Presentation on theme: "establishing multisectoral partnerships to address a silent epidemic"— Presentation transcript:
1 establishing multisectoral partnerships to address a silent epidemic Confronting “Death on Wheels” Making Roads Safe in Europe and Central Asiaestablishing multisectoral partnerships to address a silent epidemicPATRICIO MARQUEZTHE WORLD BANKKIEV, MAY 2010
2 Outline: Challenges and Opportunities in Addressing Road Safety in the ECA Region* The problem: trends, size, characteristics, causesEffective measures to improve road safetyCurrent international road safety policyPossible strategies and actions by the World Bank with partners*Baltic, Balkans, EE, CIS, Turkey.
3 Road Traffic Injury (RTI) Mortality Rate Trends Europe, EU-27 and CIS Countries, per 100,000, 1980–2007 large, increasing disparities510152025301980199020002010European RegionEUCISCISEuropean RegionEU-27Increasing RTI results from rapid growth in motorization, without adequate improvements in road infrastructure (despite significant road investments) and weak regulations on vehicle safety and driving, and weak enforcement of existing regulations.People in CIS countries drive far less than in Western Europe (800 km/per capita by car, compared to 12,000km/per capita) accident injury and death rates are far higher, with little of the improvement in road safety that concerted efforts in Western Europe have achieved.CIS countries: Azerbaijan, Belarus, Georgia, Kazakhstan, Kyrgyzstan, the Republic of Moldova, Russia, Tajikistan, Turkmenistan, Ukraine, and Uzbekistan.EU-27 countries: Austria, Belgium, Bulgaria, Cyprus, the Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Ireland, Italy, Latvia, Lithuania, Luxembourg, Malta, the Netherlands, Poland, Portugal, Romania, Slovakia, Slovenia, Spain, Sweden, and the United Kingdom.Source: WHO EURO Health for All Data Base (2009).
4 RTI Death Rates in WHO-EURO Member Countries per 100,000 Population, 2007 KazakhstanRussian FederationKyrgyzstanUkraineMontenegroTurkmenistanLatviaGeorgiaBelarusSlovakiaRep. of MoldovaGreeceEstoniaPolandSloveniaTajikistanAlbaniaArmeniaCroatiaTurkeyAverage-WHO-EUROBulgariaAzerbaijanRomaniaHungaryCzech RepublicBosnia & HerzegovinaPortugalCyprus184.108.40.206.95.05.25.45.76.06.97.27.220.127.116.11.69.79.810.010.210.410.912.012.312.713.013.213.413.613.914.114.614.714.915.115.716.817.918.620.421.522.422.825.230.60.0510152025.030.035.0San MarinoMaltaNetherlandsSwitzerlandNorwaySwedenUnited KingdomIsraelGermanyMKD*FinlandFranceAustriaIrelandSpainItalyUzbekistanSerbiaIcelandBelgiumCyprusPortugalBosnia and HerzegovinaCzech RepublicHungaryRomaniaAzerbaijanBulgariaWHO EUROTurkeyCroatiaArmeniaAlbaniaTajikistanSloveniaPolandEstoniaGreeceRepublic of MoldovaSlovakiaBelarusGeorgiaLatviaTurkmenistanMontenegroUkraineLithuaniaKyrgyzstanRussian FederationKazakhstanDeaths per populationHigh-income countriesLow- and middle-income countriesBelgiumIcelandSerbiaUzbekistanItalySpainIrelandAustriaFranceFinlandFmr Yugoslav Rep. of MacedoniaGermanyIsraelUKSwedenNorwaySwitzerlandNetherlandsMaltaSan MarinoSource: WHO-EURO, 20092530
6 Economic development does not lead automatically to lower road fatalities, therefore need for effective road safety management strategy
7 The RTI situation in Ukraine (1) Road traffic crashes decrease from 63,000 in 2007 to 51,000 inSimilarly, RTI fatalities were reduced from about 9,600 to 7,700 over this period.About 40,000 people suffered nonfatal car injuries in 2007.But, while these figures represent a drop of about 19% from to 2008, road safety in Ukraine still lags far behind than in Western European countries: that have a RTI mortality rate of less than 5 per 100,000 as compared to 16.5 in Ukraine in 2008.This is a key challenge given the upcoming European Football Cup to be held in Ukraine and Poland in June 2012.
8 The factors driving the RTI epidemic The growth of road traffic injuries depends on the rate of growth of motorization and the rate of change in fatalities per vehicle (Kopits and Cropper 2005).Since the 1990s, the number of passenger cars per 1,000 population in the CIS countries, including Ukraine, increased by more than 120%.In many transition countries of Eastern Europe and Central Asia, the rate of vehicle ownership grew faster than the decline in the rate of fatalities per vehicle, while policy and governance did not keep pace with the booming motorization.
9 Deaths, disability and damage – who bears the brunt? 4-wheel vehicle occupants: 40-75% of RTI deaths in ECAYoung adults, especially men:55% of road traffic deaths in ECA countries are people aged 15–44, mostly 15–29; > 80% of deaths are menCyclists, motorcyclists at high risk (but small % of total)Motorcyclists, pedestrians at 7-9 times greater risk of death if in an road crash than people in vehiclesPedestrians – more likely to be children or elderly, and people with lower incomesIn Albania, Belarus, Kyrgyzstan, Tajikistan, and Ukraine, pedestrians are ≥ 40% of all road fatalities, 31-38% in all ECA
10 The situation in Ukraine (i) About 70% of all car crashes occur in cities and 30% in highways—majority in international highways.Kiev and other regional urban centers together contribute to more than 30% of the country’s car crashes.Pedestrians account for more than 40% of road traffic fatalities as compared to 18% in the EU countries.The high percentage of pedestrian deaths, in sharp contrast with other European countries, is evidence of the Ukrainian transport system‘s limited ability to cope with rising traffic and the needs of vulnerable road users.
11 Deaths, disability and damage – extent 80,000 road traffic deaths, 820,000 injuries in ECA in 2007(Data underestimate and underreport – especially non-fatal injuries, and differ in availability, quality, and completeness)Economic Impact: 1-2% of GDP (health care & rehabilitation costs, insurance, legal, lost productivity, property damage)Globally, costs to governments > US$500 billion annuallyHighest costs in ECA: large economies with big populations:Air pollution, noise.Greenhouse gas emissions contribute to global warmingFear deters walking, biking. Less mobility and physical activity reduces health, increases risks for cardiovascular diseases, strokes, diabetes, obesityRussia (US$34 billion per year, 33,308 deaths in 2007)Turkey (US$14 billion)Poland (US$10 billion)Ukraine (US$5 billion)Direct costs include emergency treatment, initial medical costs, rehabilitation costs, long-term care and treatment, insurance administration expenses, legal costs, and employer/workplace costs. Indirect costs include productivity costs in the workplace due to temporary and permanent disability and decreases in household productivity emanating from these disabilities. Property damage and travel delay and crash costs are estimated for injury and non-injury crashes (Blincoe and others 2002).
12 Impact on the Health System RTIs impose a high total on health systems everywhere.Estimates for Russia indicate that road traffic victims are seven times more likely to need hospitalization compared with victims of other types of trauma. And road traffic injuries account for 75 percent of all types of injury, with victims of road traffic crashes representing more than 60 percent of severe trauma cases.The provision of medical services for traffic injuries and other external causes absorbed about percent of GDP in 2003, or about USD 1.2 billion (World Bank 2005).
13 Road Traffic Injury Causes Lack of data /problem awarenessInadequate response, resourcesRoadsBad road design (no crossings, walkways, poor visibility)Roadside hazards (trees, poles, signs)Mixing traffic and pedestriansVehiclesUnsafe vehicles, without airbags & other crash protection devicesHuge increase in vehicle numbers (poor public transport)BehaviorsInadequate laws/rules + poor enforcementBad driving (speeding, recklessness, alcohol, some medications)Not using seatbelts, helmets (cyclists, motorbikes)Mobile phone texting“Are you in a hurry to reach us?"
14 The situation in Ukraine (ii) Several factors contribute to road traffic injuries. About 60% of car crashes in Ukraine are caused by speeding vehicles and poor driving behavior.Drunk driving, accounting for 5% of all road crashes, is another risk factor, and young drivers and riders aged 18–25 are particularly at risk.Other risk factors are poor road conditions and pedestrian behavior.Also looming is distracted driving while using cell phones and sending text messages.
15 WHAT TO DO?INTERVENTIONS ALONE WILL NOT SUFFICE
16 Current Road Safety Policy – Holistic “Safe Systems” approach Principles:Cannot prevent all road crashes, can reduce traffic injuriesDesign road traffic systems to take account of human error and vulnerability of human bodyResponsibility and accountability for road safety shared by road and car designers and road users
17 Effective Approaches Action Areas: Prevent road traffic crashes and injuryMinimize injuries when crashes occurRecovery: reduce injury severity afterwardsThe Haddon Matrix: a holistic framework for intervention focusing on road transport and its risksCar crashes divided into 3 phases: before, during and after to highlight when crashes can be prevented or their effects minimizedSources for cost effectiveness estimates: ETSC 2003, SWOV 2001, and U.S. National Center for Injury Prevention and Control 2000
18 Haddon`s MatrixТравма – это кульминация комплекса обстоятельств и существующих к этому моменту условий, которые наилучшим образом можно представить как цепочку событий. Модель, важная для понимания причинной цепочки событий, приводящих к травме, предложена Вильямом Хэддоном и широко известна как матрица Хэддона.Эта модель расширяет рамки эпидемиологического подхода, предлагая матрицу, благодаря которой причинные факторы, участвующие в возникновении травмы, могут быть лучше поняты через взаимодействие множественных факторов во времени. Она содержит обозначения времени (фаза до события, событие и фаза после события), которые располагаются в таблице против хозяина или индивида, агента (продукта) и факторов окружающей среды (физических и социальных) из эпидемиологической модели. Когда эти две оси (время и другие факторы) комбинируются, получается матрица Хэддона. Обычно матрица состоит из 12 клеток, но когда физические и социальные факторы окружающей среды объединяются в одно целое, она может быть и 9-клеточной.Модель Хэддона легко позволяет отделить факторы, которые предрасполагают к тому, чтобы событие, вызвавшее травму, произошло (фаза до происшествия), от самого события (происшествие), во время которого энергия передается хозяину в количестве, вызывающем повреждение. Хэддон также добавил фазу «после происшествия», включающую транспортировку, неотложную помощь и реабилитацию, определяющие выживаемость и конечный исход после того, как перенос энергии состоялся (16).Сочетание этих фаз травмы с эпидемиологической моделью создает матрицу для изучения, как причин, так и методов предупреждения травматизма. Временные фазы в целом соответствуют первичной (до происшествия), вторичной (происшествие) и третичной (после происшествия) профилактике.Значение этой модели состоит в том, что она показывает разные области, на которые могут быть направлены вмешательства по предупреждению травматизма или уменьшению его тяжести. Точка приложения вмешательства не обязательно должна располагаться в начале цепочки событий. Она должна быть там, где вмешательство возможно или, в идеале, там, где оно наиболее эффективно.
19 Adopting a Road Safety Management System Source: Bliss and Breen, building on the frameworks of Land Transport Safety Authority, 2000; Wegman, 2001; Koornstra et al, 2002; Bliss, 2004
20 Institutional management functions Delivered by government entities, in partnership with civil society and business entities to achieve RESULTS
21 RESULT FOCUS A foremost and pivotal institutional management function It is a programmatic specification of targets and means to achieve them with accountabilityProvides cohesion and direction, strategic orientation linking interventions with results, analyzes what could be achieved over timeSets a performance management framework for delivery of interventions and their intermediate and final outcomes
22 FUNCTIONS (i) Coordination: horizontally and vertically, partnerships Legislation: the legal instruments for governance; defines responsibilities, accountabilities, interventions, and related institutional management functions
23 FUNCTIONS (ii)Funding and resource allocation: how to finance interventions and related management functions on a sustainable basisDifferent mechanisms adopted in various countries
24 Funding Sources Traditional funding sources: General tax revenuesRoad funds (fuel taxes, vehicle registration and licensing fees, and heavy vehicle road use charges)Road user fees (driver’s and car license fees, vehicle inspection fees)Vehicle insurance premium leviesEarmarked charges (eg revenue from traffic fines used to finance road safety activities)Alternative financing sources:Price/tax policy (fiscal incentives for private and business investments in safety measures such as retrofitting older vehicles with safety belts)Insurance premiums (higher premiums for less safe vehicles, and drivers with poor safety records; pay-as-you-drive or pay-as-you-speed mechanisms, spread costs of risks for injury-causing crashes more fairly; assign total cost of car crashes to the person who caused it)Financial options (make unsafe behavior more expensive and give financial reward for safe behavior)Source: Adapted from OECD (2002) and Aeron-Thomas and others (2002), cited in Peden and others (2004); ECORYS (2006).
25 FUNCTIONS (iii)Promotion: sustained communication of road safety as core business for government and society to support interventionsMonitoring and evaluation: the systematic and ongoing measurement of outputs and outcomes, and impact evaluation—did results were achieved? Need for registries for vehicles and drivers, crash databases, and survey work
26 FUNCTIONS (iv)Research and Development and Knowledge Transfer: the systematic and ongoing creation, codification, transfer and application of knowledge that contributes to improved efficiency and effectiveness of road management system.Knowledge transfer must be evidence- based and grounded in practice by a learning by doing process.
27 Classification of Interventions Intervention typesStandards and rulesCompliancePlanning, design, operation and use of the road networkStandards and rules cover the safe planning, design, construction, operation and maintenance of the road network; and govern how it is to be used safely by setting speed and alcohol limits, occupant restraint and helmet requirements, and restrictions on other unsafe behaviors.Compliance aims to make road builders and operators, the vehicle and transport industry, road users and emergency medical and rehabilitation services adhere to safety standards and rules, using a combination of education, enforcement and incentives.Conditions of entry and exit of vehicles and road users to the road networkStandards and rules also address vehicle safety standards and driver licensing requirementsRecovery and rehabilitation of crash victims from the road networkStandards and rules can also be set for the delivery of emergency medical and rehabilitation services to crash victimSource: Bliss, 2004
29 Effective proven measures (2) Improve vehicle safetyIn-vehicle crash protection (airbags, seatbelts, child car seats)Vehicle licensing and inspection to enforce roadworthy standardsDaytime running lightsRequire and enforce helmet use with bicycles, motorbikes
30 Effective proven measures (3) Behavior change - education, law/regulation enforcementLower speed limits: 30 km/hr in residential areas, 50 km/hr in other urban areasEnforcing blood alcohol level limit of ≤0.05g/dl could prevent 5- 40% of RTI deaths (random breath testing better than set checkpoints, taxes and marketing, sales regulations are effective)Mandatory, enforced seat belt usePrevention of distracting driving due to use of phones and textingMedia coverage, education campaigns + tough sanctionsGraduated driving licenses (curfew, passenger restrictions) and more training during learner period reduce deaths among young drivers (US)Better public transport and land use reduces car travel
31 Health Sector Response Public health actions: collect and analyze data, research causes of RTI, advocate effective action, define and implement protective policies and practices and preventive interventionsPrimary health care providers: medical assessments of elderly/impaired drivers, advice on alcohol use and effects on driving of medicationsEmergency medical services: communication for rapid response, initial emergency care and stabilization, transport to health facility, well-trained teams with medicines and equipment, quality assuranceSafe blood supply &transfusionRehabilitation services
32 Cost-effectiveness – depends on risk factors, and distribution of fatalities/injuries by road user groupAverage cost per disability-adjusted life (DALY) year saved, adjusted for purchasing power parityIn ECA - WHO subregions EurB and EurC—pedestrians are particularly vulnerable road users (31 to 38% of fatal RTIs), with car drivers (43%) and car passengers (24%). Risk factors -excessive speed (21 to 22%) and driving under the influence of alcohol (16 to 21%) contribute the most to the overall death toll: 97 per 1 million and 248 per 1 million population (in each case, the first number refers to subregion EurB, the second to EurC).Compared to no intervention, legislation and enforcement of bicycle helmet use by children is the most cost-effective strategy in EurB (I$10,395 per DALY saved), followed by roadside breath testing for alcohol-impaired driving (I$12,691 per DALY saved). In EurC, breath testing is the most cost-effective strategy (I$5,825 per DALY saved). Results for all single and combined interventions are shown in Figure 5. Combining roadside enforcement strategies—against alcohol-impaired driving, speeding, and non-use of seatbelts, for example—offers the prospect of major synergies on the cost side.Countries in the WHO European Region with low child and adult mortality (EurB) are: Albania, Armenia, Azerbaijan, Bosnia and Herzegovina, Bulgaria, Georgia, Kyrgyzstan, Poland, Romania, Slovakia, Tajikistan, The Former Yugoslav Republic of Macedonia, Turkey, Turkmenistan, and Uzbekistan. Countries in the WHO European Region with low child and high adult mortality (EurC) are: Belarus, Estonia, Hungary, Kazakhstan, Latvia, Lithuania, Republic of Moldova, Russia, and Ukraine.
33 Safety Target Final outcomes Final outcomes can be expressed as a long term vision of the future safety of the road traffic system (e.g., as in Vision Zero and Sustainable Safety) and as more short to medium-term targets expressed in terms of social costs, fatalities and serious injuries presented in absolute terms and also in terms of rates per capita, vehicle and volume of travelIntermediate outcomesIntermediate outcomes are linked to improvements in final outcomes and typical measures include average traffic speeds, the proportion of drunk drivers in fatal and serious injury crashes, seatbelt-wearing rates, helmet-wearing rates, the physical condition or safety rating of the road network and the standard or safety rating of the vehicle fleet.OutputsOutputs represent physical deliverables that seek improvements in intermediate and final outcomes and typical measures include kilometers of engineering safety improvements, the number of police enforcement operations required to reduce average traffic speeds and the number of vehicle safety inspections, or alternatively they can correspond to milestone showing a specific task has been completed.Source: Bliss, 2004
34 ECA Efforts to Prevent Road Transport Injuries in Ukraine The State Car Inspectorate at the Ministry of Internal Affairs is responsible for road safety: from supervision of traffic by traffic police, car inspection and registration, issuance of driver licenses, control of conditions and operation of road network to data collection and reporting of RT crashes.Effective multisectoral collaboration to implement national program with a results orientation yet to be developed: a key institutional development challenge.Governance issues, particularly improvement in the enforcing of laws and regulations (traffic supervision), and the introduction and scaled up use of mobile devices (e.g., speed cameras) represent another challenge.
35 What could be done in the health sector in Ukraine to reduce RTIs? Intensify prevention efforts through information, education and communication to modify risky behaviors among drivers and pedestrians alike.Restructure the emergency medical services as part of health system reform efforts to prevent unnecessary fatalities and lasting disabilities due to RTIs:Reorganization and improvement of pre-hospital services: centralized ambulance dispatcher centers, improved ambulance and communication systems, including use of GPS, training of paramedics.Reorganization/strengthening of trauma centers on the basis of level of complexity along the highways and creation of “centers of excellence” for addressing complex injuries.
36 What could the World Bank do? (i) Practical guidelines to help countries implement these recommendationsGlobal Road Safety Facility generates funding and Technical Assistance for country road safety effortsRoad safety management capacity reviews done in many ECA countriesWorld Bank-supported road safety investments in transport and health projectsInformation and policy dialogueIn Ukraine, it is already financing a project to improve the roads network.
37 What could the World Bank do? (ii) 2004 World Report identifies 6 key steps for success:Identify a lead agency in governmentAssess road traffic injury problems, policies and institutions, and capacity for preventionPrepare a national road safety strategy and plan of actionAllocate financial and human resourcesImplement specific actions and evaluate their impactSupport national capacity and international cooperation.Principles: systematic, sustained, successful effort has 3 parts:ResultsInstitutional managementinterventions
38 What could the World Bank do? (iii) Build institutional management capacityProvide training and information for policy makers, practitionersSupport existing networks of people responsible for road safetyHelp countries improve data on RTIs and causesSpecify lead agency reforms neededHelp countries choose interventions wellReview national road safety management capacity - assess the situation, propose strategies and actions with realistic targets and budgetsSupport a safe system approach + results focus aiming to end road deaths and serious injuries (see next slide for specifics)
39 What could the World Bank do? (iv) Support a safe system approach + results focus aiming to end road deaths and serious injuries:Analyze planned road investments for safety, improve designReview road sections where many crashes occur to target investmentsLower urban speed limits to 50 km/h; 30 km/h in residential areas; enforce – speed cameras are cost effectiveEnforce alcohol limits with systematic police enforcement (breath tests, high- visibility random road checks), high-profile media campaigns, and swift severe penaltiesEnforce use of seat belts – campaigns, penalties, car restraint specificationsReduce young driver risk – graduated licensing scheme, extended trainingReduce pedestrian risk – barriers, traffic “calming”, more pedestrian facilitiesImprove speed and quality of emergency care (at crash site and after) – evaluate, identify and fix weak areas, trainInclude road safety as a key “performance attribute” of transportDemonstration projects, with strong evaluation
40 Focus areas for World Bank support that is evidence-based, cost-effective, and follows international best practice:Capacity reviews – to ensure country commitment, customization, consensusEnsure lead agency has capacity, mandate, and funding to manage for resultsInvest in management capacity to deliver results in stagesLearn by doing demonstration projects that rapidly achieve safety improvements in high-risk areas, then build on successKey Partners:Global Road Safety Partnership of the International Red Cross FederationInternational Road Assessment Program (iRAP) - engineering safetyRoadPOL - traffic police peer-to-peer servicesInternational Road Traffic Accident Database Group - dataWorld Health Organization (WHO) - technical support in traffic injury prevention, injury surveillance, emergency trauma services & careMinistries: transport, health, law enforcement, finance, interior, educationPrivate sector: insurance, auto makers, media, regulatory agenciesCSOs: consumer organizations, faith-based organizationsParliaments
41 Effective Road Safety Program Building Blocks Intervention AreaInvestments and actions1. Institutional capacity buildingEstablish, organize and strengthen management and operational capacity of a lead agency for road safety, resource it adequately, make it publicly accountable.Training programs for all official involved in management and design of road safety programs and implementation of road safety programs.2. National road safety policies, strategies, plans; organizational & co-ordination arrangementsTechnical assistance for developing/updating legislative framework, policies, strategies and plans with targets to halve RTI fatality rates by 2020.3. Create safer road environmentsInvestments to improve safety in demonstration road corridors and beyond (e.g. guard rails, signaling and marking, reengineering most critical crossroads in urban areas). Technical assistance to do network safety rating surveys and road safety audits and inspections.4. Enforcement: equip and train traffic police to deter risky behaviorAcquire radar equipment, speed cameras, and breath analyzers, to enable roadside checks to control and monitor speed, alcohol, and seatbelt use.5. Public information and education campaignsTechnical assistance and funding to develop public IEC programs to support enforcement of laws and regulations for speed-control, seatbelt use, and deterring drinking and driving.6. Improve health promotion and prevention programs, emergency medical services, and rehabilitation servicesAs part of health system reforms and modernization, technical assistance to strengthen public health programs, national and regional road safety strategies, and organizational arrangements for first aid emergency responses; funding for ambulances, medical equipment and other inputs; training of medical personnel on basic and advanced life support systems; communication systems investments; and technical assistance and investments to develop/strengthen trauma centers, safe blood transfusion services, and rehabilitation programs.7. Monitoring and evaluationInvestments in computerized information systems for data collection, assessment and sharing information for decision-making and program management across sectors.
42 Take Away Messages:Safe, clean, affordable transport is a development priority.Preventing road traffic injuries is a major public health priority.Proven, effective, cost-effective “good practices” can save lives and money, prevent disability, improve other health outcomes and the environment.A “safe system” needs well-coordinated, cooperative action by transport, health and policing/enforcement sectors. Interventions alone will not suffice.The World Bank could do more, with partners, to help countries in Eastern Europe and Central Asia make roads safer. Specific areas for action are clear.Thank you!