UHC Blog Series

Urbanization Is an Opportunity to Advance UHC in African Cities

By Alex Levine

October 13, 2020

As the global population continues to urbanize, cities themselves become ever more important in the path to achieving universal health coverage. Africa in particular is urbanizing rapidly, with the continent’s urban population expected to triple between 2020 and 2050 . Growing cities face a critical juncture, in which choices made in urban planning now will impact how people interact with their built environment and access health services for years to come. Capitalizing on and replicating advances in health-promoting urban development strategy across the African continent, through harnessing walkable urbanism and transit-oriented development, will improve both physical and environmental health in cities. Walkable urbanism and transit-oriented development also promote safe and equitable movement through cities, facilitating access to health resources such as healthcare facilities and green space. Altogether, these elements of urban design target environmental and lifestyle factors associated with ill health and an array of non-communicable diseases, which are rapidly increasing in prevalence in African cities. Utilizing urban design to prevent illness and improve health will reduce health system burdens associated with these diseases and poor health outcomes, ultimately facilitating progress towards universal health coverage.


Walkability encompasses the ways that the built environment promotes walking. Factors influencing walkability include access to mass transit, presence and quality of footpaths or sidewalks, buffers between walking spaces and traffic, pedestrian crossings, aesthetics, nearby local destinations, air quality, shade, street furniture, and traffic volume and speed. High levels of walkability are associated with improved health through increased physical activity and reduced exposure to pollutants from vehicles. Despite these benefits, modern urban development in many lower- and middle-income countries neglects the role of walkability in urban areas, favoring ease of transportation by car over transportation by foot. Although in most Sub-Saharan African cities the majority still travel by foot, increases in private vehicle use and the proliferation of roads without sidewalks are worrying. Africa has the highest rates of road traffic injury deaths of any continent, further underscoring the need for safe walking conditions. Also essential to health-promoting city design is transit-oriented development. Transit-oriented development prioritizes building compact and walkable communities centered around public transport stations. By increasing the population in walking distance of public transport, transit-oriented development encourages the use of sustainable transportation methods, reducing vehicular air pollution and allowing for more equitable access to different destinations in the city, including access to health-promoting resources like healthcare facilities and green space.


Four African cities have illustrated how these strategies of walkable urbanism and transit-oriented development can be implemented in rapidly urbanizing areas in diverse ways:

Addis Ababa:

Addis Ababa has experienced massive horizontal growth in the past few decades. However, the city has made pedestrian infrastructure a priority, with high-quality sidewalks even in neighborhoods on the city’s periphery, and completed construction of a modern light rail, the first rapid transit system in Sub-Saharan Africa, in 2015. These improvements in both walkability and public transport allow residents to access many areas of the city safely and without contributing high levels of carbon emissions.

Addis Ababa


In Nairobi, as in many African cities, the allocation of road space between cars and pedestrians is a question of equity, as the majority of residents of the city’s slums have no means to travel other than by foot. However, the city has taken a commendable step towards improving walkability with the implementation of its comprehensive Non-Motorised Transport (NMT) Policy. This policy outlines areas for improvement in infrastructure for pedestrians, bicyclists, and public transport, incorporating feedback from city residents. This space for feedback allows the city’s walking- and public transport-using majority to impact the built environment of their city.


Johannesburg has adopted a comprehensive transit-oriented development strategy, expanding its Rea Vaya bus rapid transit network, investing in improved access for pedestrians and bicyclists along key “Corridors of Freedom” connecting lower-income areas with the city center, and transforming inner-city areas into denser, mixed-income, mixed-use developments. These interrelated efforts promise to improve access to destinations and resources across the city for people of all income levels while promoting the use of public transport and active transportation methods like walking and bicycling.


Dar es salaam:

Dar es Salaam is proving to be an excellent example of how cities can use transit-oriented development to maximize utility from existing transit corridors to achieve an array of benefits. One objective of the Dar es Salaam Metropolitan Development Project aims to capitalize on the city’s bus rapid transit line, the first of its kind in East Africa, by concentrating walkable mixed-use urban development along the line, following international best practices on transit-oriented development. This project illustrates how infrastructural improvements can build upon each other, allowing cities to derive the maximum benefit from an investment, which in the case of Dar es Salaam will be through the formation of walkable corridors across the city accommodating health-promoting transportation options.

As these examples demonstrate, there is no single path to pursuing health-promoting urban development in African cities. Replicating the successes of other countries, innovating new projects, and tailoring projects to local needs are effective ways to incorporate walkable and transit-oriented design into new urban development. Through transforming the built environment to facilitate access to essential resources like health facilities and to promote physical activity and avoid reliance on air-polluting vehicles, these urban planning principles act on key downstream determinants of health. Increased physical activity reduces the incidence of non-communicable diseases like cardiovascular illness and diabetes, and reduced air pollution precludes complications of illnesses like asthma, pneumonia, and lung cancer. As Africa faces a surge in the burden of non-communicable diseases associated with lifestyle and environmental risk factors, addressing the determinants of these illnesses will be more important than ever to achieving universal health coverage. Harnessing aspects of urban design to prevent illness and promote population health has the potential to ease health system burdens and thereby facilitate universal health coverage. The key is following the examples of cities like Addis Ababa, Nairobi, Johannesburg, and Dar es Salaam, and intervening now in the midst of urbanization to build a health-promoting city environment for the generations to come.