, health center (Cidade de Maputo, 2013). 80 MOBILITY AND TRANSPORT CONNECTIVITY SERIES CONNECTIVITY FOR HUMAN CAPITAL Figure 9: Advanced healthcare facilities and public transport network in Maputo In the analysis, type A Urban Health Centers, type I Nairobi: The list of healthcare facilities in the city is Rural Health Centers, and Hospitals are defined as available from the Kenyan Ministry of Health.90 As “advanced healthcare facilities” (altogether 32), with “advanced healthcare facilities” are grouped those subsequent analysis of only the 7 hospitals (essentially facilities that are reported to have a clinical officer and the only facilities offering comprehensive surgical, labo- some surgical capabilities (health centers, medical cen- ratory, and inpatient care). As with primary schools, the ters, and hospitals). Among these, we exclude highly presence of such advanced healthcare facilities, espe- specialized facilities – rehab centers, eye clinics, dental cially hospitals, is sparse in the less central localities of clinics, and AIDS clinics. Separate analysis is conduct- Maputo. The health network of the City of Maputo also ed for “public” health facilities (operated by faith-based comprises private healthcare facilities – those that are organizations or the MoH) and for those facilities that not managed by the Maputo City Health Directorate or are reported to provide Comprehensive Obstetric Care by Maputo City Council, which are particularly important (CMOC). All facilities were geo-located manually, using in the provision of the more specialized health services Google Earth, based on their official name and Ward (e.g., psychiatric care); however, the current analysis information, as exact coordinates were not available. does not include these various private facilities due to Within the “functional city” of Nairobi, 301 advanced lack of data. healthcare facilities were located, of which 115 are public; 111 of the 301 facilities are hospitals (Level 4-6 90 http://kmhfl.health.go.ke/#/home 81 REALIZING THE RIGHT TO EDUCATION AND HEALTHCARE THROUGH IMPROVED PUBLIC TRANSPORT IN AFRICAN CITIES Figure 10: Hospitals and health facilities providing comprehensive obstetric care in Nairobi Source: Data from Ministry of Health of Kenya in the Kenyan healthcare classification system), of which The geo-locations of facilities, in combination with 19 are identified as public. A total of 24 facilities provid- transport network and population data, provide addi- ing CMOC are located, of which 8 are public. tional insights on transport planning and transport-land use integration in the ten cities that can ultimately help Geo-located data on primary and secondary schools explain differing accessibility patterns. The first of was obtained from a dataset prepared by the Ministry these is the extent to which education and health of Education and Red Cross, posted on the Humanitar- facilities are directly accessible from the public ian Data Exchange website. The public versus private transport networks, as measured by the walking status of the schools in the database is only partially distance (1 km) metric. This is indicative of the extent available. The Ministry of Education is currently working to which these facilities have been cited in locations with UNICEF and USAID on a school mapping update; served by transit and/or the degree of overall coordi- however, the data is not yet available. Altogether, 1,385 nation of transport and land use planning. With respect primary schools and 356 secondary schools were to primary and secondary schools, Harare and Bamako geo-located within the “functional city” of Nairobi. stand out as having the highest share of share of all facilities located within direct walking distance of public 82 MOBILITY AND TRANSPORT CONNECTIVITY SERIES CONNECTIVITY FOR HUMAN CAPITAL transport – all schools in Bamako and 98-99% of them the siting of the school facilities in Conakry is more in Harare. The share of facilities near transit is also high coordinated with the (limited) transit system than it is in in Maputo and Nairobi and, especially among sec- Ouagadougou. ondary schools, Kigali. In comparison, in Conakry and Douala, at least a fifth of all secondary schools are not For the few cities where the breakdown of public vs. pri- directly accessible from transit, and for primary schools vate schools is reliably available, it appears that public the share is closer to one-quarter. Lastly, in Ouagadou- secondary schools, for example, are better accessible gou, nearly half of all schools, especially at the primary from transit compared to private ones, with 86% of school level, are not directly accessible from any bus Douala’s public secondary schools, 84% of Conakry’s, line. While the public transport network of Conakry is and 68% of Ouagadougou’s located within walking dis- arguably sparser than Ouagadougou’s, it appears that tance from a public transport route. Figure 11: Share of schools within walkable distance (1 km) from public transport (%) 92 95 93 97 98 99 100 100 88 76 75 77 80 57 59 Ouagadougou Conakry Douala Kigali Nairobi Maputo Harare Bamako Primary schools (all) Secondary schools (all) Figure 12: Share of advanced healthcare facilities within walkable distance (1 km) from public transport (%) 98 98 97 99 100 100 100 100 91 93 94 97 94 94 96 91 81 Conakry Bamako Dar es Salaam Ouagadougou Douala Kigali Nairobi Kampala Harare Maputo Health facilities (all) Health facilities (public) Source: Estimates by study team 83 REALIZING THE RIGHT TO EDUCATION AND HEALTHCARE THROUGH IMPROVED PUBLIC TRANSPORT IN AFRICAN CITIES In all the cities in scope, advanced healthcare facilities, at least one secondary school than near an advanced especially hospitals, are, on average, better accessible healthcare facility. This is especially the case for primary from the public transport networks compared to either schools, where upwards of 90% of the population live primary or secondary schools. In Harare and Maputo, all within a kilometer of a school in Conakry, Douala, and advanced care facilities are within walking distance, and Nairobi, and above 70% of people in the other cities in most other cities the share is around 95%. Only in except Harare (42%) and Maputo (41%). The direct Conakry a relatively high share of advanced health facil- presence of secondary schools in residential neighbor- ities (19%) is not within walking distance to the public hoods is slightly lower, with between 65% and 96% of transport network; however, accessibility of health facili- people living in direct proximity to at least one school, ties is still better than that of schools. In Ouagadougou, except for Harare where the share is only 42% (data advanced health facilities are significantly more likely to on secondary school locations was not available for be directly accessible from the bus network compared Maputo). Direct walking access is yet lower to public to schools: 94% of advanced healthcare facilities and all secondary schools specifically: only 51% of the resi- of hospitals specifically are within 1 km of a bus route. dents of Conakry and 24-27% of those on Douala and Public advanced healthcare facilities are nearly equal- Ouagadougou could reach such a facility within a kilo- ly accessible as private ones to transport networks in meter of their home. most cities; exceptions are Conakry and Douala, where in the former case public facilities are in fact more likely The share of population living near a primary school to be directly accessible from the minibus routes, while is closely correlated with the number of schools per in the latter case it is the opposite. capita. It is highest in Conakry, where a primary school is available per 1,168 people, and declines continuously The second indicator of land use planning that ulti- as the size of population per school increases, reaching mately matters for people to be able to easily reach over 14,000 people per primary school in Harare and education and health opportunities is the extent of land approximately 12,000 in Maputo, the two cities with the use diversity or, more specifically, the direct presence lowest shares of population living near a primary school. of health facilities and schools in residential neigh- In the case of secondary schools, the relationship is less borhoods – i.e., the opposite of a land use pattern clean; while it holds for most cities, Douala and Nairobi where the residential use is segregated. Thus, while stand out as having very high populations per second- the first indicator measured the facilities’ proximity to ary school (16,000-18,000) but also very high shares of transit, the second looks at the proximity of people to people living near a secondary school (74% and 82%, the facilities. Partly due to the larger number of schools respectively). This suggests that secondary schools in compared to healthcare facilities in most cities, a signifi- these cities are present exactly in the residential neigh- cantly higher share of people in all ten cities live within borhoods with the highest population densities. a walking distance of at least one primary school and 84 MOBILITY AND TRANSPORT CONNECTIVITY SERIES CONNECTIVITY FOR HUMAN CAPITAL Figure 13: Share of city population within walking distance (1 km) from nearest school or advanced healthcare facility (%) Population living near a school Population living near an advanced health facility Source: Estimates by study team In comparison to schools, it is less common to live walking distance; exceptions are Kampala and Nairobi near an advanced healthcare facility. In part due to where this share is at least twice as high. the somewhat varying categorization of facilities in the “advanced” group across the cities but also due to true Despite the carrying definitions of “advanced” facili- differences in the degree of land use mix, the residen- ties across the cities, the availability of such facilities tial proximity to these facilities varies significantly. While per population is quite closely correlated with the in Bamako, Harare, and Ouagadougou less than 15% share of people living directly near at least one such of people live near an advanced healthcare facility, in facility. Namely, the shares are among the lowest in Conakry, Douala, Kampala, and Nairobi over three-quar- Ouagadougou and Bamako, where a facility is available ters of the population do. Residential proximity to pub- per every 180,000-200,000 people; they are the highest lic facilities is significantly lower, however, with less than in Kampala and Conakry where a facility is available per one-fifth of people in most cities living within direct 5,000-10,000 people. 85 REALIZING THE RIGHT TO EDUCATION AND HEALTHCARE THROUGH IMPROVED PUBLIC TRANSPORT IN AFRICAN CITIES 6.4. Accessibility to health and education facilities by public transport time from each location in the city to its nearest health 6.4.1. Comparison across cities or education facility. Then, accounting for the spatial distribution of people, we compute the average accessi- This section presents the estimated physical accessi- bility in the urban area and the more detailed accessibil- bility to schools and health facilities in the ten cities, ity distributions/ curves presented later in this chapter. although direct comparison is not always possible, at least with respect to accessibility to healthcare facili- ties, given the differences in how the cities classify their Access to healthcare facilities healthcare institutions. The direct benchmarking of In accessing healthcare, lack of public transport was cities is more possible in the case of primary and sec- reported in the interviews with human rights experts ondary schools, where the classification is much more to leave people relying on private transportation (bikes, comparable. In the case of primary schools, where motorcycles, and taxi cars), which are unreliable and walking was indicated in the existing household surveys costly for many, especially for the sick; this was report- to be the by far the most dominant mode of transport, ed to be an issue specifically by the experts working in the analysis also illustrates the extent to which public Burkina Faso, Zimbabwe, and Rwanda. In Zimbabwe, transport provides an accessibility improvement (“value peripheral areas were noted to have worse road con- added”) over walking-only. nectivity and lack of transport or ambulance services. In Ethiopia, which this spatial analysis does not cover To calculate accessibility, we rely on the previously due to lack of reliable public transport data, the experts presented data on the spatial presence and speeds/ noted that some hospitals are not next to roads where headways of transport systems, the spatial distribution there is public transport or have stops for public trans- of health and education facilities in each city, and the port, and therefore must be accessed by private means. spatial distribution of the population. We first use the transport and transit network to estimate the travel Figure 14: Travel time by public transport to nearest advanced healthcare facility in Douala vs. Harare (min) Douala Harare Source: Travel time estimates by study team 86 MOBILITY AND TRANSPORT CONNECTIVITY SERIES CONNECTIVITY FOR HUMAN CAPITAL Figure 15: Travel time by public transport to nearest advanced healthcare facility (min) 78 63 57 50 51 38 35 Person access 33 32 Place access 24 21 17 13 13 14 15 12 8 Kampala Douala Nairobi Conakry Kigali Dar es Salaam Bamako Harare Ouagadougou Source: Travel time estimates by study team Indeed, the spatial analysis suggests that public trans- strategically people choose where to live – either inten- port based accessibility to healthcare facilities that pro- tionally or as a result of the existing housing availabil- vide “advanced” care services varies quite significantly ity – with respect to the public transport network and/ across the cities in scope of the study. While the aver- or locations of the healthcare facilities. This difference age resident of Kampala, Douala, Nairobi or Conakry appears to be quite large in Dar es Salaam, where can reach such a facility by public transport in less than despite relatively poor “place access” to advanced 15 minutes, the residents of Harare or Ouagadougou healthcare facilities, the “person access” is relatively have to travel over 35 minutes (in Ouagadougou, nearly good. The difference is smaller in Kampala, Douala and an hour). Conakry – cities where accessibility is relatively good regardless of the metric. World Bank (2019b) estimated that, during rush hour, only 16% of Bamako residents are within 30 minutes of What is important for many of the cities’ residents, a hospital if taking public transport, compared to 76% especially those with less means, the nearest advanced of car users. Other types of healthcare facilities were healthcare facility is not always a publicly operated one. estimated to be accessible by 81% percent of urban As noted previously, in some cities the number of pri- population within a 30-minute walk and by 84% using vately (for-profit) operated facilities vastly exceeds the public transport – suggesting a very low “value-added” public ones. The resulting difference between being of the public transport system. able to easily access any advanced healthcare facility versus a public one is illustrated in Figure 16 specific to The difference between average “person access” (i.e., Conakry, where it is quite dramatic in large parts of the the travel time for the average person living in the city; however, some level of “penalty” for people who are city) and average “place access” (travel time from a dependent only on public facilities because of afford- given location within the city) in a way illustrates how ability considerations exists in all of the cities in scope. 87 REALIZING THE RIGHT TO EDUCATION AND HEALTHCARE THROUGH IMPROVED PUBLIC TRANSPORT IN AFRICAN CITIES Figure 16: Travel time by public transport to nearest advanced health facility vs. nearest public advanced health facility in Conakry (min) To nearest advanced health facility To nearest public advanced health facility Source: Travel time estimates by study team Across the five cities for which both all advanced versus a public facility is about 8-10 minutes, compared healthcare facility and specifically publicly operated to Conakry, where it is nearly an hour. In the entire advanced healthcare facility locations are available, the northern third of Conakry, residents would have to trav- nearest public advanced facility is, on average, fur- el over an hour to a public facility; this accessibility-dis- ther away by public transport. However, the size of the advantaged area also corresponds to the part of the “penalty” of depending on public facilities (such has for city that has the lowest economic activity as measured affordability reasons) is considerably lower in Nairobi, by nighttime lights intensity, a common clue of elevated Kampala, and Dar es Salaam, where the difference in levels of poverty. average travel time by public transport to any facility Figure 17: Travel time by public transport to nearest advanced maternal care facility in Kampala (min) To advanced maternal care facility To public advanced maternal care facility Source: Travel time estimates by study team 88 MOBILITY AND TRANSPORT CONNECTIVITY SERIES CONNECTIVITY FOR HUMAN CAPITAL Access to schools As highlighted by the interviewed human rights practi- tioners, accessibility to schools – especially those that are affordable to families – is low for at least some share of students. In Rwanda, although the schools are within “The traditional old locations, they have clin- “walking distance”, this distance can be long for some. ics, they have schools, they have standards, In Uganda, due to affordability, children reportedly have but now with the recent new settlements; to walk long distances to reach schools they can afford. those ones are very far away from clinics, People in the peripheries have poorer access to trans- very far away from critical health services, and even from schools. So you can even find ports and face more constraints to access educational a child who is commuting a distance of more services, as noted in the case of Ethiopia. than 60 km, to and from, and for a small child who is supposed to be attending kindergar- In both Uganda and Zimbabwe, the interviewed experts ten, that’s too demanding, physically and highlighted the particular accessibility disadvantage emotionally and even intellectually for that faced by children living in the newer settlements, who child, by the time she gets into class, she is do not have access to education near their homes and already tired and she is not concentrating.” might have to travel a long distance to a school. — Zimbabwe As in the case of healthcare facilities, the experts high- lighted the presence of a “dual system” in education: there can be physical accessibility, but public provision is of poor quality in many of the countries. Those who live far away or in areas with less population density – as Across all the cities in scope except Kigali, public trans- mentioned in the case of Burkina Faso, Kenya, and Zim- port based accessibility is better – sometimes signifi- babwe – reportedly have access to lower quality educa- cantly so – to primary schools than secondary schools, tional services. Rwanda was highlighted as an exception, which is also partly explained by the much wider pres- with education generally considered very accessible. ence of the latter in most cities. The difference between accessibility to primary schools compared to accessibili- High-resolution data on the spatial distribution of school ty to secondary schools is larger in Harare, Douala, and age children specifically is not available. Assuming that Nairobi than in Conakry, Kigali, and Ouagadougou. In it mirrors that of the overall population distribution, we absolute terms, children in Conakry, on average, have find that, for the average child, accessibility to prima- the best accessibility by public transport to a secondary ry schools in the cities in scope is relatively good, with school across all the cities in scope with the caveat that travel times by public transport to the nearest school they travel to the nearest school to home, regardless of being in the range of 8-11 minutes in Conakry, Douala, its specific characteristics. Nairobi, and Ouagadougou. Even in the cities with com- paratively poorer accessibility – Maputo and Harare – a primary school is within reach, on average, within about 22 minutes by public transport. 89 REALIZING THE RIGHT TO EDUCATION AND HEALTHCARE THROUGH IMPROVED PUBLIC TRANSPORT IN AFRICAN CITIES Figure 18: Average travel time by public transport to nearest primary school and nearest secondary school (min) 27 22 22 15 15 15 14 Primary schools 13 13 12 11 9 9 9 Secondary schools 8 Conakry Douala Nairobi Ouagadougou Bamako Kigali Maputo Harare Source: Travel time estimates by study team Figure 19: Travel time to nearest primary school vs. nearest secondary school in Harare, Nairobi and Douala To nearest primary school To nearest secondary school Harare Nairobi Douala Nairobi 90 MOBILITY AND TRANSPORT CONNECTIVITY SERIES CONNECTIVITY FOR HUMAN CAPITAL Douala Source: Travel time estimates by study team As in the case of advanced healthcare facilities, the extent to which the “person access” is better than “place average time to reach the nearest school in all of the access” with respect to primary schools differs quite sig- cities is lower for the average city resident than for the nificantly, however, from very little – such as in Conakry, average location within the city, indicating some level of Douala, and Ouagadougou, where the average travel “strategic” residential sorting to be near these import- time by public transport is only a couple of minutes ant facilities and/or the public transport network that longer for the average location in the city than for the can improve accessibility to them. It is also indicative average city resident – to very considerable, such as in of the land use planning in the cities and the extent to Kigali, Nairobi, Maputo, and Harare, where the travel which they promote mixed-use development rather time for the average city resident is only one-third to than segregation of residential from other uses. The one-half that of the average location. Figure 20: Travel time by public transport to nearest primary school (min) 56 49 32 28 Person access 25 22 22 Place access 18 15 12 11 13 8 9 9 9 Conakry Douala Nairobi Ouagadougou Bamako Kigali Maputo Harare Source: Travel time estimates by study team 91 REALIZING THE RIGHT TO EDUCATION AND HEALTHCARE THROUGH IMPROVED PUBLIC TRANSPORT IN AFRICAN CITIES Given that in all of the cities in scope, existing survey to walking. At the same time, of course, for at least data and interviews with locally present human rights some share of the students in each city walking may not organizations suggests that the vast majority of chil- be an option in practice – unfortunately, the existing dren walk to school, especially at the primary school population distribution or survey data does not allow level, and given that walking may be the only option for identifying locations in the city where the children with households unable to afford other modes, we conduct- special needs live, but a reasonable assumption would ed a comparative analysis for these specific facilities to be that their presence is proportional to the overall illustrate the extent to which the existing public trans- population distribution. port systems provide an accessibility benefit compared Figure 21: Average walk time to nearest primary school (min) & population within 30-minute walk of a primary school (%) 60 120 52 50 100 98 100 95 96 92 92 40 77 80 30 26 58 Travel time 60 % within 30 min 20 15 15 40 9 10 7 8 10 20 0 0 Douala Nairobi Conakry Ouagadougou Kigali Bamako Harare Maputo Source: Travel time estimates by study team Figure 22: Travel time to nearest primary school by public transport vs. by walking in Maputo (min) By public transport By walking Source: Travel time estimates by study team 92 MOBILITY AND TRANSPORT CONNECTIVITY SERIES CONNECTIVITY FOR HUMAN CAPITAL Figure 23: Travel time by public transport to nearest primary school vs. nearest public primary school (min) To nearest primary school To nearest public primary school Ouagadougou Conakry Source: Travel time estimates by study team Across most cities for which primary school locations Accessibility to public primary schools specifically could were available, accessibility by walking is found to be be calculated for only a subset of the cities where data relatively good, with average travel times not much on the public vs. private status was reliably available: exceeding the average travel time associated with Ouagadougou and Conakry. Disaggregated data by traveling by public transport. For example, in Douala, public vs. private status for secondary schools is also Nairobi, Conakry, and Ouagadougou, over 95% of the available for Douala. Across the cities, accessibility is physically healthy children91 can reach a primary school significantly lower to public schools than to any school, on foot within 30 minutes, and the average child can which matters in particular for those residents who can- walk to the nearest primary school within about 7-10 not afford to send their children to private schools. For minutes. Access to primary schools by walking is com- example, in Ouagadougou, the average resident has to paratively worse in Harare, where the average walk time travel 18 minutes to reach the nearest public primary to a primary school is 26 minutes, while in Maputo the school, compared to 12 minutes to a private prima- average is over 50 minutes and only 58% of all children ry school. In case of secondary schools the difference are within a 30-minute walk of a primary school. between nearest public and nearest private school access is even larger – 12.5 minutes to private, com- 91 The analysis assumes walking speed of 3 km/h. pared to twice that to public. 93 REALIZING THE RIGHT TO EDUCATION AND HEALTHCARE THROUGH IMPROVED PUBLIC TRANSPORT IN AFRICAN CITIES average travel times to the nearest primary school and 6.4.2. Transport and land use plan- shares of population living directly near transit. ning as drivers of cross-city inequality in accessibility The overall weak correlation could be explained by the More so than in the case of secondary schools or fact that in the cities like Ouagadougou and Conakry, advanced healthcare facilities, average travel times to where, mostly due to the sparsity of the public trans- the nearest primary school across the cities appear to port networks, a lower share of people than in other be closely correlated with key transport and land use cities live directly near a transit route and where a lower planning indicators. As might be expected, the correla- share of primary schools are directly near transit, these tion is the strongest with the share of the city popu- transport deficiencies are more than compensated lation living within walking distance of a primary for by a larger number of primary schools per capita school. The correlation coefficient in this case is nearly than in the other cities and by the wide presence of 1, with the cities with more mixed land use, as mea- primary schools directly within residential neighbor- sured by higher shares of population living within a hoods. However, this might also be at least partly due kilometer of a primary school, having distinctly lower to the technical performance (speeds, headways) of average travel times to the nearest school. Similarly, the public transport services, which reduce the value the relationship is also quite strong with respect to the of being near a public transport route in some cities average population per primary school: average (e.g., Ouagadougou), and the sheer distances that have travel times are lowest in cities like Conakry, Douala, to be traveled due to the more sprawl-like nature of and Ouagadougou, where a primary school exists per the urban area in yet others (Harare, Maputo). Finally, every couple of thousand inhabitants, and they are the the fact that population proximity to transport doesn’t highest in cities like Harare and Maputo where popu- appear to translate into better primary school access lation per primary school exceeds 12,000. Finally, the may have to do with the way informal transport routes overall average population density of a city is also – which dominate many of the cities in scope – are quite closely correlated with how long an average city allocating themselves: as also noted by the interviewed resident has to travel by public transport to reach the human rights practitioners, the informal transporters nearest primary school: average travel times increase likely prioritize routes that are profitable, such as those as population densities decline, with the average res- used for daily commuting to jobs and major economic idents of the denser cities like Conakry, Douala, and activity centers. Nairobi seeing distinctly lower travel times. In the case of accessibility to secondary schools, the In contrast, the correlation of average travel times to overall correlation patterns with transport and land use the nearest primary school is weak with any of the two planning characteristics are similar although the mag- variables that characterize the extent to which the nitudes are lower. The correlation remains by far the city development is transit-oriented: the share of strongest with the share of population living within a population living within walking distance of transit and walking distance to a secondary school - i.e., the direct the share of primary schools located within walking presence of secondary schools within residentially distance of transit. Exceptions are Douala and Nairobi dense neighborhoods. On the other hand, accessibility which perform among the best both in terms of the to secondary schools is much more weakly correlated 94 MOBILITY AND TRANSPORT CONNECTIVITY SERIES CONNECTIVITY FOR HUMAN CAPITAL with the two other land use planning characteristics that Nevertheless, also accessibility to advanced healthcare mattered much more in the case of primary schools: facilities, similarly to accessibility to schools, remains overall population density of the city and the average the most strongly related to the direct presence of size of population per secondary school. This might be healthcare facilities within residential neighborhoods due to some individual “outlier” cities such as, for exam- (“mixed land use”) as measured by the share of pop- ple, Douala, in which population density is the highest ulation able to reach at least one such facility within a across the ten cities while the average travel time to the 1-km radius. Thus, travel times are distinctly the high- nearest secondary school is longer than in several other est in Ouagadougou, Harare, and Bamako, where only cities, likely due to the comparatively low share of its between 7 and 12 percent of the urban residents live population living directly near a secondary school. directly near an advanced health facility, and by far the lowest in Kampala, Douala, and Conakry, where over 80 Lastly, accessibility to advanced healthcare facilities percent do. stands out as being comparatively highly correlated with at least one transit-oriented development indica- tor, namely, the share of people living within walking distance of transit. Thus, average travel times to near- 6.4.3. Spatial inequality within cities est facility are among the lowest in cities like Kampala, Douala, and Nairobi, where the vast majority of resi- To better understand the patterns of accessibility dents live near at least one public transport route, and inequality not only across but also within the cities, we it is by far the highest in Ouagadougou, where less apply inequality metrics similar to those well estab- than half of the population can reach a bus route within lished in the economic literature. Rather than deriving a 1-km radius from home. This might be indicative of a single indicator of inequality, akin to a Gini coefficient, the “value added” of public transport services specifi- however, we derive accessibility-population curves to cally for reaching these types of facilities; however, it illustrate, across cities and across different facility types could also be just a spurious correlation, in that the within a given city, how access is distributed – how same cities in which many people live near transit also equal or unequal it is – in terms of the cumulative share have wider availability of advanced healthcare facilities of the population that can reach the facility within a cer- as measured by the average population per facility. tain time threshold. The visualization also reveals what For example, in Ouagadougou, the very long average share of the population in each city and with respect to travel times are likely only partly due to the lack of tran- each type of health or education service is “accessibility sit-oriented development of the urban area or the long poor”, as measured by inability to reach even the near- bus service headways, and are at least to some extent est facility within an hour of travel by public transport. driven by the sheer sparsity of advanced healthcare In the case of schools, it could be argued that a more facilities per population, which means that the trips are reasonable metric for accessibility poverty is a travel long even for many of those who can easily reach a bus time exceeding half an hour, given that the trip there service. This same reason probably also explains the and back to school and back is made every day. long average travel times in Bamako despite the high share of its residents living within walking distance to a public transport route. 95 REALIZING THE RIGHT TO EDUCATION AND HEALTHCARE THROUGH IMPROVED PUBLIC TRANSPORT IN AFRICAN CITIES Figure 24: Share of population able to reach an advanced healthcare facility by public transport within the time threshold 100% Kampala 90% 80% Douala 70% Nairobi Share of city population 60% Conakry 50% Kigali 40% 30% Dar es Salaam 20% Bamako 10% Harare 0% 5 10 15 20 25 30 35 40 45 50 55 60 Ouagadougou Travel time to nearest facility (min) Source: Travel time estimates by study team Figure 25: Share of population able to reach a primary school by public transport within the time threshold 100% 90% Conakry 80% Nairobi 70% Share of city population Douala 60% 50% Ouagadougou 40% Bamako 30% Kigali 20% Harare 10% Maputo 0% 5 10 15 20 25 30 35 40 45 50 55 60 Travel time to nearest primary school (min) Source: Travel time estimates by study team 96 MOBILITY AND TRANSPORT CONNECTIVITY SERIES CONNECTIVITY FOR HUMAN CAPITAL Figure 24 visualizes inequality in advanced health facil- even assuming a travel time threshold of 20 minutes ity access within each of the cities where geo-located (see Figure 25). And, while all of Douala’s population has facility data was available. As noted before, a direct access to at least one primary school if assuming travel benchmarking of cities against one another is not the time of 25 minutes, in Ouagadougou 1% of the popu- indention, given the inevitably varying definitions of lation remain without access even at a time threshold “advanced health facilities” in each of them. Rather, of 50 minutes. A similar pattern can be observed in it illustrates the distribution of accessibility within a Kigali, although a lower share of its population than given city and the share of population that is particu- Ouagadougou’s can access a primary school within larly accessibility-poor. For example, it shows that in 5-10 minutes. Lastly, in Maputo and Harare, where in Ouagadougou, nearly 40% of all people are accessibili- both cases the average travel time by public transport ty-poor, compared to less than 10% in the other cities. to the nearest primary school is estimated at 22 min- Key metrics that can be used to assess the inequality utes, the accessibility distribution patterns slightly dif- of accessibility include the time threshold that cor- fer: in both cities about 10% of the population has a pri- responds to 50% of the population, and the rate at mary school within reach even assuming a travel time which the curves relating population share and travel of just 5 minutes; however, the share of population with time approach 100% (indicating universal accessibil- access increases more rapidly in Harare than Maputo, ity). While in Douala, Nairobi, Conakry, and Kigali the with 90% of Harare’s population having access at a time threshold corresponding to at least half of the 35-minute threshold, compared to 80% of Maputo’s. If population having access is about 10 minutes, with the assuming an accessibility poverty threshold of half an share with access increasing quite rapidly as the time hour, only in Douala no one is accessibility poor, com- threshold increases, in Bamako and Harare the time pared to between 1 and 5 percent of the populations of threshold corresponding to at least half of the popu- Conakry, Nairobi, and Ouagadougou, between 7 and 9 lation having access is closer to 25-30 minutes. In Dar percent of those of Bamako and Kigali, and as many as es Salaam, while over half of the population can access 15-25% of Harare and Maputo’s. an advanced healthcare facility within about 15-20 minutes, the share of population with access does not If assuming – as is evidenced from existing survey increase as rapidly thereafter, and even at a 40-min- data – that most children commute to school on foot, ute threshold still about 15% of the city’s population the share of the population that is actually accessibility remains unserved. poor is nearly 50% in Maputo and nearly 30% in Harare. In Conakry, the share of accessibility poor children A direct comparison of the cities can more reliably be increases from just 1% if assuming that public transport made for accessibility to schools, of course assuming is used to commute to about 16% if assuming that all their geo-located data is equally reliable. In half of the children commute on foot. This also illustrates the rela- cities – Conakry, Nairobi, Douala, and Ouagadougou – tively high “value-added” of the existing public transport half or more of the population can reach at least one system for primary school access specifically, or, specif- primary school by public transport (or just by walking) ically, its role in improving access for those who do not in within five minutes; however, in Ouagadougou, the have a primary school in direct vicinity and would other- share of the population with access does not increase wise have to commute for over half hour. In contrast, in as rapidly thereafter, and about 10% remain unserved Ouagadougou, the accessibility distribution among the 97 REALIZING THE RIGHT TO EDUCATION AND HEALTHCARE THROUGH IMPROVED PUBLIC TRANSPORT IN AFRICAN CITIES city’s population is much more similar whether travel poverty: one-quarter of all children living within the by bus or on foot is assumed, indicating a low benefit boundaries of the “functional city” are unable to reach provided by the bus system. For example, at the acces- a secondary school by public transport with the acces- sibility poverty cutoff time of half hour, the same share sibility poverty threshold of half an hour, while for 4% of the population – 5% - are accessibility poor regard- travel times exceed a full hour. The other cities in scope less of whether travel by bus or on foot is assumed. are more comparable to one another, with 20-40% of Even assuming an hour of travel as acceptable, in all all children having a secondary school within immedi- cities but Douala at least some share of the population ate reach, and relatively few having to travel over 30 remain unable to reach even a single primary school – minutes. Conakry stands out as a positive exception, in Conakry this share is 10% and in Maputo – 28%. with most of its population within immediate reach of a secondary school. In Conakry, as well as Douala and Accessibility distribution within cities is similar also with Ouagadougou, accessibility is universal if assuming a respect to secondary schools. Secondary school loca- travel time threshold of an hour. However, at the strict- tions could not be identified for Maputo; therefore, it is er accessibility poverty threshold of half an hour, in all of not included in this comparison. Harare again stands the cities at least some share of the population remains out as having lower overall accessibility and a larg- unserved, ranging from 2% in Conakry to 8% in Bamako er share of population characterized by accessibility and Kigali and the aforementioned 25% in Harare. Figure 26: Share of population able to reach a secondary school by public transport within the time threshold 100% 90% 80% Bamako 70% Conakry Share of city population 60% Douala 50% Ouagadougou 40% Nairobi 30% Kigali 20% Harare 10% 0% 5 10 15 20 25 30 35 40 45 50 55 60 Travel time to nearest primary school (min) Source: Travel time estimates by study team 98 MOBILITY AND TRANSPORT CONNECTIVITY SERIES CONNECTIVITY FOR HUMAN CAPITAL Figure 27: Share of population able to reach specific types of schools by public transport within the time threshold in Ouagadougou and Conakry Ouagadougou Conakry 100% 100% 90% 90% 80% 80% Secondary 70% – public 70% 60% 60% Primary – 50% public 50% 40% Secondary 40% 30% – private 30% 20% Primary – 20% private 10% 10% 0% 0% 5 10 15 20 25 30 35 40 45 50 55 60 5 10 15 20 25 30 35 40 45 50 55 60 Travel time to nearest primary school (min) Travel time to nearest school (min) Source: Travel time estimates by study team mapping was conducted as part of the study in the 6.4.4. Accessibility gaps in high- absence of readily-available poverty maps but given that poverty neighborhoods relevant household survey data was available. In sev- Complementing the within-city accessibility inequali- eral other cities (Kampala, Kigali, Maputo, and Harare), ty analysis presented above, we analyze inequality of we using existing poverty maps to derive poor-specific accessibility within cities by relating the mapping of accessibility indicators. In the remaining cities (Nairobi, accessibility with the mapping of the city-specific Dar es Salaam, Bamako), we rely on indirect poverty poverty incidence. We examine the spatial relation- proxies such as the spatial distribution of nighttime ship between socio-economic status and accessibility to light intensity, a well-known indicator highly predictive health and education opportunities in each of the cities; of variability in the strength of economic activity, to and how this relationship differs across the cities. In provide qualitative insights on the accessibility penalties two of the cities – Ouagadougou and Douala – poverty faced by those cities’ lower income populations. 99 REALIZING THE RIGHT TO EDUCATION AND HEALTHCARE THROUGH IMPROVED PUBLIC TRANSPORT IN AFRICAN CITIES Figure 28: Poverty distribution and travel time by public transport to advanced healthcare facilities in Ouagadougou Poverty incidence and advanced health facilities Travel time to nearest advanced health facility (min) Source: Estimates by study team In Ouagadougou, the study team generated pover- poor. When expressed in density terms, the poverty dis- ty estimates using household survey data from the tribution is fairly similar, with the exception of individual 2017/2018 version of the Harmonized Survey on high poverty density secteurs in the city’s north and east. Household Living Conditions and based on the pover- ty line defined by the Burkina Faso National Institute The sparse public transport network of Ouagadougou for Statistics and Demography. Small-area estimation appears to reach the poorest parts of the city equal- methods were then applied to estimate poverty at the ly well, although its effectiveness in terms of ensuring city scale as well as at the level of individual administra- accessibility to health and education facilities for the tive units (secteurs). Because accurate census data for poor is low, as in the case of the overall population. Ouagadougou could not be accessed, a pseudo census Some differences in accessibility compared to the over- was constructed using estimates of the size of the pop- all city population emerge at the secondary school level, ulation using population density estimates created by where 56% of the city’s poor are estimated to be able Facebook’s Data for Good project. To further increase to access at least one public school within half hour of the precision of poverty estimates, the team also incor- travel by bus, compared to 60% among the overall pop- porated additional geospatial data on land cover clas- ulation, and accessibility for the poor is also slightly low- sification (built-up area, vegetation, and water) and the er for private secondary schools with Catholic or Muslim presence of forced displacement. affiliation specifically. The value-added of the bus sys- tem as compared to just walking is equally low for the The estimated poverty rate in Ouagadougou is about poor population, with only a very marginal accessibility 17% but exceeds 25% in individual secteurs in the city’s improvement for accessing some education facilities southwest. The lowest levels of poverty are in the city (e.g., public secondary schools) and none for others. center, where less than 5 percent of the population are 100 MOBILITY AND TRANSPORT CONNECTIVITY SERIES CONNECTIVITY FOR HUMAN CAPITAL Figure 29: Poverty density vs. travel time by public transport to nearest public advanced health facility in Douala Number of poor people per km2 in 2020 Travel time to nearest public advanced health facility (min) Source: Poverty estimates by the study team based on Cameroon Census 2005; travel time estimates by study team The differences in accessibility between the overall Cameroon’s national poverty line92 – about 150,000 of population and the poor are greater with respect to the city’s residents in 2020 were estimated to be poor, advanced healthcare facilities. Compared to the over- representing 4.5 percent of the population. The poor in all population of Ouagadougou, the poor appear to Douala are largely concentrated in the peripheries: in be nearly equally able to rely on walking for accessing the south and the west however, in density terms, pov- schools but are at a clear disadvantage for accessing erty pockets are present also in central Douala. advanced medical facilities: for example, over one-fifth of the city’s residents could reach a hospital within an In Douala, the difference between accessibility to hour walk, compared to just 13% of the city’s poor. If nearest advanced healthcare facility (clinic or hospi- considering accessibility by public transport, the poor tal) and nearest public advanced healthcare facility is face a considerably higher average travel time to the quite considerable – increasing from just 13 minutes, nearest healthcare facility providing any advanced ser- on average, by public transport if all advanced facilities vices – travel to a hospital is about 15 minutes longer are considered to nearly double that if the only facilities by bus than for the overall population. considered are public. In the case of primary schools, similarly, while the average person in Douala can reach Poverty incidence at the neighborhood (quartier) level the nearest primary school within 9 minutes by public in Douala was estimated using data from the 2005 transport, the nearest public primary school is, on aver- Cameroon census. The large sample size of the Census age, more than 18 minutes away. In the case of second- allows estimating poverty rates very precisely, and the ary schools, the respective figures are 14 minutes and data likely reflect long-term poverty and asset owner- 22 minutes – hence, the “penalty” associated with only ship well, even if at the expense of failing to capture considering public facilities is slightly lower. more recent, short-term monetary shocks. Based on 92 Fixed at CFA931 per day (about US$1.58). As a comparison, the global poverty line is set at US$1.90/day. 101 REALIZING THE RIGHT TO EDUCATION AND HEALTHCARE THROUGH IMPROVED PUBLIC TRANSPORT IN AFRICAN CITIES Some of the zones within Douala with low accessibili- (World Bank, 2016b). However, implementation gaps ty to public facilities specifically are in the city’s south, in the delivery of public services such as education and where both the poverty incidence and poverty density health remain, threatening the achievement of the per area are high. Indeed, when disaggregating acces- country’s 2040 Vision of becoming a middle-income sibility indicators specifically for the city’s poor popula- country. A detailed poverty assessment for Kampala tion, travel times to the nearest public advanced health- was completed in late 2019 based on the 2016/17 care facility is over half hour for the poor, compared to Uganda National Household Survey and the 2014 25 minutes for Douala’s overall population. In the case National Population and Housing Census, conducted by of secondary schools, the city’s poor in fact have short- the Uganda Bureau of Statistics in close collaboration er average travel times to the nearest private facility but with UNICEF and the World Bank (World Bank, 2019a). slightly longer – to a public one. The assessment found that just 2.6 percent of the total population of Kampala live below the national poverty In Uganda, the national poverty rate has fallen at an line; however, poverty rates in all of the city’s Divisions impressive 1.6 percentage points per year since 2006, are consistently higher among children than among the while the international extreme poverty rate fell by 2.7 population as a whole. At the parish level, some parish- percentage points per year, the second fastest reduc- es have very high poverty rates, exceeding 50 percent. tion in extreme poverty per year in SSA during this time Figure 30: Poverty rate in Kampala at the Parish level, 2016/17 (%) Poverty headcount rate – overall population Child poverty headcount rate Source: World Bank (2019) 102 MOBILITY AND TRANSPORT CONNECTIVITY SERIES CONNECTIVITY FOR HUMAN CAPITAL As already mentioned, reliable school locations data Figure 31: Poverty headcount in Kigali (%) could not be identified for Kampala, and the accessibil- ity analysis for this city is limited to healthcare facilities. The disaggregated analysis of accessibility to these facilities suggests that the average travel times faced by the poor – at least assuming that public transport is used – are nearly the same as for the city’s overall population, with only a minute of difference in the case of any advanced healthcare facility or even specifically a public one. Also facilities offering advanced maternal care appear to be nearly equally well accessible for the city’s poor. These findings are quite intuitive given the spatial distribution of poverty incidence, which appears to be relatively high in the more central parts of Kam- pala – areas that also have relatively high density of healthcare facilities. At the same time, when comparing to the other cities, these findings should be viewed in the context of the more limited definition of Kampala’s extent compared to the other cities, whereby the outer areas of the true “functional city” are not covered in the analysis but almost surely have high poverty pockets as well as lower density of healthcare facilities. Source: World Bank (2019) A poverty map for Kigali had previously been prepared with World Bank assistance based on the 2013/14 Household Budget Survey. Poverty in Kigali has a dis- advanced healthcare facilities and 14 minutes in the tinct spatial pattern, with the central areas significantly case of hospitals specifically. However, the poor also lower poverty incidence – up to 10% in most neighbor- have to travel longer to reach schools: 9 minutes longer hoods – compared to the outlying areas, where in many and 7 minutes longer, respectively, in the case of prima- neighborhoods upwards of 55% of the people are ry schools and secondary schools. considered poor. However, given the higher population densities in central areas, poverty density per land area In Harare, poverty analysis was undertaken in 2018 by is highest in the center. the World Bank’s Poverty Global Practice, based on the 2012 Census. The pattern is roughly similar to those Kigali’s poor population is estimated to face a pay a found in many other cities, with the central area less larger penalty in travel times to advanced healthcare poor in percentage terms but with individual high abso- facilities than schools, like in the other cities, with the lute poor-density neighborhoods as well. Southern- and difference between the poor and the overall popula- easternmost Harare, however, stands out as having tion at 10 minutes by public transport in the case of high poverty according to both metrics. 103 REALIZING THE RIGHT TO EDUCATION AND HEALTHCARE THROUGH IMPROVED PUBLIC TRANSPORT IN AFRICAN CITIES Figure 32: Poverty distribution in Harare and its suburbs, 2012 Food poverty prevalence (% of population) Number of food-poor people per km2 Source: World Bank Poverty Global Practice, based on 2012 Zimbabwe Population Census The disaggregated accessibility analysis for the services, while over 50% live below the poverty line; city’s poor population suggests that, in light of the the low level of investment in urban areas over many city’s already relatively low accessibility, especially to years has reduced the quality and quantity of service advanced healthcare facilities, the poor do not appear delivery (World Bank, 2011). The latest poverty map to be particularly penalized – the average travel time to for the Greater Maputo Area (GMA) is available World the nearest facility offering advanced care is 38 minutes Bank (2017) which conducted an in-depth poverty and by public transport for the poor compared to 35 for vulnerability analysis based on the 2007 Census and the overall population. The difference in average travel 2008-09 household welfare surveys. It found that pov- time is also about 3 minutes for traveling to the nearest erty significantly declined in most neighborhoods in primary school or the nearest secondary school of any GMA from 1997 to 2007, and there is a strong correla- kind; unfortunately, for Harare the public-private break- tion between poverty reduction and access to basic down of facilities was not available. Despite the small services. Nonetheless, most of the population in GMA differences in travel time by public transport between continue to live in underserved neighborhoods, with the poor and the overall population, it is important to only basic infrastructure, unpaved roads, lack of piped note that the poor in reality are more dependent public sanitation, and most housing built of nondurable mate- transport – and non-motorized modes – than are the rial. A comparison of the poverty map with more recent better-off. proxies such as nighttime light intensity in 2018 sug- gests that the two are consistent even if the 2007 Cen- In Maputo, approximately 70% of the urban popula- sus based poverty map may not be reflective of more tion still live in informal settlements with insufficient recent and temporary income shocks. 104 MOBILITY AND TRANSPORT CONNECTIVITY SERIES CONNECTIVITY FOR HUMAN CAPITAL Figure 33: Poverty distribution vs. travel time by public transport to nearest public hospital in Maputo Nighttime light intensity (higher=more activity) Travel time to nearest public hospital Poverty incidence in Greater Maputo Area A visual comparison of the poverty map and the acces- sibility estimates suggests that accessibility to advanced healthcare facilities, especially at the hospital level, is lower than average in large parts of mainland GMA to the West and Northwest of the downtown – especially central Matola City, where upwards of three-quarters of the population are poor. It is interesting to note that this area not only has higher-than-average poverty inci- dence but also saw a poverty rate increase between 1997 and 2007 according to World Bank (2017), by up to 7%, in contrast to the most accessible parts of GMA where poverty rate declined by over 80%. Source: VIIRS nighttime light data from Goodman et al. (2018); poverty headcount estimates by World Bank (2017) based on 2007 Census; travel time estimates by study team 105 REALIZING THE RIGHT TO EDUCATION AND HEALTHCARE THROUGH IMPROVED PUBLIC TRANSPORT IN AFRICAN CITIES Figure 34: Nighttime light intensity vs. travel time by public transport to nearest public adv. health facility in Dar es Salaam Nighttime light intensity (higher = more activity) Travel time to nearest public advanced health facility (min) Source: VIIRS nighttime light data from Goodman et al. (2018); travel time estimates by study team In the peninsula south of downtown Maputo, which was percent of children in urban Tanzania live in multi-di- not covered in the 2017 World Bank poverty mapping mensional poverty.94 Dar es Salaam’s poor population but where economic activity is low according to night- in absolute terms in 2018 was estimated at just over time lights data, accessibility is estimated to be very low 410,000. However, detailed poverty maps for the city to key services that are more applicable to the poor specifically are not available. For the purposes of the households, such as public hospitals. As shown in the current study, the Tanzania Population and Housing maps below, travel times by public transport to nearest Census 2012 ward-level data was used to construct an public hospital in this area exceeds two hours. Howev- asset ownership index, combined with information on er, it should be noted that the recent construction of a whether the household head has primary education. bridge connecting the peninsula to the central down- These are considered to be reliable variables to provide town is not reflected in the available public transport an inference on the relative poverty distribution in the data but is believed to have improved the opportunities city, although the asset-based (non-monetary) poverty for the peninsula’s residents to access key services. measure does not capture the effect of recent shocks. An alternative measure of economic wellbeing – the Tanzania’s poverty incidence93 in 2018 was estimat- intensity of nighttime lights in 2018 – proved to be spa- ed at 26.4%, down from 34.4% in 2007; in the Dar es tially closely correlated with the asset ownership based Salaam region it was significantly lower, at 8%, which measure, with most wealth concentrated in the central is about half of the average for the country’s urban downtown wards. areas overall (United Republic of Tanzania, 2019). Forty 93 The basic needs poverty line for Tanzania Mainland for 2017/18 was defined at 49,320 Tanzanian Shillings per adult equivalent per month (~US$21). 94 Child Poverty in Tanzania report, 2016 106 MOBILITY AND TRANSPORT CONNECTIVITY SERIES CONNECTIVITY FOR HUMAN CAPITAL While quantitative accessibility indicators for Dar es are clusters of poverty around the CBD, like Kibera, Salaam’s poor population specifically could not be esti- which is only about 6 km from the CBD; overall, more mated, the visual comparison of the spatial distribution than half of Nairobi’s residents live in informal settle- of proxies of income/wealth and the accessibility indica- ments, suggesting the trade-off people prefer to make tors for the city overall suggest that physical accessibil- in favor of more convenient access to opportunities at ity – at least to advanced medical care – is lower in the the expense of housing quality. poorer areas outside the city center and further away from the coast. For example, in large parts of the city Extensive surveys conducted by Salon & Gulyani (2019) where nighttime light intensity is the lowest, average across 15 Kenyan cities found that 92% of household travel times to the nearest public advanced healthcare have a matatu service near their home, while in Nairobi facility exceed an hour, compared to about 35 minutes the figure reaches 98%. However, the physical availability for the city’s population overall. The travel time pen- of matatus doesn’t always translate into use. In Nairobi alty faced by the poor to travel to schools – if there is and Mombasa, only approximately 60% of households one at all – is likely lower, given that, unlike advanced report using matatus, which the authors suggest may healthcare facilities, schools at least at the primary level point to an affordability problem, poor destination cov- in most cities tend to be distributed much more pro- erage, or low service frequency. As had been found by portionately to population, with at least one available in the earlier surveys by the Africa Centre of Excellence for each neighborhood. Studies in Public and Non-Motorised Transport survey (ACET, 2010), among Nairobi’s slum dwellers, even when Nairobi’s central business district (CBD) has good acces- controlling for factors, such as childcare responsibilities sibility and presence of services, and middle-income and education level, women were less likely to commute residents tend to live close by the CBD. However, there using motorized transport than men. Figure 35: Poverty proxies vs. travel time by public transport to nearest public advanced health facility in Nairobi Nighttime light intensity (higher=more activity) Travel time to nearest public advanced health facility (min) Piped water coverage (% of households) Slum locations 107 REALIZING THE RIGHT TO EDUCATION AND HEALTHCARE THROUGH IMPROVED PUBLIC TRANSPORT IN AFRICAN CITIES Piped water coverage (% of households) Slum locations Source: VIIRS nighttime lights data from Goodman et al. (2018); piped water coverage mapping by Ledant (2013); Nairobi slums mapping by World Food Programme/VAM Kenya; travel time estimates by study team The visual comparison of Nairobi’s nighttime light inten- to schools and healthcare facilities but also livelihood sity distribution and accessibility estimates to advanced opportunities – at the expense of housing quality. care facilities suggests similar conclusions as in Dar es Salaam – the city’s CBD, which corresponds to high Spatial correlations between accessibility and nighttime nighttime light intensity and thus, likely, lower poverty lights intensity as a proxy for the residential location of incidence, has average travel times of less than 15 min- lower-income households are quite distinct in the final utes to any of the facility types considered, compared two cities: Bamako95 and Conakry. These are due not to travel times exceeding 45 minutes or an hour in the only to the reach of the public transport systems but outer areas. also due to the spatial distribution of health and educa- tion facilities; for example, due to the sparser availabil- However, whether or not the average poor resident ity of schools in Bamako’s suburbs, which correspond of Nairobi faces a travel time penalty to a specific type to areas with much lower economic activity and, likely, of facility is not as easy to conclude in the absence of household incomes, also walking-based accessibility in a robust poverty estimate; unlike in Dar es Salaam, these areas is lower. Similarly, in Conakry, the combina- densely populated slums, some of them (Mathare, tion of low public transport network coverage and lack Huruma, Kibera) estimated to provide shelter to over of locally present advanced healthcare facilities in the half a million people each, are located in central Nairo- city’s lower economic activity neighborhoods results bi where accessibility to key services is good. Another in those neighborhoods having significantly inferior proxy for the presence of lower income populations accessibility than in downtown Conakry, with travel – similarly suggesting that many of Nairobi’s poor live times by minibus exceeding an hour. People living in in centrally located and accessible areas – is the pro- the lower-income neighborhoods in the city’s North and portion of households enjoying piped water access; this East are not only less able to access health and educa- figure dips below 50% in the parts of town character- tion facilities but also face other spatially distinct disad- ized as slums. As noted before, this type of residential vantages, such as significantly higher student-teacher sorting is intuitive and suggests an intentional trade-off ratios in schools, which impacts the quality of the ser- made by households in favor of accessibility – not just vice received even once it is accessed. 95 The poverty assessment by the World Bank (2020) suggests that the poverty rate in Bamako declined from 10.7% in 2011-12 to 3.8 percent in 2019/20; however, the assessment did not generate detailed enough indicators to allow understanding poverty distribution within the city. 108 MOBILITY AND TRANSPORT CONNECTIVITY SERIES CONNECTIVITY FOR HUMAN CAPITAL Figure 36: Accessibility and resource availability disadvantages in the lower-income neighborhoods of Bamako and Conakry Nighttime light intensity in Bamako (higher=more activity) Walk time to nearest primary school in Bamako (min) Nighttime light intensity and secondary schools, Travel time by public transport to nearest public by student-teacher ratio, in Conakry advanced healthcare facility in Conakry (min) Source: Conakry schools data from Ministry of Education’s Office for Strategy and Development; nighttime lights data from Goodman et al. (2018); travel time estimates by study team Insights on the spatial patterns of low accessibility to Spatial inequality is also apparent in the quality of care, services in relation to poverty were also provided by with the poor communities clearly at a disadvantage: several of the human rights organization staff that we even though physical structures may be relatively well interviewed as part of this study. They pointed to the distributed within the city in some countries, the units relatively common pattern where population living in in the periphery are of lower quality. In Zimbabwe, while peripheries and informal settlements (new and old) people living in the most densely populated areas have often have to travel many kilometers to access medical access to clinics, their treatment or medication may not treatment. In Zimbabwe, for example, private health be available, as some treatments are only offered in service providers and pharmacies reportedly strategi- large clinics that are much more sparsely distributed. cally position themselves “where the money is”; thus, The smaller clinics where one can obtain more basic they are lacking in the poor communities. treatments tend to be distributed throughout the cities; 109 REALIZING THE RIGHT TO EDUCATION AND HEALTHCARE THROUGH IMPROVED PUBLIC TRANSPORT IN AFRICAN CITIES however, the largest health centers are located in the city centers (e.g., mentioned in interviews specific to Rwanda and Senegal). Because of the spatially uneven “So education is free and the two years of quality and the range of services and medication avail- basic education are compulsory but they are able, one needs to travel for quality or higher complexi- associated costs that make some people not ty treatments. being able to afford, and you would be sur- prised in Kigali, especially in Gasawo district, In face of the physical accessibility challenges to health- because of the landscape or geographical care facilities, community health volunteers were noted setup, I don’t know how to call that, there to play a major role in helping people from informal set- are localities where children need to travel tlements access to health information and treatments two hours by feet before reaching a primary in Kenya, Rwanda and Ethiopia, is in part because they school, so because of those circumstances, there are a lot of dropouts and they are still can easily reach the community. In Rwanda, communi- in Kigali.” ty health workers are considered essential in ensuring access to prenatal care and to healthcare for people — Rwanda with disabilities as they actively search for patients and bring the services to them. Similarly to healthcare, access to education is not seen as equal by the interviewed human rights experts, with settings. Some schools are present locally within inequalities arising in the available infrastructure and informal settlements, as was mentioned in the case of resources. In the case of Kenya, Zimbabwe, and Sene- Ethiopia, but may still be inaccessible for the families gal, public education was noted to be of inferior quality living there due to high cost. Schools in the poorer and with worse infrastructure; in Zimbabwe, education neighborhoods are also reportedly more likely to have quality was also noted to have a spatial pattern, declin- overcrowding, as was noted in the case of Kigali, which ing as one moves away from the more densely populat- may necessitate traveling long distances to schools ed areas. further away. As in the case of healthcare, affordability of education Spatial inequality in transport access that affects access – as well as the choice of which school to attend – is to school in the poorer neighborhoods is reportedly reported to be very much linked to transport (or lack compounded by transport safety issues which further thereof) and is further worsened by geographic loca- impede children’s access to education. There is no tion. Walking – sometimes over an hour – is commonly public transportation that goes to informal settlements, the only option for accessing school for children liv- and even where public transportation is available, it is ing in informal settlements (e.g., noted in the case of dangerous for a child – especially if the child is a girl – Ethiopia), as no school buses come to these informal to travel alone. 110 MOBILITY AND TRANSPORT CONNECTIVITY SERIES CONNECTIVITY FOR HUMAN CAPITAL “Again, in Kigali, as P1 said, there is high density of children in one classroom, which may push some from this area to skip school that’s nearby and go further schools which may require them to take a bus or any other means of transportation, and if they can’t afford, then children from poor family may either drop or take these long distances every day and they may also delay to school and that affects their education.” — Rwanda “I can afford a bus or transport for my kid in school. Let’s say a 9-year-old, because I am working, I will be taking this girl to school, she will be expected to go and get public transport on herself, and in these places, some of our transport is super packed, it is super busy and it is full of adults and the use of them, in navigation is extremely danger- ous for a child: I am talking about pedestri- an behavior, issues of sexual harassment for girls or grown women, let alone children and for them to come back home [breaking] so even though they are accessible, whether you are able to use it, they are not safe plac- es for young children to be, so sometimes parents will keep their children at home.” — Ethiopia Photo credits: Dominic Chavez 111 REALIZING THE RIGHT TO EDUCATION AND HEALTHCARE THROUGH IMPROVED PUBLIC TRANSPORT IN AFRICAN CITIES 7. Policy Implications Photo credits: Dominic Chavez 112 MOBILITY AND TRANSPORT CONNECTIVITY SERIES CONNECTIVITY FOR HUMAN CAPITAL Urban transport availability and the accessibili- few percent of the urban residents in all of the cities but ty it ensures between homes and education and one – are scarcely a sign of adequate access. Another healthcare facilities matter for the ability of people finding from the analysis is that public transport in most to realize their Rights to Education and Health. If of the cities does not appear to provide a large acces- children cannot get so schools, their ability to keep up sibility benefit above and beyond traveling on foot, and with learning will be severely limited. And, if pregnant average accessibility to schools does not seem to be women cannot reach maternal health facilities or if par- higher in cities where a larger share of people living ents do not have transport options available to bring directly near public transport (i.e., more transit-orient- their children to clinics, maternal and infant health will ed cities). This latter observation might indicate that inevitably suffer. However, the strive to ensure that the the public transport operators, some of them informal Rights to Education and Health are fulfilled equitably by and already scrambling to break even, do not prioritize all members of the society, transport affordability and routes to schools; that the technical characteristics of appropriateness – such as for the poor, the disabled, public transport services (speed, headway) are so poor the elderly, and the otherwise marginalized – need to that the value of being near a service is significantly be equally central policy objectives. diminished; or that the sprawling nature of some cities make travel distances long regardless. As suggested by the analysis presented in this study, health and education accessibility inequities across In comparison, higher residential proximity to space and through the exclusion of specific socio-eco- transit appears to translate more directly into bet- nomic groups continue to persist in African cities. ter accessibility to advanced healthcare facilities, In most cities, at least one in ten residents faces although it is nevertheless less predictive compared to a one-way travel time to the nearest advanced the local presence of the facilities directly within resi- healthcare facility of over half an hour by public dential neighborhoods or the average population size transport – assuming they can afford the trip in the per facility. The greater correlation between residen- first place and do no have a disability that would pre- tial proximity to transit and accessibility to advanced vent them from boarding the vehicle. In four of the healthcare facilities – compared to accessibility to cities, travel times of over an hour in public transport, schools – might be due to these facilities being more indicative of true “accessibility poverty,” are faced by at commonly located in economic activity centers well least 5 percent of the population – these are often res- served by public transport; the relative scarcity of these idents of outlying, poor settlements that also lack any facilities compared to schools also means that one has private mobility options. to travel by a motorized mode to reach them, as many people do not have a facility within their neighborhood. Public transport based travel times to nearest pri- mary and secondary schools tend to be lower than While some accessibility challenges persist across to advanced healthcare facilities, and fewer people all ten cities, different approaches in prioritizing are completely cut off from any opportunities. Nev- policy interventions are likely needed depending on ertheless, given that the trip to school must be made the specific accessibility landscape. The first group of every day, one-way travel times by public transport cities includes those – such as Douala, Conakry, Nairobi, exceeding half an hour – which is the case for at least a Kampala, and Kigali – where average accessibility to not 113 REALIZING THE RIGHT TO EDUCATION AND HEALTHCARE THROUGH IMPROVED PUBLIC TRANSPORT IN AFRICAN CITIES only schools but also advanced healthcare facilities is Lower-hanging fruit relatively good, but where there are individual accessi- bility poverty pockets or evidence that socio-econom- Data collection to track accessibility gaps for differ- ic groups are not able to afford transport services. In ent groups: The use of spatial tools to measure trans- these cities, policy interventions should be more spe- port disadvantage in different areas around a city is by cifically targeted to those spatial areas or groups of definition at the aggregate geographic level; they do people, such as through: limited spatial reforms and not measure the impacts on individuals living in these investments in transport system coverage; investing in locations (Delbosc & Currie, 2011a). The interviews con- data and analytics to understand why existing transport ducted as part of this study therefore provide crucial operators do not serve these locations if they’re poten- complementary evidence on the accessibility disadvan- tially high demand (due to low incomes of users? lack tages faced by specific marginalized groups in the cities of access roads? absence or irregularity of work com- in scope of the analysis, such as women (in particular, mute trips?); and providing targeted incentives, such elderly and low-income women) and the disabled, for as a short-term franchise subsidy or cross-incentive for whom travel in public transport may be unaffordable transport operators or health/education facility oper- if a guide needs to be hired to accompany them to a ators to expand their services to these areas. In the healthcare facility. second group of cities – such as Harare, Ouagadougou, Bamako, and perhaps Dar es Salaam – also average Quantifying to what extent a specific person or fam- travel times to the nearest advanced healthcare facility ily suffers from public transport deficiencies is diffi- are high, even if accessibility to schools is significantly cult because transport poverty manifests itself at the better (except in Harare). In these cities, there might individual and household level, while appropriate data be a need for a more general overhaul or large-scale are generally only available at an aggregate scale. The investment in additional high-capacity transport corri- setting of an “access poverty” line is both a political dors and public transport solutions as well as additional issue (what differences in access levels are deemed health infrastructure. acceptable?), and an empirical issue (what differences in access levels are correlated with significant differ- For both sets of cities, possible policy interventions can ences in levels of activity participation and well-being?). be aligned along the feasibility-versus-impact axes, with It is beyond the scope of this paper to address these some easier to implement actions and some others issues. Similarly, more advanced accessibility measures that would require overcoming significant coordination could be employed, such as measures which account challenges but would ensure a more transformational for competition between populations seeking to access impact in the long run. the same destinations (Golub & Martens, 2014). The 114 MOBILITY AND TRANSPORT CONNECTIVITY SERIES CONNECTIVITY FOR HUMAN CAPITAL relevance and importance of this latter issue in the Afri- implemented in nearly every country albeit with only can city context came through clearly in the interviews limited frequency and without statistically representa- with the human rights practitioners working on the tive samples at the sub-city level. ground. Namely, even in cities where accessibility to the nearest healthcare facility or school is acceptable, the Improving the process of decision-making in the ability to access care in reality may be limited, as facili- transport sector: Given the significant resources ties in higher density locations and on city peripheries involved and the lasting effect that transport infrastruc- are reported to be overcrowded. ture investment has on regional and urban develop- ment, the decisions concerning which infrastructure Therefore, among the first priorities for any city willing and where to construct it needs to be carefully consid- to improve accessibility for all is the investment in good ered (ITF, 2019), and input from the users should serve data. Specifically, gender-, income- and otherwise dis- as a key input into this decision-making. Governance aggregated data, collected regularly over time, is need- issues need to be addressed, even if in an incremental ed to track accessibility, affordability, and appropriate- way, to improve the accountability of transport planning ness constraints faced by city residents to inform policy, and health and education sector institutions and their planning, budgeting, and implementation. The data feedback look with city residents, including through collection would allow grounding the existing access more meaningful, bottom-up participation of vulner- voids in local reality, allowing to identify interventions able groups in the planning process. A human rights that would allow a city to quickly and affordably improve based approach to infrastructure and services plan- accessibility for specific groups of people – for exam- ning, applying in practice the principles of participation, ple, through the implementation of new transit routes, transparency, accountability, and non-discrimination, adding missing links in the road network or pedestrian would help policy makers to reach the most vulnerable infrastructure, prioritization of new facility locations – groups and identify interventions that would make the and also providing evidence on potential bigger issues biggest immediate impact. The transport system plan- that limit accessibility, such as a profound spatial mis- ning process in particular should include not only the match. Adequate data can also help transport planners city residents but also the transport workers to bring understand the role and value of transport investment them into the same room and allow more clearly com- relative to other policy measures in solving the problems municating the residents’ expectations and needs vis-à- of areas with high levels of poverty and social exclusion. vis the transit providers, the transit providers’ ability to For example, marginal improvements to already high fulfill those needs, and the actions from planners/cities levels of physical accessibility may make little difference that can bridge the gap. For example, the city may be to residents whose principal barriers to movement may able to provide incentives to transport service providers be related to cost. to ensure that transit services are not limited only to the routes with the high and predictable ridership but Lastly, comprehensive and consistent data collec- also serves the lower frequency and more variable des- tion efforts would also enable cross-neighborhood tinations, such as hospitals, especially from residential and cross-city comparisons and allow for more direct neighborhoods that are inhabited by transit-dependent benchmarking, similarly to how this is already done populations. by Demographic and Household Surveys that are 115 REALIZING THE RIGHT TO EDUCATION AND HEALTHCARE THROUGH IMPROVED PUBLIC TRANSPORT IN AFRICAN CITIES Improving transport infrastructure and services: there is prevalence of informal public transport forms Transport infrastructure improvements tend to be in the analyzed cities, there is potential for utilizing costly, with the price tag for even a single Bus Rapid emerging technologies to develop on-demand services Transit route typically well exceeding US$100 million to less frequent but essential/critical trips; for example, in the African city context. However, targeted improve- the implementation of a network of privately operat- ments in the transport infrastructure and services in ed “ambulance taxis” could be supported by the city the ten cities covered in this study arguably represent governments to improve maternal health outcomes for a relatively low hanging fruit – from the feasibility of the women living in accessibility-poor neighborhoods. implementation perspective – that would allow making A similar system was already launched in rural Tanzania a significant dent in accessibility poverty. In addition with external donor help in 2016 and since then has to high-capacity transport corridors, however, invest- had a significant impact on reducing maternal mortality. ments in improving the non-motorized and, especially, pedestrian infrastructure could help improve access for In many world cities, those whose school access needs many, especially for reaching schools which are known cannot be economically served by profit-seeking trans- to be relatively more widely available. Previous studies port operators have been reached through govern- in African cities have recommended not only extending ment supported dedicated transport (school buses), and improving the efficiency of the mostly dilapidated which is not the case in the cities analyzed in this report public transport networks but also separating spaces and could be a solution for connecting the children liv- for cyclists and pedestrians, integrating NMT within the ing beyond reasonable walking distance. In some of the rest of the transport system, and implementing traffic cities, indeed, on-demand services, in the form of taxis calming measures within the boundaries of nurseries and moto-taxis, have become the de facto solution but and schools. Given the overwhelming dependence on these are not affordable to everyone. Therefore, target- walking to primary schools in African cities, as evi- ed financial support, such as in the form of vouchers denced in the interview and survey data presented in for private taxis, would be needed to improve accessi- this study, policy makers should focus on improving the bility for some groups, underlying the reality that even walking experience, ensuring that these trips are safe, just transport connectivity needs to go beyond physical and providing appropriate infrastructure for people distance and also consider other travel-related costs with disabilities. in terms of money, time, and personal safety. Similarly, the city governments could introduce new geographi- Across the analyzed cities, accessibility to higher level cal zones of public transport service by incentivizing or of service, such as those available in only in hospitals, subsidizing operations there in some small, immediate is consistently worse than accessibility to services that ways (e.g., through a simple 1 or 2 ticket price operat- are used regularly and by a predictable share of the ing subsidy per-vehicle that arrives at an underserved population, which is economically rational from the school or hospital), without pushing for more funda- perspective of the public transport providers. Since mental transport sector reforms (in the short term). 116 MOBILITY AND TRANSPORT CONNECTIVITY SERIES CONNECTIVITY FOR HUMAN CAPITAL Longer-term actions Improved institutional coordination: Proximity of interventions include, above all, improved regulation public transport to people’s homes matters, especial- or even reorganization of transport service provision, ly so for accessing advanced healthcare facilities and much of which in many African cities is currently infor- among transit-dependent populations. Similarly, the mal and highly fragmented, with many operators barely residential proximity to schools is important for ensur- breaking even, which encourages the clear prioritiza- ing access, given the dependence of many children on tion of only highest ridership destinations. Similarly, walking. Thus, the coordination of transport, housing, while to date a lot of the discussion of formalization and health education sector planning and investment is or reform of transport in cities has centered on safety, fundamentally important for achieving good, equitable emissions, congestion, and similar aspects while taking access to education and health. Transit-oriented devel- the existing networks as sort of axiomatic, the spatial opment, channeling new population growth in tran- analysis presented in this study suggests that the trans- sit-accessible areas, and urban planning policies that port route geographies in some cities have significant ensure that health and education centers are accessible shortcomings from the perspective of ensuring ade- to transit and to residential communities are key ingre- quate access and mobility. dients for closing accessibility gaps over the longer term. For example, the urban policy-makers’ attempts Addressing the supply side: Transport sector inter- to support the poor by providing decent urban housing ventions can address only a sub-set of the issues that need to be mindful of the spatial distribution of schools in practice limit access to schooling and healthcare for and healthcare facilities – i.e. ensuring land use that is all. The other fundamentals that have to be worked on mixed – rather than placing housing in distant areas over time are those on the supply side of health and that would require the poor to travel long distances to education sectors, above all, the quality of the services access services in a context of already high congestion provided. The interviews conducted as part of the cur- and lack of coverage of public transportation. rent study suggest the presence of a clear “dual sys- tem” in many cities, with the quality of services available The coordination of transport and land use planning at in public schools and health facilities significantly com- the metropolitan scale can also help limit the sprawl of promised by insufficient resources and staffing. In this haphazard, disconnected development that has charac- context, distance or transport connectivity is not always terized many African cities over the last decade (see Lall a good predictor of individuals’ decisions to actually et al., 2017) and that makes the provision of efficient use the services available at a specific clinic or school; transport services unaffordable. Overall, cities need to instead, the facility’s reputation or perceived quality address their fundamental structure and more strategi- may matter equally or more. The dual quality of service cally plan ahead where new facilities should be located provision must be tackled to ensure not only accessibili- or existing ones enhanced to service more people; to ty but also the quality is more equitably distributed. do so, it is important that land is preserved for these purposes well in advance. Annexes 1 and 2 lay out a more detailed menu of pol- icy recommendations that should be considered to Public transport reforms: Some of the interventions improve accessibility in Bamako and Ouagadougou, two with the potentially highest payoff inevitable require cities in scope of this study with some of the most chal- overcoming significant political economy issues. These lenging – albeit different – accessibility gaps. 117 REALIZING THE RIGHT TO EDUCATION AND HEALTHCARE THROUGH IMPROVED PUBLIC TRANSPORT IN AFRICAN CITIES 8. Annexes Photo credits: Arne Hoel 118 MOBILITY AND TRANSPORT CONNECTIVITY SERIES CONNECTIVITY FOR HUMAN CAPITAL Annex 1: Accessibility analysis and rec- ommendations for Bamako, Mali in Bamako, behind getting the money to pay for the 1.  Summary of findings: the cate- services and getting the permission to seek treatment gories and the spatial lenses (Republique du Mali, 2019). In Mali overall, distance Access to education has played an important role in the to school is named as a reason for never attending poverty reduction in Mali over the last decade: in 2014- a formal school by about 10% of children and young 2018, improvements in education and access to basic adults aged 7-24, approximately the same among girls services was estimated to have led to a 10 percentage as among boys. However, among children ages 5–10, point reduction in multidimensional poverty (World girls are less likely than boys to visit a clinic or other Bank, 2020). In Bamako, the poverty rate was estimated health facility when they experience an illness, possibly at 3.8% in 2019/20, down from 10.7% in 2011/12. Nev- because boys’ health is being prioritized (World Bank, ertheless, Mali remains one of the poorest countries in 2020). Even if a health facility is accessible, the Harmo- the world, and in 2020 had a Human Capital Index of nized Survey on Household Living Conditions (EHCVM) only 0.32 (0.44 in Bamako), meaning that a child born 2018-19 survey data suggests that the cost of health today in Mali can expect to achieve roughly 32% of her services causes many to forego treatment: about a productive potential. And, while children’s educational quarter of households in the lowest wealth quintile do outcomes improved in 2014-18, the health component not seek help at a health facility at all when they are sick of the multi-dimensional poverty index deteriorated; for due to this reason. example, the share of household with a member who fell sick or ill in the last 30 days but was unable to con- In Bamako, walking is the mode of transport for more sult with a health specialist increased during the same than half of all trips (SSATP, 2020b). Another 17% of period from 21.7% to 37.0%, including due to lack of the trips are made by bus, and 9% by car, although infrastructure (World Bank, 2020). data is not available on the differences by gender. In major African cities, on average, buses and minibuses A poverty map is not available for Bamako; thus, track- jointly account for about 20% of motorized trips, while ing the accessibility indicators specific to the poor motorcycles are used in about 15% of motorized trips. residents was not possible. However, the Modular and However, Bamako stands out as having an overwhelm- Permanent Household Survey (EMOP) 2011-19 and ing dependence on motorcycle transport, representing the periodic Demographic and Health Survey allows more than half of all motorized trips, although the data- to monitor progress in improving the living condi- set underlying this figure is now over a decade old (see tions of Bamako’s households belonging to different Kumar and Barrett, 2008). socio-economic groups. For example, this data sug- gests that 30.9% of urban households are concerned The fixed-route public transport system in Bamako is about health expenditure, 27.1% about school supplies, entirely dominated by minibus transport (Société des and 25.9% about children’s school fees. For access- Transports du Mali, SOTRAMA), consisting of about 200 ing healthcare, distance to the facilities is mentioned routes. The system provides a relatively good coverage as a major constraint by 17.4% of women aged 15-49 of the city’s more populated areas. Approximately 92% 119 REALIZING THE RIGHT TO EDUCATION AND HEALTHCARE THROUGH IMPROVED PUBLIC TRANSPORT IN AFRICAN CITIES of the residents of the “functional city” – the city area as The average travel time, by public transport, to the defined by actual employment and commuting pat- nearest primary school and secondary school is esti- terns – live within walking distance to a route. However, mated at about 13 minutes and 15 minutes, respec- the quality of the service is poor in terms of frequency, tively, although exceeds half an hour in relatively large speed and comfort: there are no designated stops, and parts of the city’s outskirts. The value-added provided frequency of the service is unpredictable with often by the SOTRAMA network for accessing primary schools lengthy wait times (up to an hour for certain lines) is relatively marginal, as the average travel time to (World Bank, 2019b). the nearest school on foot is only a couple of minutes higher (15 minutes). This is explained by the fact that In the “functional city” of Bamako, which spans an area about 76% of the city’s population live in close proximity of about 478 km2, there are 72 CSCOM facilities, seven to a primary school, although this share is significantly CSRef facilities, and eight hospitals. The spatial analysis lower than in Conakry, Douala, Nairobi, and Ouagadou- suggests that, for the average resident of the “function- gou. Residential proximity to secondary schools – i.e., al city” of Bamako, it takes about 18 minutes to reach the presence of secondary schools locally in residential the nearest facility (either CSCOM, CSRef or a hospital). neighborhoods – is even lower, with only about 65% However, the average travel time is considerably longer, of Bamako’s population living within a kilometer from about 32 minutes by public transport, to reach specif- a school, below any other city analyzed in this study ically the facilities providing relatively more advanced except for Harare. care – hospitals and CSRef – and over 40 minutes are needed to reach a hospital. Accessibility to hospitals is particularly low in the south-western and north-eastern Figure 1.1: Share of housing that is informal parts of Bamako, roughly corresponding to Communes I and V, where travel times exceed an hour but reach nearly three hours in the very outskirts. The high travel times to individual hospitals are at least partly due to them not being directly accessible from the SOTRAMA network: one of the eight hospitals (CHU Point G) is located further than a kilometer from the nearest route, while two others (Hôpital Gavardo and Hôpital du Mali) are almost a kilometer away. A total of 547 primary schools and 317 secondary schools were located in the city; however, the public versus private status was not available for the schools located in Bamako’s outskirts and therefore the accessi- bility analysis did not separately address public schools. Source: Data from Geospatial Operations Support Team 120 MOBILITY AND TRANSPORT CONNECTIVITY SERIES CONNECTIVITY FOR HUMAN CAPITAL The public transport network density and the availability About 10% of Bamako’s population are characterized of hospitals is higher in northern Bamako, which also by “accessibility poverty” for accessing hospitals (over corresponds to neighborhoods with a particularly high an hour of travel time by public transport), while 1% of proportion of informal housing, exceeding 50% in some the city’s population cannot reach neither a hospital, areas. It may indicate that poor households locate there nor a CSRef facility or CSCOM within this time threshold. not only because of more affordable (even if worse The share of “accessibility poor” to primary schools – quality) housing but also because of better walkability defined as those who face travel time in excess of half to these key services and accessibility to employment an hour one way by public transport – is 7%, slightly opportunities that being near the SOTRAMA network less than to secondary schools (8%). About 1-2% of the and to the central business district helps ensure. The city’s population cannot reach even a single primary or rise in informal housing subdivisions is likely to contin- secondary school within a full hour of travel. ue with the influx into Bamako of internally displaced persons (IDPs), although spatial data on their specific residential locations is not available. Figure 1.2: Inequality in accessibility: cumulative population share able to access the nearest facility by public transport 100% 90% Hospitals + CSRef 80% + CSCOM Share of population 70% Hospitals + CSRef 60% 50% 40% Hospitals 30% 20% Primary sch. 10% 0% 5 10 15 20 25 30 35 40 45 50 55 60 Secondary sch. Travel time to nearest facility (min) 121 REALIZING THE RIGHT TO EDUCATION AND HEALTHCARE THROUGH IMPROVED PUBLIC TRANSPORT IN AFRICAN CITIES Figure 1.3: Locations and travel time by public transport to nearest facility Locations of Hospitals, CSREF, and CSCOM Travel time to the nearest Hospital, CSREF, or CSCOM Travel time to the nearest Hospitals or CSREF Travel time to the nearest Hospital 122 MOBILITY AND TRANSPORT CONNECTIVITY SERIES CONNECTIVITY FOR HUMAN CAPITAL Figure 1.4: Locations and travel time by public transport to nearest primary and secondary school Locations of primary schools Locations of secondary schools Travel time to primary school Travel time to secondary school 123 REALIZING THE RIGHT TO EDUCATION AND HEALTHCARE THROUGH IMPROVED PUBLIC TRANSPORT IN AFRICAN CITIES 2.  Explaining the findings 2.1.  Transport efficiency of the city, and Hôpital du Mali on the southern bank of the river near the city’s eastern boundary. The accessi- The identified accessibility patterns, especially to the bility benefits – such as to hospitals – that are provided much more sparsely distributed hospitals and CSRef by the public transport network in Bamako are more facilities, are at least partly driven by the public trans- noticeable than in the case of some of the other cities, port route allocation across the city. Serving relatively with areas near the SOTRAMA routes estimated to have low-frequency destinations such as hospitals may not better accessibility than those not. be an economically rational choice for public transport providers, especially if these destinations do not over- Despite the outward expansion of Bamako over the last lap with high-frequency and predictable-demand desti- decade, most of the administration, higher education nations such as employment hubs. Based on the analy- buildings, and the main market have remined concen- sis conducted by Peralta-Quiros et al. (2019) using data trated in Rive Gauche, which contributes significantly to from a business registry carried out in 2015, Bamako’s increasing congestion. Congestion in Bamako is high employment opportunities are relatively tightly concen- also because of the natural bottlenecks created by the trated in central parts of the city, with opportunities in river Niger, owing to which only three bridges can chan- the outlying areas. nel the flow of commuters mainly coming from the Rive Droite of the river to the Rive Gauche in the morning. Finally, congestion is also magnified by the lack of ring Figure 1.5: Bamako population (height) and accessibility to roads, which means that freight transport is channelled employment opportunities (color) through the city, and the sparsity of the paved road net- work, which reduces travel speeds. The limited traffic management also contributes to congestion. Figure 1.6: Public transport and paved road networks Source: Peralta-Quiros et al. (2019) The areas with highest economic densities also corre- spond to the highest density of SOTRAMA routes, at more than 18 km per km2. In contrast, the routes are much sparser – at below 8 km per km2 - in neighbor- hoods with low employment density near two of the city’s eight hospitals – Hôpital Gavardo, located on the northern bank of River Niger in the westernmost part Source: Road network data from Global Road Inventory Project (GRIP) 2018; World Pop population data (2020) 124 MOBILITY AND TRANSPORT CONNECTIVITY SERIES CONNECTIVITY FOR HUMAN CAPITAL Sparsity of the good quality road network is another Figure 1.7: Transport networks and Bamako Circle boundary factor that explains the difficulty of reaching healthcare and education opportunities in some parts of Bamako, given that the road network is denser in the city core while leaving the outer areas more poorly connect- ed. Analysis of the available spatial data suggests that, although the paved road network is not particularly concentrated in central Bamako, it is very sparse and to a large extent explains the public transport route avail- ability, with very few of the routes – especially in Bama- ko’s southern half – going on roads that are not paved. The Urban Sector Review for Bamako found that, while 80% of Bamako’s population live within walking dis- tance of an arterial road, insufficient paving is a major Source: Road data from Global Road Inventory Project 2018 issue, significantly lowering travel speeds (World Bank, 2019b). Paved road density in Bamako lags other cit- ies in Africa, with only 0.8 km of paved roads per km2, Moreover, according to analysis by the World Bank’s compared to over 2 km in Accra, Douala, Conakry, and Urban Team based on the 2016 budget execution Abidjan (Kumar and Barrett, 2008). The public transport reports for District of Bamako and communes II, III, IV, providers’ apparent preference for traveling on paved V, and VI and the 2015 budget execution report for roads is intuitive and can be explained by the lower commune I, Bamako’s infrastructure expenditure is wear and tear and risk of damage to the vehicles, which $0.72 per capita and $8,155 per km2, which is one of affects the transport providers’ earnings, and the lower the lowest among developing cities, and of which only commercial speeds, due to the road condition, which 8% and 4% is dedicated to motor transportation and mean less profit for equal density of demand. Direct roads and to public transport, respectively. evidence on the route allocation decision-making for Bamako is not available; however, recent research by As a result, travel costs are still proving to be a heavy Kelley at al. (2019) from Nairobi suggests that informal burden for citizens, especially those living in areas far minibus owners in particular have a strong preference from Commune III. The same analysis finds that Bamako for deploying their vehicles only on paved roads. allocates only 2.5% of its total budget to infrastructure expenditures whereas the average low-income city allo- The limitations of the road network and the public cates 54.3% and an average African city allocates 34.2%. transport system – in particular, gaps in the outlying areas of the “functional city” – also have to do with insti- tutional aspects: the reach of the Bamako city jurisdic- tion – such as in terms of the road network planning and public transport regulation – is limited vis-à-vis the actual size of the metropolitan area. 125 REALIZING THE RIGHT TO EDUCATION AND HEALTHCARE THROUGH IMPROVED PUBLIC TRANSPORT IN AFRICAN CITIES 2.2.  Land use and city form land that do not border on or overlap existing develop- ment. Lall et al.’s (2017) analysis of spatial imagery for Another driver of the accessibility analysis results 21 African cities over 2000–2010 shows that, during this identified in the current study is the overall form of period, much of new development occurred as outward Bamako city and its population distribution, which is expansion. However, a particularly worrying trends was notably even, without a significant downtown peak. This the increase in leapfrog development – which was the explains one of the findings of the current study, nota- most notable in Bamako across all the cities analysed, bly the very low share of the population living in direct where it accounted for more than 50 percent of the walking distance to an advanced healthcare facility (12% change to the urban fabric (in comparison to less than to a hospital or an CSRef and 6% to a hospital specifical- 20 percent in Windhoek, Niamey, and Conakry). ly, compared to 78% and 43% in Nairobi, for instance), given that some of the already scarce facilities are locat- The population of Bamako is expected to expand ed in low-density outskirts, while the population densi- steadily in the coming decades, with over 3 million peo- ties around the centrally located facilities are also not ple to be added by 2030 in the Bamako District alone high enough to ensure that a large share of the city’s (Ville de Bamako, 2012). Inevitably, the demand for overall population is directly served. urban land will continue to grow, also because of the less predictable but likely significant additional demand In fact, as was identified in the regional study by Lall generated by the arriving IDPs. et al. (2017), Bamako, similarly to many African cit- ies, is characterized by disconnectedness and spatial Bamako’s expansion pattern has been attributed to the dispersion that makes the provision of infrastructure land tenure system, which is characterized by several costly. Despite an average population density of nearly layers of complexity and deters efficient and equitable 5,700 per km2, which places Bamako above several of urban development: currently, different land tenure its comparator cities (Harare, Dar es Salaam, Maputo, regimes co-exist, ranging in formality from customary Ouagadougou, and Kigali), in many of the city’s neigh- possession of land (mostly in the peri-urban area or the borhoods population densities are low, which implies rural hinterland) all the way to ownership with a title/ a low ridership base for public transport services. The deed (in the urban core), and this complexity is com- authors point out that the high fragmentation is driven bined with poor governance in the management of by the relative lack of new development near the cen- land at all levels of government. The city’s formal land ter: new construction is not clustered to make capital market with title deeds is very small and formalization more concentrated and increase economic density; costly, which means that the supply of formal land is instead, it tends to push the boundaries of the city limited, driving up its price (World Bank, 2019b). In the outward, resulting in so-called “leapfrog development” 2016 budget executions of the Bamako District hous- as opposed to infill, which makes cities denser. Leap- ing does not appear as a budget entry at all, reflecting frog development differs from simple expansion in that the current state where land subdivision schemes are expansion development enlarges a city’s footprint at pervasive and where the public has little control over the edge of the consolidated urban area, while leapfrog the land/housing sector; it could do more to proactive- development also enlarges the footprint, but does so ly build affordable housing in areas accessible to key by establishing satellite areas — parcels of newly built public services. 126 MOBILITY AND TRANSPORT CONNECTIVITY SERIES CONNECTIVITY FOR HUMAN CAPITAL Figure 1.8: Land use patterns in Bamako Circle Source: Land use data from Earth Observation for Sustainable Development (2019) The land market inefficiencies notwithstanding, analysis city government’s efforts to provide the networked by Earth Observation for Sustainable Development services that require scale economies. However, parts (2019) suggests that only in few parts of the city of city, mainly on the edges, remain underdeveloped, so opportunities for densification have been exhausted. there is a space for further development and strategic During 1985-2015, there was important expansion axis land preservation for essential infrastructure facilities along the Niger river and in south-west and east part such as hospitals (according to the analysis, vacant land of the city, with traditional villages becoming gradually and bare soil within Bamako district alone amount to attached to the growing city. Because the new, dis- over 12 km2, in addition to sizable areas of developed connected development patches are often small, their publicly owned land that could be redeveloped). isolation from existing development undermines the 127 REALIZING THE RIGHT TO EDUCATION AND HEALTHCARE THROUGH IMPROVED PUBLIC TRANSPORT IN AFRICAN CITIES 2.3.  Institutional landscape Another institutional gap that should be addressed to improve metropolitan scale transport and land Another key driver of the planning and delivery of use planning is the currently insufficient coordination health and education services in the Greater Bamako between, on the one hand, the Ministry of Infrastruc- region is the current institutional structure. The admin- ture in terms of the planning of major infrastructure istrative landscape in Mali is characterized by insti- projects and, on the other hand, the Ministry of Terri- tutional fragmentation and a complex relationship torial Administration and Decentralization in terms of among deconcentrated and decentralized units of urban development. government. The District of Bamako has a governing council and six local governments (communes), with an 2.4.  “Dual quality” system additional 29 local governments composing the great- er Bamako metropolitan region. Overlaps in competen- Crowding and long wait times in schools and health cies bestowed upon local governments by legislation facilities – even if these are physically accessible – is makes responsibility for delivery of services unclear, explained by the perceived low quality of public and and the lack of clearly defined and implemented func- community facilities in particular. According to the tional mandates of the different decentralized authority EHCVM 2018-19 data, almost 60% of public school levels constrains coordination and integrated urban students in Mali report teacher absenteeism as a planning. Some progress in this regard has already problem, versus 14% in private schools. Students in been made, with the District of Bamako’s Cellule de public schools also commonly cite a lack of teachers as Préconfiguration de l’Agence d’Urbanisme de Bamako suc- a problem. Similarly, among the most common prob- ceeding in getting the surrounding communes to sign lems faced by households when visiting a health facility up to more formalized arrangements for collaboration are long waiting times and lack of medicine, both more to plan the Bamako metropolitan area; however, the likely to be experienced in public facilities; the shortage coordination attempts so far have failed to materialize of health personnel at government health facilities is (World Bank, 2019b). similarly noted (Ataullahjan et al., 2020). 128 MOBILITY AND TRANSPORT CONNECTIVITY SERIES CONNECTIVITY FOR HUMAN CAPITAL 3.  Policy actions to improve accessibility Average accessibility to advanced healthcare facilities is infrastructure, an insufficient coverage of public trans- lower in Bamako than in many other cities, with travel port, the natural bottleneck that the Niger river poses time to the nearest facility more than twice exceeding and competition for public space – including road and the travel times in Kampala, Douala, Nairobi, and Con- sidewalk. Service delivery in Bamako is hindered also akry, even if average travel times to schools are more by institutional fragmentation and lack of metropolitan acceptable. However, in addition to the overall low aver- coordination, as well as institutional and fiscal capac- age accessibility to hospitals, Bamako is also character- ity at the local level (World Bank, 2019b). Finally, the ized by significant accessibility poverty pockets, espe- Bamako residents’ use of specific facilities, even if they cially in Commune VI and western Commune IV, as well are accessible, is hindered by quality issues. The rest of as on the city’s north-eastern outskirts. this Annex outlines a menu of policies that, if operation- alized, could improve accessibility for all in Bamako’s Urban accessibility in Bamako, as in other cities, is “functional city”. These range in complexity and poten- a product of the efficiency of the transport system tial impact from relatively straightforward improve- and the land use patterns. Specifically, it is limited by ments in infrastructure, to more complex, yet potential- its fragmented urban form, poor quality of the road ly much more impactful institutional changes. Figure 1.9: Policy menu for Bamako to improve accessibility to health and education services Figure 1.9: Policy menu for Bamako to improve accessibility to health and education services Data collection to inform policy and targeting To help identify pockets of land within the city that could be dedicated to strategically Identification of impactful and inclusive accessibility enhancing policies important infrastructure and facilities, the Bamako city should conduct an inventory would be enabled by data collection on the specific constraints faced by of public property holdings – land, administrative buildings and infrastructure. the most marginalized individuals and on their perceptions about the health and education sector facilities/services that drive use behaviors. Transport infrastructure and services Health and education facilities and housing Improvements to the pedestrian infrastructure, including in terms of Strategic land use preservation by the design that is friendly to people with disabilities. government for housing and essential services in Longer term Shorter term public transport-accessible areas will be key to ensure Longer term Shorter term Given the overwhelming dependence on motorbikes in Bamako’s that average accessibility to services does not motorized mobility, this mode should be allocated sufficient space in the deteriorate further as the population growth road network to allow them to operate safely. continues. Improvement of the overall quality of the public minibus services. To increase the currently low share of population living within walking distance from a secondary On-demand “ambulance taxi” services could be introduced to serve school, additional secondary schools should be remote neighborhoods where extending public transport services/ planned in residential areas or additional housing hospitals is not economically justified due to low population densities. options provided near schools that have spare student capacity. Alleviating congestion on specific corridors used by the SOTRAMA vehicles, such as the Sogoniko, the Kalabancoro, and the Banconi Densification of development in the core city, corridor, and expansion of the paved road network to incentivize the including through increased building heights, would transport service provision at a higher density and radius would improve have a significant impact on increasing accessibility to accessibility to hospitals and CSRef facilities located in central Bamako advanced health facilities, at least for the average for the populations currently facing travel times in excess of an hour. Bamako resident. Metropolitan scale institutions and coordination Quality and cost of services Addressing the cost of schooling and healthcare – e.g., implementing Longer Shorter Longer Shorter The operationalization of the metropolitan scale the reform package announced by the Mali government in 2019 that planning agency, bringing together transport, land would provide free healthcare to pregnant women and young children. use, and health/education facility planning, with direct feedback links to civil society/ service users. To address the “dual quality” system, the quality of services in public facilities should be improved through increasing staffing to reduce Addressing and market inefficiencies could have a wait times and incentives to reduce teacher absenteeism. transformative impact on accessibility to services. 129 REALIZING THE RIGHT TO EDUCATION AND HEALTHCARE THROUGH IMPROVED PUBLIC TRANSPORT IN AFRICAN CITIES Annex 2: Accessibility analysis and recommenda- tions for Ouagadougou, Burkina Faso respondents have at least one motorcycle/ scooter or 1.  Summary of findings: the categories car available to the household, it may not be available and the spatial lenses specifically for the transport of children to school or the To better understand the connectivity constraints faced school may simply be conveniently close to home. In by Ouagadougou residents for accessing key social contrast, only 6% use a car and less than 1% take public services and facilities, a field survey as part of this study transport. Nearly one in four respondents say that dis- was conducted in the city in June, 2020, altogether sur- tance/availability of transport is the main constraint or veying 2,086 individuals of whom about 13% are from among the main constraints for their children to attend households that earn less than CFA 50,000 (US$90) school. Thus, transport availability appears to be a per month and another 15% from households earn- slightly more common constraint for children to access ing between CFA 50,000 and 100,000. About 70% of all schooling than for the overall population to satisfy their respondents report not having any private cars owned regular medical needs. by their household; however, 93% have at least one motorcycle or scooter (even among the respondents Transport cost appears to be a less important obsta- belonging to the < CFA 50,000 households, 72% do, cle than transport availability/ distance in the ability of indicating that this is perceived by households to be an Ouagadougou’s residents to access healthcare services, absolute necessity to move around in the city). About with 16% of the respondents saying it is among the 82% of Ouagadougou’s households were estimated to main constraints. However, transport cost is among the own a motorcycle or scooter, and 66% - a bicycle – in a main constraints affecting children’s access to school- study conducted in 2018 (see Burkina Faso, 2018). ing for over one-fourth of Ouagadougou’s residents. Only about 3% of all respondents report traveling on Burkina Faso has a fast growing motorization rate, foot to get to a healthcare facility for regular medical especially in motorbikes, with 116 motorbikes per 1,000 needs, another 6% bike, and less than 2% use public residents (SSATP, 2020a). The country has a total of 2.5 bus or communal taxi. The vast majority of respon- million registered two-wheelers, and it is estimated that dents (71%) typically use a motorcycle or a scooter. two of every three trips are made by motorbikes. About Distance/availability of transport represent a major two-thirds of all motorized trips are made by motorcy- constraint to accessing healthcare for about a fifth cle, in contrast to other West African capital cities where of Ouagadougou’s residents, but exceeds one-third transport services are dominated by paratransit – among the lowest income group. moto-taxis, minibuses, and similar. Compared to many other major cities in the region, a much higher share About 35% report using a motorcycle or scooter for of mobility needs in Ouagadougou is also ensured the transport of their children to school, and another by biking, which accounts for about 10% of all trips 31% bike. Walking is also a common mode, reported (Olvera et al., 2012), and nearly half of all trips in the by 27% of the respondents (92% among the lowest city are made on foot, which underscores the impor- income households); while nearly nine-tenths of these tance of providing adequate and safe non-motorized 130 MOBILITY AND TRANSPORT CONNECTIVITY SERIES CONNECTIVITY FOR HUMAN CAPITAL transport infrastructure. Bus transport services are The spatial analysis suggests that, for the average res- provided by SOTRACO (Société de Transport en Commun ident of the “functional city” of Ouagadougou, near- de Ouagadougou). Bus ridership represents less than ly 57 minutes by SOTRACO bus to reach the nearest 1% of all trips, which can be explained by the sparsity of advanced healthcare facility (hospital or CMA), while the bus network, with only about 30 lines operating at reaching a hospital specifically requires an hour and a modest frequency of one bus every 20 or 30 minutes a half, on average, by far the longest among the ana- (up to two hours on individual routes). Moreover, the lyzed cities. Accessibility to hospitals and CMAs is low buses are overloaded and unreliable (Commune of – exceeding an hour or even three hours in some Ouagadougou, 2019). locations to reach either type of facility – everywhere outside the immediate city center, and the SOTRACO In the “functional city” of Ouagadougou, which spans an bus lines do not appear to provide any tangible acces- area of about 689 km2 and is home to about 3.56 mil- sibility benefits to the immediately surrounding neigh- lion people, there are 13 medical centers with a surgical borhoods, explained by the limited speeds and the antenna (CMA) and five hospitals, which together rep- yet more limited headways of the bus service on most resent the “advanced healthcare facilities”, in addition routes. In other words, one has to live next to a facility to 31 medical centers without surgical capabilities (CM), for it to be accessible, while living near a bus line, even and 56 basic health posts (CSPS). The 3rd arrondisse- if this line connects to a facility, does not make much ment concentrates the largest number of health estab- difference. All of Ouagadougou’s hospitals and nearly lishments (19), while the 12th only has 3. While the all of CMAs are located within direct walking distance to hospitals and most health centers are located in the at least one bus route; however, the transport services central part of Ouagadougou and appear relatively offered on these routes are extremely limited. Only 9% well-connected to the SOTRACO bus network, these of the city’s population lives within 15 minutes of a hos- types of facilities are comparatively absent in the more pital or a CMA (and only 5% from a hospital specifically), peripheral parts of the city, especially in the north and and this modest share appears to be almost entire- south-east corners. While the distribution of CSPSs is ly accounted for by the people who can reach these more balanced, many of these facilities are far removed facilities by walking less than a kilometer (7% and 2%, from the bus network. According to the National Health respectively). Policy published in 2011 (Ministère de la Sante, 2011), some progress has been made in reaching the policy A total of 1,204 primary schools (of which 282 are pub- goals defined in the earlier National Health Develop- lic) and 758 secondary schools (88 public) were located ment Plan 2001-2010: in urban areas, the ratio of pop- in the city. The average travel time, by public transport, ulation per one CSPS decreased from 14,177 to 9,835 to the nearest primary school and secondary school is between 2001 and 2009 (compared to the defined goal estimated about 11 minutes and 12 minutes, respec- of 10,000). However, the ratio is many times higher with tively, although accessing a public school takes consid- respect to any of the more advanced medical facilities erably longer – 18 minutes and 24 minutes, respective- (CM, CMA, hospitals). ly. While accessibility to schools is certainly better than to advanced healthcare facilities, significant parts of the 131 REALIZING THE RIGHT TO EDUCATION AND HEALTHCARE THROUGH IMPROVED PUBLIC TRANSPORT IN AFRICAN CITIES city on its edges, such as the south-eastern boundary, The differences in accessibility between the overall have travel times in excess of 45 minutes or even an population and the city’s poor are greater with respect hour. The value-added provided by the SOTRACO net- to healthcare facilities, especially the more advanced work for accessing primary schools is only about a min- ones (CHU, and CMA). Compared to the overall city ute of time savings, on average, which is intuitive given population of whom 18% can access a CHU within 45 that primary schools are widely available in the city and minutes of travel by bus, among the poor population about 84% of the population lives within a kilometer the share is only 10%. Similarly, for accessing CMAs, the of at least one (however, this share is below those in share of the poor able to access at least one within this Conakry, Douala, and Nairobi). The presence of sec- time threshold is only 22%, compared to 34% among ondary schools locally in residential neighborhoods is all city residents combined. Either a hospital or a CMA is almost as high (81%); however, only slightly more than accessible within 45 minutes for one-fourth of the city’s a quarter Ouagadougou’s residents live within close poor, compared to 37% of the overall population. In walking distance of a public secondary school specifical- contrast, when it comes to lower-level healthcare facili- ly. For those who cannot easily walk to a school, relying ties (CSPS), accessibility for the poor by bus appears to on the bus network may not be feasible, either, as only be the same as for the overall population. With respect 57% of primary schools and 59% of secondary schools to school access, differences in accessibility compared are directly accessible from a bus line; especially in the to the overall city population emerge at the secondary northern and south-western corners of the city, numer- school level, where 56% of the city’s poor are estimat- ous schools are not connected to the bus network, in ed to be able to access at least one public secondary addition to the bus service typically being available only school within half hour of travel by bus, compared to a couple of times an hour. 60% among the overall population. These accessibility differences vis-à-vis the overall population appear to be The sparse bus network of Ouagadougou appears mostly driven by the absence of advanced healthcare to reach the poorest parts of the city equally well, facilities and sparsity of public secondary schools in the although its effectiveness in terms of ensuring acces- secteurs of the city where the poverty incidence and/or sibility to health and education facilities is also nearly the density of the poor per area is high. equally low. 132 MOBILITY AND TRANSPORT CONNECTIVITY SERIES CONNECTIVITY FOR HUMAN CAPITAL Figure 2.1: Locations and travel time by public transport to nearest facility Locations of Hospitals, CMA, CM, and CSPS Travel time to a Hospital, CMA, CM or CSPS Travel time to a Hospital or CMA Travel time to a Hospital 133 REALIZING THE RIGHT TO EDUCATION AND HEALTHCARE THROUGH IMPROVED PUBLIC TRANSPORT IN AFRICAN CITIES Figure 2.2: Locations and travel time by public transport to nearest primary and secondary school Locations of primary schools Locations of secondary schools Travel time to nearest primary school Travel time to nearest secondary school 134 MOBILITY AND TRANSPORT CONNECTIVITY SERIES CONNECTIVITY FOR HUMAN CAPITAL Figure 2.3: Inequality in accessibility: cumulative population share able to access the nearest facility by public transport 100% Secondary sch. (public) 90% 80% Secondary sch. 70% Primary sch. (public) Share of population 60% Primary sch. 50% 40% Hospital 30% Hospital + CMA 20% Hospital + CMA + CM 10% + CSPS 0% 5 10 15 20 25 30 35 40 45 50 55 60 Travel time (minutes) A staggering two-thirds of Ouagadougou’s population this share is relatively low, it does not reflect the very are characterized by “accessibility poverty” for access- limited school choice that is also present, especially ing hospitals (over an hour of travel time by public with respect to secondary schools: in several city sec- transport), while 38% of the city’s population cannot teurs, only one or a couple of schools are accessible reach neither a hospital, nor a CMA within this time within the 30-minute threshold to the average resi- threshold. The share of accessibility poor to primary dent, which means that children in reality likely have to schools and secondary schools – defined as those who travel longer to reach a school of satisfactory quality or face travel time in excess of half an hour one way by specific religious affiliation or a school that is affordable public transport – is 5% in both cases. However, while (public rather than private). Figure 2.4: Public primary and secondary schools accessible to the average secteur resident by bus within 30 minutestransport Public primary schools accessible from each secteur Public secondary schools accessible from each secteur 135 REALIZING THE RIGHT TO EDUCATION AND HEALTHCARE THROUGH IMPROVED PUBLIC TRANSPORT IN AFRICAN CITIES 2.  Explaining the findings 2.1.  Transport efficiency While the identified accessibility patterns are influenced Figure 2.5: Public transport and paved road networks to some extent by the public transport route allocation across the city, the accessibility benefits the bus system provides are very limited. As already mentioned, near- ly all of the advanced medical facilities are connected to a bus route despite being a relatively low-frequency destination; however, this immediate proximity to bus service does not translate into accessibility gains. This is intuitive given the very limited speeds on some routes, as low as 11-15 km/h on SOTRACO lines 6 and 16 which connect Naaba Koom in the city center to Termi- nus Koulw Toghin (north, half way between city cen- ter and the city boundary) and Terminus Eau Maman (near the north-western edge of the city), respectively. Moreover, the headways on line 16 is reported at 140 Source: Road network data from Global Road Inventory Project (GRIP) 2018; minutes, which means that the residents of the entire World Pop population data (2020) north-western quadrant of Ouagadougou are served by a single route that can accommodate the needs of at most 50-80 people every 2.5 hours. Headways on Even more so than in Bamako, the paved road network the bus network are an hour or more on many of the in Ouagadougou is extremely sparse, limited to seven routes in the city’s central and northern part; however, radial national-importance roads. Based on the Global also the most frequent bus service across the entire Road Inventory Project (GRIP) 2018 data, which indi- network – on routes traveling from the city center east cates that there are 359 km of paved roads within the and south-east – is only available every 25-30 min- “functional city” of Ouagadougou, the estimated paved utes, which means that the buses that do arrive are road density is thus only 0.52 km per km2 of area, overcrowded. which is well below the level in Bamako (estimated at 0.8 km in 2008) and only about a quarter of the level in These spatial patterns in bus transport service availabil- Accra, Douala, Conakry, and Abidjan. The existing bus ity help explain the findings from the household survey transport is limited almost entirely to this paved net- implemented in Ouagadougou in June 2020, which work, and even neighborhoods that are relatively cen- suggested that, at the level of the individual arrondisse- tral and have population densities that are moderate ments of the respondents’ home locations, Nr. 9 locat- to high by Ouagadougou standards do not have direct ed on the north-western edge of the city stands out access to a paved road. as having a particularly high share of residents who perceive transport availability/ distance as a major con- straint for both attending to regular medical needs and also for children’s schooling. 136 MOBILITY AND TRANSPORT CONNECTIVITY SERIES CONNECTIVITY FOR HUMAN CAPITAL Figure 2.6: Transport networks and the Ouagadougou This sparsity increases congestion on the roads that do Department boundary exist, reducing travel times for private modes – motor- cycles and cars – as well. Traffic in Ouagadougou is estimated to have increased by a staggering 125% just between 2014 and 2016. Recent analysis conducted for a regional report on urbanization in the Sahel region found that inland capitals, including Ouagadougou, would be the biggest gainers from investments to relieve present transportation bottlenecks across West Africa (see World Bank, 2018). The increased conges- tion appears to be associated with reduced overall mobility rather than longer commutes: the number of daily trips per person in Ouagadougou, at 3.8, is well below the averages in Douala (4.6) and Niamey (4.4), and 43% of the residents surveyed had either not trav- Source: Road data from Global Road Inventory Project 2018 elled at all or only by walking on the previous day (see Diaz et al., 2013). While in cities dominated by informal public transport (minibuses) the limitation of the service to paved roads can be attributed to the private operators’ lack of incen- 2.2.  Land use and city form tives to operate their vehicles in sub-standard road con- ditions, this explanation is less relevant for Ouagadou- Another driver of the limited accessibility, especially gou, where the bus system is not run by a private firm.96 to advanced healthcare facilities and for the city res- idents who live in the outlying secteurs, is the urban The limitations of the road network and the bus system form of Ouagadougou and its evolution over time. have to also be seen in light of the somewhat limited Ouagadougou is growing at a staggering 9% annu- span of the Ouagadougou administrative jurisdiction, ally, with associated challenges to efficient mobility. which does not cover the entirety of the “functional city” Ouagadougou almost tripled its built-up area between (the de facto metropolitan area). However, also within 1983 and 2005, according to Schéma Directeur du the boundaries of the Ouagadougou Department the Grand Ouagadougou of 2008, expanding in the form transport network is nearly equally sparse. The limited of urban sprawl and informal housing development in radial road network is highly saturated also because of the periphery. As a result, travel demand is increasing the historical structure of the city and its layout, whereby rapidly: the flow of people moving into and out of the populations living in the periphery have to travel all the city center each day was estimated to have reached way to the city center to access the highly concentrated 1 million in 2014 and is expected to double by 2030, economic opportunities and administrative buildings. while the length of trips will also increase. 96 SOTRACO was established in 2003 by the State of Burkina Faso, the Municipality of Ouagadougou and private operators. 137 REALIZING THE RIGHT TO EDUCATION AND HEALTHCARE THROUGH IMPROVED PUBLIC TRANSPORT IN AFRICAN CITIES Figure 2.7: Increase in the built settlements in and As was identified in the regional study by Lall et al. around Ouagadougou metropolitan area, 2001-2019 (2017), Ouagadougou, similarly to many African cities, is characterized by disconnectedness, spatial disper- sion, and the so-called leapfrog outward development, whereby new, previously disconnected neighbour- hoods are absorbed by the growing sprawling city while new development near the center is lacking. In the decade between 2000 and 2010, leapfrog devel- opment accounted for nearly 40% of Ouagadougou’s overall expansion, an increase compared to the pre- vious decade and much above the shares of leapfrog development observed in many other major African cities. Given Ouagadougou’s rapid population growth, which adds over a quarter million residents annually, the demand for urban land in the broader metropolitan area will continue to grow. Based on the global built settlement spatial data, As a result of the outward sprawl during the last few the built-up land area in the Centre region in which decades, already today the average population den- Ouagadougou is located increased by about 77% sity of the Ouagadougou metropolitan area is low, at between 2001 and 2019, with many of the newly built- only about 5,200 inhabitants per square-kilometer, up areas located along the few paved roads. Beyond which is half of the average density of Douala and the boundaries of Centre, significant new develop- Kampala. Moreover, as was illustrated in Figure 2.5, ment in the two decades emerged around nearby Ouagadougou lacks a distinct density gradient or peak towns such as Loumbila and Ziniare to the northeast even in its very center. This lack of density articulation and Kombissiri to the southeast. The most densifica- implies that providing public services is costly, as any tion within the Ouagadougou Department boundaries given facility or transport link directly serves only a happened along its western boundaries, corresponding limited number of people. For example, only 7% of the to the secteurs with the highest poverty incidence and city’s population lives within a kilometer of an advanced the lowest accessibility to advanced healthcare facilities, healthcare facility (hospital or CMA) – in contrast to over while nearly no increase in built settlement area took 50% in most of the other analyzed cities – and any addi- place in the city center. tional facilities or bus routes to be located in parts of the city where they are currently lacking would, similar- ly, serve only a limited population in their direct vicinity. 138 MOBILITY AND TRANSPORT CONNECTIVITY SERIES CONNECTIVITY FOR HUMAN CAPITAL 3.  Policy actions to improve accessibility Accessibility to advanced healthcare facilities – not planning at the metropolitan scale to ensure that future only hospitals but also advanced medical centers and population growth is channeled into areas that are – or even more regular health facilities – is much lower in that could be – served by efficient public transport or Ouagadougou than in any other of the cities analyzed that surround existing or potential new health facilities. in this report. In addition, large parts of the city’s west- Institutional coordination between, on the one hand, ern and south-eastern secteurs are characterized by transport and housing sectors and, on the other hand, extreme accessibility poverty, with over two hours of the health sector will be essential to ensure that any travel by bus required to reach any type of advanced new health facilities that are built are served by cur- healthcare facility. rent or potential new bus service or are located directly within rapidly densifying neighborhoods, such as on the In recent years, substantial investments in the road net- city’s western periphery. work have been made in Ouagadougou to improve traf- fic conditions. The city’s bypass project is also expected Improving accessibility to schools could be achieved to shift transiting traffic away from city roads. However, through targeted siting of a few additional school given motorization dynamics, the new infrastructures facilities in the (relatively limited) areas currently char- will not resolve congestion problems in Ouagadougou. acterized by excessive travel times or through the To optimize public spending, a multimodal mobility provision of school bus services to allow the children strategy is needed (SSATP, 2020a). Moreover, both living in these areas to reach the existing school facil- the transport system – infrastructure and, especially, ities within a reasonable travel time. Considering the transport services – and land use planning have to be importance of biking, walking, and motorcycle transport addressed in order to improve the currently low acces- in Ouagadougou’s mobility, especially of the poorest sibility to healthcare opportunities. While the accessi- residents, investments in NMT infrastructure and safe bility landscape is considerably better with respect to space for motorcycles in on the existing road network schools, targeted interventions are needed to eliminate would help improve accessibility to both health and the poverty accessibility pockets that remain or that education facilities for many of the most vulnerable res- may be created if residential development continues in idents. In particular, well-lit and safe pedestrian infra- the form of unabated outward sprawl rather be con- structure is essential to improve the safety of girls while centrated near the existing school facilities and the en route to school. transport network. As proposed in SSATP (2020a), a Transport Council for As alluded to before, improving accessibility to the Greater Ouagadougou metropolitan area should advanced healthcare opportunities will require more be created to bring together the city of Ouagadougou fundamental and costly improvements in the city’s and the seven neighboring municipalities and thus transport system and strategic changes in land use ensure efficient, metropolitan scale transport and urban planning. 139 REALIZING THE RIGHT TO EDUCATION AND HEALTHCARE THROUGH IMPROVED PUBLIC TRANSPORT IN AFRICAN CITIES Figure 2.8: Figure 2.8: Policy menu for Policy menu for Ouagadougou to improve accessibility to health and education services Ouagadougou to improve accessibility to health and education services Data collection to inform policy and targeting To help identify pockets of land within the city that could be dedicated to strategically important infrastructure and facilities, the Bamako city should conduct an inventory of public property holdings – land, administrative buildings and infrastructure. Transport infrastructure and services Health and education facilities and housing Improvements to the non-motorized infrastructure Strategic land use preservation by the government for (pedestrian and bicycle), including in terms of design that is housing and essential services in public transport-accessible Longer term Shorter term friendly to people with disabilities. areas will be key to ensure that average accessibility to services Longer term Shorter term does not deteriorate further as the population growth continues. Allocation of dedicated, safe space to motorbikes in the existing road network and development of schemes that To increase the share of population living within walking promote environmentally friendly motorbike technologies distance from schools, additional school facilities, especially (e.g., e-bikes) to reduce the pollution impact of the rapidly public secondary schools, could be planned in the rapidly growing fleet. growing residential areas or additional housing options provided near schools that have spare student capacity. On-demand “ambulance taxi” services and school bus service could be introduced to serve remote neighborhoods An additional hospital or CMA should be planned in the rapidly where extending public transport services or building new growing western periphery of the city, where currently none are facilities is not economically justified due to low population available and where further growth in demand can be densities. anticipated. Significantly expanding bus services (frequency and Significant densification of development in the core city or speed) on the seven arterial roads connecting the peripheral in new centralities that are well served by the transport areas to the advanced healthcare facilities in the city center. network would have improve the average accessibility to advanced health facilities. Metropolitan scale and inter-sectoral coordination Quality and cost of services Building on the Observatory for Urban Movement established by the Commune of Ouagadougou, the development of metropolitan scale planning agency or The cost of schooling and healthcare needs to be addressed and the forum that collects detailed data on the accessibility challenges in the city, brings quality of the schooling offered in public schools in particular should be together infrastructure and human development sector stakeholders, and has a improved to reach the most marginalized groups in terms of income. direct feedback link to the intended service users. 100 140 MOBILITY AND TRANSPORT CONNECTIVITY SERIES CONNECTIVITY FOR HUMAN CAPITAL References Abt Associates In. (2018). RAPPORT DE LA CARTOGRAPHIE Barrett, P., A. Treves, T. Shmis, D. Ambasz, and M. Ustinova. DES STRUCTURES PRIVEES DE SANTE DE LA VILLE DE (2019). The Impact of School Infrastructure on Learning: CONAKRY - RAPPORT FINAL. Prepared for USAID Health A Synthesis of the Evidence. Development in Focus, World Finance & Governance Project. Rockville, MD. Bank, Washington, DC. African Development Bank, the United Nations, and the World Basu, J., Friedman, B. (2001). Preventable illness and out-of- Bank. (2019). Joint Needs Assessment for Zimbabwe (JNA). area travel of children in New York counties. Health Econ, 10:67-78. American Public Transport Association. (2005). Safe, Accountable, Flexible, Efficient Equity Act, A Legacy for Betts, J. (2007). Transport and social disadvantage in Victoria: Users: A Guide to Transit-Related Provisions. a government perspective. In: Currie, G., Stanley, J., Stanley, J. (Eds.), No Way to Go: Transport and Social Arcury, T.A., J.S. Preisser, W.M. Gesler, J.M. Powers. (2005). Disadvantage in Australian Communities. Monash Access to Transportation and Health Care Utilization in a University Press. Rural Region. J Rural Health, 21(1), 31-38. doi: 10.1111/ j.1748-0361.2005.tb00059.x. Bhutta, Z.A, Das, J.K., Bahl, R. et al. (2014). Can available interventions end preventable deaths in mothers, new- Asahi, K. (2014). The Impact of Better School Accessibility on born babies, and stillbirths, and at what cost? Lancet; Student Outcomes. SERC Discussion Paper 156. Spatial 384:347–70. Economics Research Centre, March. Brabyn, L., Skelly, C. (2002). Modeling population access to Asim, S., R. S. Chase, A. Dar, and A. Schmillen. (2015). New Zealand public hospitals. International Journal of “Improving Education Outcomes in South Asia: Findings Health Geographics 1, 1–9. from a Decade of Impact Evaluations.” Policy Research Working Papers 73622015, The World Bank, Washington, Buchmueller, T.C., Jacobson, M., Wold, C. (2006). How far to DC. the hospital? The effect of hospital closures on access to care. J. of Health Economics 25, 740–761. Ataullahjan, A., M. F. Gaffey, M. Tounkara, S. Diarra, S. Doumbia, Z. A. Bhutta, and D. G. Bassani. (2020). C’est Burkina Faso. (2018). Enquête sur les Indicateurs du vraiment compliqué: A case study on the delivery of Paludisme (EIPBF) 2017-2018. December. maternal and child health and nutrition interventions in Burkina Faso. (2010). Enquête Démographique et de Santé et the conflict-affected regions of Mali. Conflict and Health à Indicateurs Multiples (EDSBF-MICS IV). 14 (36). Cervero, R. (2004). Job isolation in the US: narrowing the gap Athas, W.F., Adams-Cameron, M., Hunt, W.C., Amir-Fazli, A., through job access and reverse-commute programs. Key, C.R. (2000). Travel distance to radiation therapy and In: Lucas, K. (Ed.), Running on Empty: Transport, Social receipt of radiotherapy following breast-conserving sur- Exclusion and Environmental Justice. The Policy Press, gery. J Natl Cancer Inst, 92:269-71. Bristol, pp. 181–196. Badland, H., S. Mavoa, K. Villanueva, R. Roberts, M. Davern, Chang, H., Liao, C. (2011). Exploring an integrated method for and B. Gilles-Corti. (2015). The development of policy-rel- measuring the relative spatial equity in public facilities in evant transport indicators to monitor health behaviours the context of urban parks. Cities 28, 361–371. and outcomes. J. of Transp. & Health, 2(2), 103-110. Church, A., M. Frost, K. Sullivan. (2000). Transport and social Bambra, C., M. Gibson, A. Snowden, K. Wright, M. Whitehead, exclusion in London. Transport Policy 7, 195-205. and M. Petticrew. (2009). Tackling the wider social deter- minants of health and health inequalities: evidence from Cidade de Maputo. (2013). MAPA SANITÁRIO: systematic reviews. J Epidemiol Community Health, 64: CARACTERIZAÇÃO DO SISTEMA DE PRESTAÇÃO DE 284-291. SERVIÇOS DE SAÚDE. Municipio de Maputo Conselho Municipal, May. 141 REALIZING THE RIGHT TO EDUCATION AND HEALTHCARE THROUGH IMPROVED PUBLIC TRANSPORT IN AFRICAN CITIES Comité de Conselheiros. (2003). Agenda 2025 - Nation’s Esri Rwanda Ltd. (2019). Road and Public Transport Vision and Strategies. November. Accessibility Study in Rwanda. Commune of Ouagadougou. (2019). Ouagadougou Public Falch, T., P. Lujala, and B. Strøm. (2013). Geographical Transport Implementation Study (OPTIS): Terms of Constraints and Educational Attainment. Regional Science Reference. June. and Urban Economics 43 (1): 164–76. Commune de Ouagadougou. (2018). Rapport Provisoire Farber, S., Morang, M.Z.,Widener, M.J. (2014). Temporal vari- Etude OD. ability in transit-based accessibility to supermarkets. Appl. Geogr. 53, 149–159. Conseil National de Prospective et de Planification Stratégique. (2005). Etude Nationale Prospective Burkina Filmer, D. (2003). Determinants of Health and Education 2025. Outcomes. Background Note for World Development Report 2004: Making Services Work for Poor People. World Currie, G., Stanley, J., Stanley, J. (Eds.) (2007). No Way to Bank, Washington, DC. Go – Transport and Social Disadvantage in Australian Communities. Monash Univesity ePress, Melbourne, Flores, G., et al. (1998). Access Barriers to Health Care for Australia. Latino Children. Archives of Pediatric and Adolescent Medicine, 152, p. 1119-1125. Deakin, E. (2007). Equity and Environmental Justice in Sustainable Transportation: Toward a Research Agenda. Fortney, J., Rost, K., Zhang, M., Warren, J. (1999). The impact University of California Transportation Centre, Berkeley. of geographic accessibility on the intensity and quality of depression treatment. Med Care, 37:884-93. Delbosc, A. and G. Currie. (2011a). The spatial context of transport disadvantage, social exclusion and well-being. J. Fournier, P.A.D., C. Tourigny, G. Dunkley & S. Dramé. (2009). of Transp. Geogr., 19, 1130-1137. Improved access to comprehensive emergency obstetric care and its effect on institutional maternal mortality in Delbosc, A. and G. Currie. (2011b). Using Lorenz curves to rural Mali Bull World Health Organization; 87: 30-8. assess public transport equity. J. of Transport Geography, 19, 1252-59. Foth, N., K. Manaugh, A.M. El-Geneidy. (2013). Towards equita- ble transit: examining transit accessibility and social need Delmelle, E.C., I. Casas. (2012). Evaluating the spatial equi- in Toronto, Canada, 1996–2006. Journal of Transport ty of bus rapid transit-based accessibility patterns in a Geography, 29, 1-10. developing country: The case of Cali, Colombia. Transport Policy, 20, 36-46. Fransen, K., T. Neutens, S. Farber, P. de Maeyer, G. Deruyter, and F. Witlox. (2015). Identifying public transport gaps Department of the Environment, Transport and the Regions. using time-dependent accessibility levels. Journal of (2000). Women and Public Transport: The Checklist, DETR, Transport Geography, 48, 176-187. London. Geurs, K., Van Wee, B. (2004). Accessibility evaluation of land- Diaz, L., O., Plat, D., Pochet, P. (2013). The puzzle of mobility use and transport strategies: review and research direc- and access to the city in Sub-Saharan Africa. Journal of tions. Journal of Transport Geography 12, 127–140. Transport Geography. Golub, A., Martens, K. (2014). Using principles of justice to Dickerson, A. and S. McIntosh. (2013). The Impact of Distance assess the modal equity of regional transportation plans. to Nearest Education Institution on the Post-Compulsory Journal of Transport Geography, 41, 10-20. Education Participation Decision. Urban Studies 50 (4): 742–58. Goodman, S., BenYishay, A., Lv, Z., & Runfola, D. (2019). GeoQuery: Integrating HPC systems and public web- Douala Urban Council. (2010). Agenda Douala 2021. based geospatial data tools. Computers & Geosciences, Earth Observation for Sustainable Development. (2019). 122, 103-112. EO4SD-Urban Project: Bamako City Report. 142 MOBILITY AND TRANSPORT CONNECTIVITY SERIES CONNECTIVITY FOR HUMAN CAPITAL Government of Burkina Faso. (2016). Plan National de Human Rights Watch. (2020a). Their War Against Education, Développement Economique et Social (PNDES) May 26, 2020. 2016-2020. Human Rights Watch. (2020b). World Report, 2020, Government of Cameroon. (2009). Document de la Strategie Cameroon. pour la Croissance et l’Emploi. Human Rights Watch. (2020c). Targeted for Going to School, Government of Mozambique. (2020). Five Year Program March 12, 2020. 2020-2024. Human Rights Watch. (2020d). Cameroon Should Investigate Government of Mozambique. (2015). National Strategy for Distribution of Health Fund, June 12. Basic Social Security 2016-2024. Human Rights Watch. (2020e). World Report, 2020, Government of Mozambique. (2014). National Development Mozambique. Strategy 2015-2035. Human Rights Watch. (2019a). Annual report, Zimbabwe. Government of Mozambique. (2013). Health Sector Strategic Human Rights Watch. (2019b). World Report 2019, Tanzania. Plan PESS 2014-2019. Human Rights Watch. (2019c). Education Barriers to Children Government of Mozambique. (2011). Action Plan for Poverty with Albinism, June 13. Reduction 2011-2014. Human Rights Watch. (2019d). Mozambique: Education Government of the Republic of Kenya. (2008). Nairobi Metro Barriers for Children with Albinism, June 13. 2030: A World Class African Metropolis. Ministry of Nairobi Metropolitan Development. Human Rights Watch. (2014). Submission regarding Uganda’s ICESR session, 2014. Government of the Republic of Kenya. (2007). Vision 2030. Instituto Nacional de Estatística. (2013). MOÇAMBIQUE Guest Editorial. (2012). Social impacts and equity issues in Inquérito Demográfico e de Saúde 2011. transport: an introduction. J. of Transport Geography, 21, 1-3. ITF. (2019). Benchmarking Accessibility in Cities: Measuring the Impact of Proximity and Transport Performance. Guidry, J.J., L.A. Aday, D. Zhang, and R.J. Winn. (1997). International Transport Forum. Transportation as a Barrier to Cancer Treatment. Cancer Practice, 5(6), 361-6. JICA. (2014a). Integrated Urban Development Master Plan for the City of Nairobi. Japan International Co-operation Guagliardo, M. (2004). Spatial accessibility of primary care: Agency. concepts, methods, and challenges. International J. of Health Geographics 3, 1–13. JICA. (2014b). Comprehensive Urban Transport Master Plan for the Greater Maputo. Japan International Co-operation Hanson, S., & Schwab, M. (1995). Describing disaggregate Agency. March. flows: Individual and household activity patterns. In S. Hanson (Ed.), The geography of urban transportation JICA. (2012). Data Collection Survey on Health Sector. Japan (2nd ed., pp. 166-187). International Co-operation Agency. Hardon, A.P., Akurut, D., Comoro, C., Ekezie, C., Irunde, H.F., JICA. (2008). Dar es Salaam Transport Policy and System Gerrits, T., et al. (2007). Hunger, waiting time and trans- Development Master Plan. Final Report. Prepared port costs: Time to confront challenges to ART adherence for Dar es Salaam City Council by Japan International in Africa. AIDS Care, 19(5), 658–665. Co-operation Agency. June. Hine, J., Grieco, M. (2003). Scatters and clusters in time and Jones, P., K. Lucas. (2012). The social consequences of trans- space: implications for delivering integrated and inclusive port decision-making: clarifying concepts, synthesising transport. Transp. Policy 10, 299–306. knowledge and assessing implications. J. of Transp. Geography, 21, 4-16. 143 REALIZING THE RIGHT TO EDUCATION AND HEALTHCARE THROUGH IMPROVED PUBLIC TRANSPORT IN AFRICAN CITIES Jones, S., M. Tefe, S. Zephaniah, E. Tedla, S. Appiah-Opoku, and Lankowski, A.J., M.J. Siedner, D.R. Bangsberg, and A.C. Tsai. J. Walsh. (2016). Public transport and health outcomes (2014). Impact of Geographic and Transportation-Related in rural sub-Saharan Africa – A synthesis of professional Barriers on HIV Outcomes in Sub-Saharan Africa: A opinion. J. of Transport & Health, 3, 211-219. Systematic Review. AIDS and Behavior, 18, 1199-1223. Kaplan, S., D. Popoks, C.G. Prato, A. Ceder. (2014). Using Ledant, M. (2013). Water in Nairobi: Unveiling inequalities and connectivity for measuring equity in transit provision. J. of its causes. Les Cahiers d’Outre-Mer 263, 289-392. Transport Geography, 37, 82-92. Litman, T. (2007). Evaluating Transportation Equity: Guidance Karra, M., G. Fink, and D. Cumming. (2017). Facility distance for Incorporating Distributional Impacts in Transportation and child mortality: a multicountry study of health facility Planning. Victoria Transport Policy Institute. access, service utilization, and child health outcomes. Lorenz, M.O. (1905). Methods of measuring the concentra- International Journal of Epidemiology, 817–826 tion of wealth. Publications of the American Statistical KCCA. (2020). Kampala Capital City Strategic Plan 2020/21- Association 9, 209–219. 2024/25. Kampala Capital City Authority. Lucas, K., (2012). Transport and social exclusion: where are we KCCA. (2014). Strategic Plan 2014/15 – 2018/19. Kampala now? Transport Policy 20, 105–113. Capital City Authority. Lucas, K. (2011). Making the connections between transport Kelley, E.M., G. Lane, D. Schoenholzer. (2019). The Impact of disadvantage and the social exclusion of low income pop- Monitoring Technologies on Contracts and Employee ulations in the Tshwane Region of South Africa. J. Transp. Behavior: Experimental Evidence from Kenya’s Transit Geogr. 19, 1320–1334. Industry. University of California, Berkeley. Luo, W., Wang, F. (2003). Measures of spatial accessibility to Kenya National Bureau of Statistics. (2015). Demographic and health care in a GIS environment: synthesis and a case Health Survey 2015. study in the Chicago region. Environment and Planning B 30, 865–884. Khan, A.A. (1992). An integrated approach to measuring potential spatial access to health care services. Socio- Lynch, K. (1981). A theory of good city form. Cambridge, MA: Economic Planning Sciences, 26(4): 275-287. MIT Press. Klopp, J.M., C. Cavoli. (2019). Mapping minibuses in Maputo Ma, T., Jan-Knaap, G. (2014). Analyzing employment acces- and Nairobi: engaging paratransit in transportation plan- sibility in a multimodal network using GTFS: a demon- ning in African cities, Transport Reviews 39(4), 657-76. stration of the purple line, Maryland. The Association of Collegiate Schools of Planning (ACSP) Annual Conference, Kneeling, D. (2008). Latin America’s transportation conun- Philadelphia, Pennsylvania. drum. Journal of Latin American Geography 7, 133–154. Martens, K. (2012). Justice in transport as justice in accessibil- Kuépié, M. (2016). Determinants of labour market gender ity: applying Walzer’s ‘Spheres of Justice’ to the transport inequalities in Cameroon, Senegal and Mali: The role of sector. Transportation 39 (6), 1035–1053. human capital and fertility burden. Canadian Journal of Development Studies 37 (1): 66-82. Martens, K., Golub, A., Robinson, G. (2012). A justice-theoretic approach to the distribution of transportation benefits: Krueger, Alan B., and Diane M. Whitmore. (2001). The Effect implications for transportation planning practice in the of Attending a Small Class in the Early Grades on College- United States. Transportation Research Part A: Policy and Test Taking and Middle School Test Results: Evidence Practice 46, 684–695. from Project Star. The Economic Journal 111 (468): 1–28. Ministère de l’Enseignement de Base et de l’Alphabétisation. Kumar, A., F. Barrett. (2008). Stuck in Traffic: Urban transport (2012). Programme de Développement Stratégique de in Africa. World Bank, Washington, DC. l’Education de Base (PDSEB) Période : 2012-2021. Lall, S.V., J.V. Handerson, A.J. Venables. (2017). Africa’s Cities: Opening Doors to the World. World Bank, Washington, DC. 144 MOBILITY AND TRANSPORT CONNECTIVITY SERIES CONNECTIVITY FOR HUMAN CAPITAL Ministère de l’Habitat et de l’Urbanisme. (2008). Politique Nairobi City County Government. (2015). Non Motorized Nationale de l’Habitat et du Développement Urbain. Transport Policy: Towards NMT as the Mode of Choice. March. March. Ministère de la Sante. (2011). Politique Nationale de Sante. Nattinger, A.B., Kneusel, R.T., Hoffmann, R.G., Gilligan, M.A. (2001). Relationship of distance from a radiography facil- Ministère de la Sante. (2001). Plan National de ity and initial breast cancer treatment. J Natl Cancer Inst, Developpement Sanitaire 2001-2010. 93(17):1344-1346. Ministères en Charge de l’Education. (2013). Programme Olvera, L., Plat, D. and Pochet. P. (2012). Mobilité et accès à la Sectoriel de l’Education et de la Formation (PSEF) 2012- ville en Afrique Subsaharienne. 2021. February. Owen, D., T. Hogarth, A.E. Green. (2012). Skills, transport and Ministry of Economy and Finance. (2019). Cadre Stratégique economic development: evidence from a rural area in pour la Relance Économique et le Développement England. Journal of Transport Geography 21, 80-92. Durable. May. Owen, A., Levinson, D.M. (2014). Modeling the commute mode Ministry of Economy, Planning and Regional Development share of transit using continuous accessibility to jobs. (2009). [Cameroon] Vision 2035. 93rd Annual Meeting of the Transportation Research Ministry of Land and Physical Planning. (2015). National Board, Washington D.C. Spatial Plan (2015-2045). Parkhurst, J.O., Ssengooba, F. (2009). Assessing access barri- Ministry of Public Health. (2016a). Stratégie Sectorielle de ers to maternal health care: measuring bypassing to iden- Santé 2016 – 2027. tify health centre needs in rural Uganda. Health Policy Planning; 24(5): 377-84. Ministry of Public Health. (2016b). Plan National de Développement Sanitaire PNDS 2016-2020. Parliament of Zimbabwe. (2002). Roads Act. Ch. 13: 18 Mitullah, W.V., R. Opiyo, P. Asingo. (2013). Planning, infrastruc- Penchansky, R., Thomas, J.W. (1981). The concept of access: ture and travel patterns among pedestrians, cyclists and definition and relationship to consumer satisfaction. handcart pushers in Nairobi City County, Kenya, Working Medical Care, 19(2):127-140. draft. Peralta-Quiros, T., Kerzhner, T., Avner, P. (2019). Exploring Morris, E.A. (2011). Access and Outcomes: Transportation, Accessibility to Employment Opportunities in African Location, and Subjective Well-Being. University of Cities: A first benchmark. Policy Research Working Paper California Transportation Center UCTC Dissertation 8971, World Bank, Washington, DC. UCTC-DISS-2011-07. Pesata, V., G. Pallija, and A.A. Webb. (1999). A Descriptive Mshana, G.H., Wamoyi, J., Busza, J., Zaba, B., Changalucha, J., Study of Missed Appointments: Families’ Perceptions of Kaluvya, S., et al. (2006). Barriers to accessing antiretrovi- Barriers to Care. J Pediatr Health Care, 13(4), 178-82. ral therapy in Kisesa, Tanzania: A qualitative study of early Petrosino, A., C. Morgan, T. A. Fronius, E. E. Tanner-Smith, and rural referrals to the national program. AIDS Patient Care R. F. Boruch. (2012). “Interventions in Developing Nations and STDs, 20(9), 649–657. for Improving Primary and Secondary School Enrollment Murray, A., Davis, R. (2001). Equity in regional service provi- of Children: A Systematic Review.” Campbell Systematic sion. Journal of Regional Science 41, 557–600. Reviews 2012: 19. Mucunguzi, S., H. Wamani, P. Lochoro, and T. Tylleskar. Porter, G., Hampshire, K., Abane, A., Munthali, A., Robson, (2014). Effects of Improved Access to Transportation on E., Mashiri, M., Tanle, A., Maponya, G., Dube, S. (2012). Emergency obstetric Care Outcomes in Uganda. African Child porterage and Africa’s transport Gap: evidence Journal of Reproductive Health. 18(3): 87. from Ghana, Malawi and South Africa. World Dev. 40, 2136–2154. 145 REALIZING THE RIGHT TO EDUCATION AND HEALTHCARE THROUGH IMPROVED PUBLIC TRANSPORT IN AFRICAN CITIES Probst, J.C., S.B. Laditka, J.-Y. Wang, and A.O. Johnson. (2007). Republic of Zimbabwe. (2016b). Demographic and Health Effects of residence and race on burden of travel for Survey 2015. Zimbabwe National Statistics Agency and care: cross sectional analysis of the 2001 US National ICF International. Household Travel Survey. BMC Health Services Research, Republique de Guinee. (2019a). Plan de Déplacements 7:40. Urbains de Conakry. January. Pucher, J., Renne, J.L. (2005). Rural mobility and mode choice. Republique de Guinee. (2019b). Programme Décennal de Evidence from the 2001 National Household Travel l’Education en Guinée ProDEG 2020-2029. Survey. Transportation 32, 165–186. Republique de Guinee. (2018). Enquête Démographique et de Rask, K.J., M.V. Williams, R.M. Parker, and S.E. McNagny. (1994). Santé. Obstacles Predicting Lack of a Regular Provider and Delays in Seeking Care for Patients at an Urban Public Republique de Guinee. (2017). Vision 2040 pour une Guinée Hospital. JAMA, 271(24), 1931-3. émergente et prospère. Ministry of Planning and International Cooperation. Republic of Cameroon. (2020). Stratégie Nationale de Développement 2020-2030. Ministry of Economy, Republique de Guinee. (2016). Rapport National Habitat III. Planning, and Territorial Development. Comité National Habitat III. February. Republic of Cameroon. (2013). Document de Stratégie du Republique de Guinee. (2014). Politique Nationale de Sante. Secteur de l’Education et de la Formation (2013-2020). Ministry of Health. Conakry, November. Republic of Cameroon. (2009). Stratégie pour le Republique de Guinee. (2012). Enquete Legere Pour Développement de la Ville de Douala et de son Aire L’evaluation De La Pauvrete ELEP-2012. Métropolitaine. December. Republique du Cameroun. (2018). Enquête Démographique Republic of Cote d’Ivoire. (2013). Household Interview Survey et de Santé. in Greater Abidjan in the Republic of Cote d’Ivoire. Republique du Mali. (2019). Enquête Démographique et de Republic of Rwanda. (2017a). Rwanda National Strategy for Santé 2018. Institut National de la Statistique, Bamako. Transformation 2017-2024. Republique du Mali. (2015). Politique Nationale des Republic of Rwanda. (2017b). Malaria Indicator Survey. Malaria Transports, des Infrastructures de Transport et du and Other Parasitic Diseases Division of the Rwanda Desenclavement. Biomedical Center Ministry of Health/Rwanda and ICF. Republique du Mali. (2014a). Politique Nationale de la Ville. Republic of Rwanda. (2015a). National Urbanization Policy. Ministere de l’Urbanisme et de la Politique de la Ville. Ministry of Infrastructure, December. February. Republic of Rwanda. (2015b). Demographic and Health Survey Republique du Mali. (2014b). Plan Decennal de 2014/15. Ministry of Finance and Economic Planning/ Developpement Sanitaire et Social (PDDSS) 2014-2023. Rwanda, Ministry of Health/Rwanda, and ICF International. Secretariat Permanent du Prodess. Republic of Zimbabwe. (2020). Educational Management Republique du Senegal. (2015). Enquête ménages sur la Information System (EMIS) 2019. Ministry of Primary and mobilité, le transport et l’accès aux services urbains dans Secondary Education. l’agglomération de Dakar. Republic of Zimbabwe. (2018). Vision 2030. September. Ricciardi, A.M., J. Xia, and . Currie. (2015). Exploring pub- lic transport equity between separate disadvantaged Republic of Zimbabwe. (2016a). Interim Poverty Reduction cohorts, a case study in Perth, Australia. J. of Transp. Strategy Paper (IPRS, 2016-2018). Ministry of Finance and Geography, 43, 111-122. Economic Development. 146 MOBILITY AND TRANSPORT CONNECTIVITY SERIES CONNECTIVITY FOR HUMAN CAPITAL Rockoff, J.E. (2004). The Impact of Individual Teachers on Syed, S.T., B.S. Gerber, and L.K. Sharp. (2013). Traveling Student Achievement: Evidence from Panel Data. Towards Disease: Transportation Barriers to Health Care The American Economic Review 94 (2): 247–52. Access. Journal of Community Health, 38, 976–993. doi:10.2307/3592891. The Republic of Uganda. (2015). Second National Rutherford, M.E., Mulholland, K., Hill, P.C. (2010). How access Development Plan (NDPII) 2015/16 – 2019/20. to health care relates to under-five mortality in sub-Sa- The Republic of Uganda. (2010). Uganda Vision 2040. haran Africa: systematic review. Trop Med Int Health,15, 508–519. The Republic of Uganda. (2008). National Transport Master Plan 2008-2023. Ministry of Works & Transport. Rwanda Environment Management Authority. (2013). Kigali State of the Environment and Outlook Report 2013. The United Republic of Tanzania. (2017). National Transport Policy. Ministry of Works, Transport, and Communications. Salon, D., S. Gulyani. (2019). Commuting in Urban Kenya: Draft. Unpacking Travel Demand in Large and Small Kenyan Cities. Sustainability, 11 (4): 3823. The United Republic of Tanzania. (2016a). National Five Year Development Plan II 2016/17-2020/21. Ministry of Schmitz, P., S. Eksteen. (2014). The Effect of GIS Data Quality Finance and Planning. on Infrastructure Planning: School Accessibility in the City of Tshwane, South Africa. The United Republic of Tanzania. (2016b). Demographic and Health Survey 2015/16. Ministry of Health, Community Silver, D., J. Blustein, and B.C. Weitzman. (2012). Development, Gender, Elderly and Children [Tanzania Transportation to Clinic: Findings from a Pilot Clinic-Based Mainland], Ministry of Health [Zanzibar], National Bureau of Survey of Low-Income Suburbanites. Journal of Immigrant Statistics, Office of the Chief Government Statistician, ICF. and Minority Health, 14, 350–355. The United Republic of Tanzania. (2013a). National Transport Sohnesen, T.P., P. Fisker, and D. Malmgren-Hansen. (2019). Policy. Ministry of Communications and Transport. Using Satellite Data to Guide Urban Poverty Reduction. Special IARIW-World Bank Conference “New Approaches The United Republic of Tanzania. (2013b). 2011/12 Household to Defining and Measuring Poverty in a Growing World” Budget Survey Tanzania Mainland. National Bureau of Washington, DC, November 7-8, 2019. Statistics and Ministry of Finance and Planning, Dar es Salaam, November. SSATP. (2020a). Policies for Sustainable Accessibility and Mobility in the Cities of Burkina Faso. March. The United Republic of Tanzania. (2000). Vision 2025. SSATP. (2020b). Policies for Sustainable Accessibility and Transportation for Healthy Communities Collaborative. (2002). Mobility in Urban Areas of Mali. Final Report. Africa Roadblocks to Health: Transportation Barriers to Healthy Transport Policy Program, April. Communities. SSATP. (2018a). Politiques de mobilité et d’accessibilité dura- UBOS. (2016). The National Service Delivery Survey 2015. bles dans les villes guinéennes. October. Uganda Bureau of Statistics. SSATP. (2018b). Policies for Sustainable Accessibility and UBOS. (2018). Uganda National Household Survey 2016. Mobility in Cities of Kenya. Final Report. Africa Transport Uganda Bureau of Statistics. Policy Program, December. UBOS & ICF. (2018). Demographic and Health Surveys 2016. SSATP. (2004a). Poverty and Mobility in Douala. Sub-Saharan Uganda Bureau of Statistics. Africa Transport Policy Program. UNICEF. (2019). For Every Child, Every Right: The Convention SSATP. (2004b). Poverty and Urban Mobility in Conakry. Sub- on the Rights of the Child at a crossroads. Saharan Africa Transport Program. UNICEF Tanzania. (2018). Annual Report 2018. Surbana Jurong Consultants Private Limited. (2018). Kigali Master Plan. 147 REALIZING THE RIGHT TO EDUCATION AND HEALTHCARE THROUGH IMPROVED PUBLIC TRANSPORT IN AFRICAN CITIES United Republic of Tanzania. (2019). Tanzania Mainland Key World Bank. (2016a). Kenya Urbanization Review. Report No: Indicators Report: 2017-18 Household Budget Survey. AUS8099. February. National Bureau of Statistics, Ministry of Finance and World Bank. (2016b). Uganda: Poverty Assessment (FY15). May. Planning. Dodoma, June. World Bank. (2016c). Republic of Mozambique Systematic U.S. Department of State. (2019). Human Rights Report, Country Diagnostic. June. Burkina Faso, 2019. World Bank. (2011). Maputo Municipal Development Program Ville de Bamako. (2012). Bamako 2030: Croissance et II. Project Appraisal Document. Développement – Imaginer des Stratégies Urbaines pour un Avenir Maîtrisé et Partagé. World Bank Group. (2019). Republic of Guinea: Planning, Connecting, Financing in Conakry. Urban Sector Review. Ville de Douala. (2009). Élaboration d’un Plan de Transport et de Déplacements Urbains de la Ville de Douala. Rapport World Bank Group. (2018a). World Development Report: Final. December. Learning to Realize Education’s Promise. Washington, DC. Welch, T.F., S. Mishra. (2013). A measure of equity for public World Bank Group. (2018b). Republic of Guinea: Overcoming transit connectivity. Journal of Transport Geography, 33, Growth Stagnation to Reduce Poverty. Systematic 29-41. Country Diagnostic. March 16. Welty, T.E., S.L. Wills, E.A. Welty. (2010). Effect of limited trans- Yang, S., R.L. Zarr, T.A. Kass-Hout, A. Kourosh, and N.R. Kelly. portation on medication adherence in patients with epi- (2006). Transportation Barriers to Accessing Health Care lepsy. Journal of the American Pharmacists Association, for Urban Children. J Health Care Poor Underserved, 50(6), 698-703. 17(4), 928-43. Wesolowski, A., W. Prudhomme O’Meara, A.J. Tatem, S. Ndege, ZIMSTAT. (2019). Multiple Indicator Cluster Survey: 2019 N. Eagle, and C.O. Buckee. (2015). Quantifying the Impact Survey Findings Report. Zimbabwe National Statistics of Accessibility on Preventive Healthcare in Sub-Saharan Agency. Africa Using Mobile Phone Data. Epidemiology, 26, ZIMSTAT. (2014). Multiple Indicator Cluster Survey: 2019 223-228. Survey Findings Report. Zimbabwe National Statistics WHO. (2017). Primary Health Care Systems (PRIMASYS): Case Agency. study from Rwanda. World Health Organization, Alliance ZIMSTAT. (2013). Poverty Income Consumption and for Health Policy Systems Research. Expenditure Survey 2011/2012. Zimbabwe National World Bank. (2020). Bolstering Poverty Reduction in Mali: A Statistics Agency. Poverty Assessment. Draft. December 10. World Bank. (2019a). Poverty Maps of Uganda: Mapping the Spatial Distribution of Poor Households and Child Poverty Based on Data from the 2016/17 Uganda National Household Survey and the 2014 National Housing and Population Census. Technical Report. November. World Bank. (2019b). Bamako: An Engine of Growth and Service Delivery. World Bank. (2018). Unlocking Productivity and Livability – A Tale of 3 West African Cities. World Bank. (2017). Greater Maputo Urban Poverty and Inclusive Growth. June. 148 MOBILITY AND TRANSPORT CONNECTIVITY SERIES CONNECTIVITY FOR HUMAN CAPITAL