In this section, we present the set of themes emerging from the literature and aim to highlight the persistent gaps, and some of the measures being developed to close them, in other low- and middle-income countries. These may also enable low-income countries to target this issue, and reach the global goals, more effectively
3.4. Affordability and Subsidies for Individual Journeys
Included in debates around the ‘inclusiveness’ of sustainable accessible transport are issues of cost and affordability. In part due to inequalities and exclusionary practices, in many countries around the world, people with disabilities experience poverty. One form of poverty is transport poverty, which can be related to cost, affordability as well as accessibility [27
]. However, transport poverty is hard to measure, and there are no universally agreed definitions. Moreover, some question whether it even exists as a stand-alone phenomenon or whether it is simply an extension of being poor. Put differently, the question remains as to whether transport poverty a ‘real’ problem for individuals, or is it a systemic problem that has a systemic solution, and if so, what are these solutions? Given this, is it a problem that has a transport solution, or rather is it a broader issue of social welfare? [28
] (p. 353).
In many (usually higher-income) countries, a range of measures have been put in place within transport policies, including concessionary fares, subsidised public transport services and free special transport services (STS) for eligible groups such as older people, children, and/or people with disabilities. As such, they are only viable where there are (public) transport systems in place.
South Africa provides a heavily subsidised public transport system for older adults and people with disabilities [22
]. However, in his study reviewing provision of services, Venter found that it was access, rather than affordability, that was the largest barrier to use, and the solution was therefore to increase access more broadly, rather than to provide targeted subsidies:
“The overall implication is that the limited funds that are available for improving public transport in cities should go towards improving accessibility for all, rather than towards lowering fares for all disabled persons as a group. This is not to say that subsidisation is not needed: the evidence shows that both disabled and non-disabled commuters benefit substantially from having access to subsidised bus and rail services. But the benefit stems from the subsidies being available to all low-income workers.”
Such universal coverage may also help overcome the predictable eligibility challenges, as assessment of disability is already a complex and much debated issue, particularly in low-income countries which have limited mechanisms for assessment [29
]. In addition, most of the debates in the literature tend to focus on the delivery structures and mechanisms, rather than eligibility criteria, so there is limited evidence on what are the most effective mechanism for assessment or identification of eligibility.
3.5. Measuring Access to Services
In addition to limited evidence about assessment and eligibility criteria, there are also significant gaps in the literature about what specific impact transport restrictions have on people with disabilities’ lives (e.g., opportunities lost), or the additional costs that may be associated with this lack of access (e.g., hiring taxis to get to work, or not getting to work at all) [25
]. This gap exists across high- [20
] and low-income countries and is largely due to a lack of agreed measures to estimate access and inclusion. Of the limited literature available that does address this, intersecting issues of age, gender, poverty, ethnicity, disability, etc., come to the fore (e.g., [2
]). These make it difficult to attribute transport—or lack of—as a singular cause for exclusion. In recent research undertaken by authors in Liberia [33
], when asking matched household heads about barriers to accessing healthcare services, distance to health facilities was weighted similarly between disabled (11.0%) and non-disabled households (12.8%). Unfortunately, the study did not ask what the most commonly used mechanism of transport was, nor whether this resulted in additional costs, for example if persons with disabilities had to use more expensive means of transport (e.g., taxi cars instead of taxi motorbikes), or spend more on transport overall. Therefore, while the issue of transport—or lack of—is a barrier to access and inclusion in all aspects of life and is highlighted in many papers (e.g., [1
]), there are few papers that identify mechanisms to quantify this.
One of the few pieces of research available that does attempt to do this is Venter [25
] discussing the situation in South Africa. Here the research found that geographic location was a key determinant of the affordability of transport, with transport in urban areas being unaffordable for poor people generally, but not specifically people with disabilities or older people, whereas in rural areas limited travel options constrain everybody as much as affordability, thus the solutions again point to improving the affordability, availability and quality for all users, not just specific groups, as all users would then benefit [25
] (p. 129).
3.6. Transport Services Available
One area of transport provision that aims to address a lack of mobility are special transport services (STS). These are designed to address services gap and are usually (though not exclusively) for people with mobility difficulties, such as older adults or people with disabilities. There have been some well-reported models in South Africa, Brazil and Russia [4
] (pp. 178–184), all high middle-income counties and we found none from low-income countries. STS (also known by a variety of other names, including ‘paratransit, or ‘dial-a-ride’ in other countries) vary not only in name, but also in delivery and funding structures, as well as types of vehicles used. Some supplement existing services, or link to feeder routes (such as mass rapid transport (MRT) services in Cape Town and Brazil), while others offer specific door-to-door services in adapted accessible vehicles (such as Dial-a-Ride in South Africa, which offers users a heavily subsidised service).
There are a number of debates about the provision of STS, particularly around equity, as they tend to offer a segregated service (see for example [16
] p. 4), as well as cost. In some countries, provision of STS (e.g., to schools, hospitals, etc.) is a mandatory requirement by law, though provision can be costly, and demand likely to increase with an ageing population. They are often publicly funded, or at least subsidised. Some high-income countries are exploring different models of payment for these services (see for example [35
]). Though their findings are from a wealthy country with high levels of service provision (Sweden), they do have some implications for decentralised budgets elsewhere—not the least of which is the need to coordinate service provision (e.g., school buses) and that overall improved public transport services can have a positive impact on access and inclusion more generally. According to one study from eThekwini Municipality (South Africa), the Dial-a-Ride service provided faces an array of challenges, including high costs, difficulty in managing high demand, scheduling of services and lack of flexibility in adapting route planning. In fact, demand was such that it had to be restricted to people going to study or work. Complaints about the tendering process were also made [30
] (p. 35).
An excellent practical guidance for setting up STS in low-income countries but drawing on experience from high-income countries, suggests using a variety of state and non-state funding mechanisms [36
]. The guide suggests utilising existing locally available transport mechanisms, including motorised auto-rickshaws, cycle-rickshaws, and similar vehicles operated exclusively or partly for mobility-impaired people. The one thing they all have in common is that they are “demand-responsive”, which can be interpreted in one of several ways—pre-booked, scheduled or instant access. This approach strengthens the idea that public transport provision needs to move away from traditional delivery approaches, as well as addresses the challenge that the provision of STS does not address equity, inclusion or attitudinal and other barriers to transport access, nor does it confer independence or autonomy on users, as there is still a reliance on others to provide a service. On the other hand, if there is no way to get to a station or bus stop—no matter how accessible the route is, then it could be argued that the provision of special transport enables people with transport restrictions to make necessary journeys. To be genuinely effective, special transport needs to be included as part of a wider package of measures to address barriers to access and inclusion, such as increased and accessible information and financial aids, such as concessionary travel passes [37
] (p. 54).
However, if users require a high degree of assistance, there are still limitations in most current transport provisions around driver capacity, attitudes and willingness to provide such services. Another criticism of STS is the extent to which such systems include alternative (as well as sustainable and healthy) modes of transport such as cycling or walking.
3.8. Mobility as a Service
Taking the idea of shared, often private, services a step further is the idea of ‘mobility as a service’. In some respects, such an approach may well be undertaken informally in a range of settings. While the idea of a barrier-free, door-to-door journey is not new, new ways to conceptualise what a ‘total’ journey, or ‘continuity of travel chain’ or even ‘integrated mobility’ might look like are in development. These factor in age, health, mobility status as well as a range of other intersectional aspects and move away from the more traditional ‘special transport’ models discussed above to more integrated approaches that acknowledge that what works in one location or for one group may not be effective or utilised in another.
One of the most innovative and exciting area that links up discussions about autonomy, choice, continuity of journey, as well as bringing in new technology is that of ‘Mobility as a Service’ (MaaS). Not specifically designed for people with disabilities, MaaS is a way:
“…to see transport or mobility not as a physical asset to purchase (e.g., a car) but as a single service available on demand and incorporating all transport services from cars to buses to rail and on-demand services.”
Originating in Sweden, it offers users the opportunity for door-to-door integrated services, paying for a package of services ‘as they go’ via one (often online) payment system. Though most of the research around MaaS has been in higher-income countries, the concept has relevance to low-income countries, making it worth raising in this paper, and some very preliminary research about transposing it to such contexts has begun [39
MaaS has the potential to cover a range of transport options, from self-drive cars (still under research), through to taxis (similar to Uber, which already operates via an app-based service), bicycles and even walking. However, despite the ideology, such tailored services can be expensive, and inefficient to deliver, so researchers have begun to conceptualise how journeys can be ‘bundled’, so users can and buy specifically tailored transport packages, in much the same way as they can buy satellite or cable TV packages to suit their specific viewing requirements [38
The research focused on developing and delivering a broad range of options for both type of journey (work, socialising, etc.) and mode of transport (buses, taxis, etc.), which could be standardised to some extent to reduce costs. These ‘service packages’ could also be customised, perhaps including add-ons such as household travel-planning, availability of car space in localities, travel training, ICT training, providing a driver for own car and learning to drive [38
] (p. 590). These were offered as alternatives to car ownership, increasing car-sharing to reduce individual ownership, and therefore increase sustainability, but at the same time maintaining independence and freedom of movement. As the researchers note, whilst MaaS was not specifically set up for use by people with disabilities, the system could offer opportunities for flexibility and autonomy. Viewing transport as part of a service package has the potential to move discussions away from seeing transport provision for older adults and people with disabilities as a welfare issue, as, they argue, it currently is. Although they caution about the need to take the social benefits of mobility into account when thinking about MaaS too [38
While MaaS offers an exciting potential for people with disabilities, it was not (necessarily) designed specifically for people with disabilities, but rather it is a transport system that can be used by people with disabilities. In this, it is similar to existing ‘community’ or ‘flexible’ transport’ systems, usually privately-funded or run cooperatively. Community transport can be funded and provided through a variety of mechanisms, including shared transport (such as cars or taxis), and may be a viable option in low-income countries, as they may lessen costs for passengers, as well as reduce the number of vehicles on the road. However, there are debates about the extent to which they are likely to be viable as a long-term solution to reduced mobility in rural or semi-urban areas, in particular for people with disabilities, as they do not solve broader issues around mobility, including social aspects, such as independency and autonomy.
Technology has enabled significant improvements across a range of domains, including transport-specific services such as Uber and MaaS, as discussed above, as well as facilitate mapping of journeys to better understand patterns and usage and adapt services accordingly. There is already a significant body of literature exploring the benefits (as well as some of the more negative aspects) that technology can bring to the lives of people with disabilities, in particular how it can support and maintain independence [40
]. This is reflected in the array of transport-focused literature on technological advances in the transport sector, some of which may have been specifically designed and intended for use by people with disabilities, though not all. However, all have had a major impact on the ability to travel. These fall largely into two categories: technology which provides information; and technology which provides a service. Some, but not all, of these are mainly used in higher-income countries, but all have the potential for transfer and adaptation.
Information-providing technologies include apps which give live updates about planes, trains, buses and other (usually public) transport, as well as live trackers, digital maps, etc. These often use location-tracking devices, such as GPS. Use of these tracking devices has extended to support independent travel for people with disabilities [15
]. Whilst all these examples have been tested in higher-income countries with existing infrastructure and services, what the results demonstrate is that whilst accessible infrastructure is a necessary condition, it is not enough. Many of the challenges faced are related to, but not inherent within, the transport system, such as uncertainly about scheduling or routes. This indicates that not just the transport mode, station or service need to be inclusive, but the whole journey, requiring a joined-up approach to inclusive transport.
Technologies which support service provision include online ticketing systems, as well as automated and integrated payment systems. However, whilst convenient, for some users with disabilities it has been argued that these integrated payment systems can also present challenges. In their work in Durban, Lister and Dhunpath talk about these in relation to the Muvo Card, a single smartcard that can be used across all three of Durban’s transport systems. Users in Durban report difficulties with locating the machines, drivers being in a hurry, no signalling facilities for blind or visually impaired users and numerous other problems with the machinery [30
] (p. 40).
Similarly, in their findings from the Philippines, Cendana et al. [43
] argue that such a single-use smart card could be a mechanism for more equitable urban transport, though their main concern was about implementation and eligibility. To overcome this, they argued for a provider that would enable the implementation of the use of the smart card across multiple transport platforms (hence multiple providers) to enable discounts to be systematic to eligible travellers.
However, in the end, while technology is an enabler, a facilitator for accessible and inclusive transport for people with disabilities, it is not in itself enough. Much more research is needed on the systems within which it is embedded—including the costs (demand and supply) and user needs (especially the voices of adults and children with disabilities who will use the services—see [1
]). Moreover, focusing solely on access tends to lead researchers to create solutions to overcome physical and environmental barriers, rather than attitudinal or social barriers [44
3.10. Intersectionalities, Inequalities and the Lifespan
Disability, like gender and age, is a factor that cuts across mobility, access to transport services from operational and employment perspectives [45
]. However, much of the existing research around accessible transport has tended to compare transport use between disabled and non-disabled populations, rather than between different groups of people with disabilities. As a result, there is limited evidence of what works for specific groups, but as noted above, it is clear there is not a one-size-fits-all solution to these challenges. Perhaps as a consequence, increasingly in both high- and low-income countries, researchers and advocates have drawn attention to the need for a broader focus on inclusion, making it accessible and inclusive to all, not just people with disabilities, but also those with temporary mobility difficulties, older adults, people using pushchairs or prams, small children, cyclists and many other groups as well. However, while these design-led solutions tend to address the access issues, there are fewer indicators of measures of success around inclusion, or the socio-political changes required more broadly (see [46
] for discussion around the application of these principles in South Africa). Moreover, such universal approaches may unintentionally benefit most those who need it the least if underlying issues such as poverty or fear are not addressed.
These issues have been discussed more widely in the fields of gender and to some extent ageing (see for example [47
]). Ahmad (2015) highlights how in Pakistan, in order to make public transport accessible for women, including women with disabilities, planners and politicians need to consider religious and social issues as much as financial and logistical ones, as it is these that have the most impact on women. He draws on work which focuses on the gendered aspects of public transport access and provision (e.g., [31
]) to show how dialogue between disability scholars, feminist critiques, and transport planners is needed to address continuing gaps [49
Overall, less is known about the complex interactions of disability with a range of other factors including age, sex, location, class, caste, etc. One aspect highlighted in the literature is the unavoidable fact that as people age, their ability to drive safely is compromised, so there is also a safety aspect to reducing the number of older drivers on the road—for example, through mandatory vision screening [50
]. This raises challenges when much of the research highlights how cars confer a sense of independence and autonomy, but which can be taken away at the very point when it is most needed, often leaving older adults with disabilities without alternatives.
There is a significant body of research that highlights the changing patterns of transport use across the lifespan, as well as according to location (e.g., [31
]). However, the majority tends to focus on older adults in higher-income countries, with much less focus on children or young adults (for some exceptions, see [52
]). Other researchers have highlighted the social aspects of public transport for older adults [54
]. Older people have also become a focus for advances in travel technology (see for example, [55
]). However, there is much less evidence on these complex intersections in low- and middle-income countries. One study, from Mexico, highlights the range of factors that mediate access to transport, with subjective ‘transport deficiency’ being strongly associated with being female, illiterate, having a mobility disability and using assistive walking devices [31
]. The researchers also noted the most commonly used mode of transport for older adults in Mexico City is private car, followed by walking, with a range of factors given for this, including fear, geographical location and limited accessibility of transport options for older adults in Mexico City [31
]. Similarly, data in South Africa also suggests that travel options are limited by factors other than affordability [25
Venter suggests that it is spatiality, rather than affordability or even accessibility, that determines use, a finding also found in other higher-income countries [21
]. Venter further suggests that initiatives such as road and footpath upgrading in rural areas would improve access and use [25
] (p. 138). Moreover, he suggests that current subsidies in South Africa actively disincentivise older adults from using public transport. Sammer et al. [37
] go even further in highlighting the intersecting, and accumulating nature of transport inequalities, referring to ‘mobility impairment’ more broadly:
“In the past, mobility problems of physically disabled or sensory-disabled people were the focus of attention, whereas, more recently, problems of the elderly have been recognized as well. However, if such problems concern other groups, such as immigrants and people with learning disabilities, they have been more or less neglected”
These findings highlight not only how disability can lead to exclusion, which comes about from a complex intersecting of factors, but also the inequalities this exclusion can create. It is clear from the literature that disability can lead to inequalities more broadly within the transport sector, particularly with regards to access and inclusion, but also health inequalities more specifically. As noted above, this paper has not included the vast literature around road traffic accidents, the impact of which can be most severely felt by people in low-income countries, where there is often less regulated transport systems, poor infrastructure and limited availability and access to emergency services.
It is also clear that beyond these negative aspects, adults and children with disabilities may miss out on the mental and physical benefits of travel (see for example Vancampfort et al. [57
] for a discussion about the associations between active travel and physical multi-morbidity). As Mindell [58
] notes, disability and illness, along with age, is associated with ‘non-travel’; and recent research has shown that urban residents in the USA with health conditions that limit travel, particularly driving, are more likely to limit their travel than their rural counterparts (Henning-Smith et al., 2018, cited in [58
]). This is problematic from a number of angles, not least of which is social isolation and loneliness, all of which impact on mental and physical health. Transport policies that are good for health and reduce inequalities are low carbon, sustainable approaches, promoting active travel and public transport use, and reducing private car use [58
]. Moreover, Mindell notes that in the majority of countries, motor vehicles are owned and used more by the rich while the adverse health effects, such as injuries, air and noise pollution, and community severance are experienced primarily by those with fewer resources [58
] (p. 1). This implies that not only are people with disabilities less likely to travel, but they are at higher risk of the consequences of the overall health effects of non-travel.
There is also a cautionary note to this, in that much of the discussions around inclusion in the transport sector have not focused on sustainable alternative modes of transport, such as cycling or walking. It is worth noting that there is almost no literature that focuses on redressing these inequalities, from legislative or other perspectives, for people with disabilities, and there remains a gap in the literature addressing the inequities of the health benefits of active travel and transport for adults and children with disabilities.