Confronting “Death on Wheels” Making Roads Safe in Europe and Central Asia ESTABLISHING MULTISECTORAL PARTNERSHIPS TO ADDRESS A SILENT EPIDEMIC J ANUARY 2010

Outline: Challenges and Opportunities in Addressing Road Safety in the ECA Region* 1. The problem: trends, size, characteristics, causes 2. Effective measures to improve road safety 3. Current international road safety policy 4. Possible strategies and actions by the World Bank with partners * Baltic, Balkans, EE, CIS, Turkey.

Road Traffic Injury (RTI) Mortality Rate Trends Europe, EU-27 and CIS Countries, per 100,000, 1980–2007 large, increasing disparities 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) European Region EU CIS European Region EU-27

RTI Death Rates in WHO-EURO Member Countries, per 100,000 Population, San Marino Malta Netherlands Switzerland Norway Sweden United Kingdom Israel Germany MKD* Finland France Austria Ireland Spain Italy Uzbekistan Serbia Iceland Belgium Cyprus Portugal Bosnia and Herzegovina Czech Republic Hungary Romania Azerbaijan Bulgaria WHO EURO Turkey Croatia Armenia Albania Tajikistan Slovenia Poland Estonia Greece Republic of Moldova Slovakia Belarus Georgia Latvia Turkmenistan Montenegro Ukraine Lithuania Kyrgyzstan Russian Federation Kazakhstan Deaths per population High-income countries Low- and middle-income countries Source: WHO-EURO, 2009 Kazakhstan Russian Federation Kyrgyzstan Ukraine Montenegro Turkmenistan Latvia Georgia Belarus Slovakia Rep. of Moldova Greece Estonia Poland Slovenia Tajikistan Albania Armenia Croatia Turkey Average-WHO-EURO Bulgaria Azerbaijan Romania Hungary Czech Republic Bosnia & Herzegovina Portugal Cyprus Belgium Iceland Serbia Uzbekistan Italy Spain Ireland Austria France Finland Fmr Yugoslav Rep. of Macedonia Germany Israel UK Sweden Norway Switzerland Netherlands Malta San Marino 3025

Deaths, disability and damage – who bears the brunt? 4-wheel vehicle occupants: 40-75% of RTI deaths in ECA Young adults, especially men: 55% of road traffic deaths in ECA countries are people aged 15–44, mostly 15–29; > 80% of deaths are men Cyclists, 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 vehicles Pedestrians – more likely to be children or elderly, and people with lower incomes In Albania, Belarus, Kyrgyzstan, Tajikistan, and Ukraine, pedestrians are ≥ 40% of all road fatalities, 31-38% in all ECA

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 annually Highest costs in ECA: large economies with big populations: Air pollution, noise Greenhouse gas emissions contribute to global warming Fear deters walking, biking. Less mobility and physical activity reduces health, increases risks for cardiovascular diseases, strokes, diabetes, obesity Russia (US$34 billion per year, 33,308 deaths in 2007) Turkey (US$14 billion) Poland (US$10 billion) Ukraine (US$5 billion) Russia (US$34 billion per year, 33,308 deaths in 2007) Turkey (US$14 billion) Poland (US$10 billion) Ukraine (US$5 billion)

Road Traffic Injury Causes Lack of data /problem awareness Inadequate response, resources Roads Bad road design (no crossings, walkways, poor visibility) Roadside hazards (trees, poles, signs) Mixing traffic and pedestrians Vehicles Unsafe vehicles, without airbags & other crash protection devices Huge increase in vehicle numbers (poor public transport) Behaviors Inadequate laws/rules + poor enforcement Bad driving (speeding, recklessness, alcohol, some medications) Not using seatbelts, helmets (cyclists, motorbikes) Mobile phone texting “Are you in a hurry to reach us?"

Effective Approaches Action Areas: Prevent road traffic crashes and injury Minimize injuries when crashes occur Recovery: reduce injury severity afterwards Cost effectiveness: Savings vary from $1 (motorcycle helmets) to $36 (random alcohol level testing) per dollar spent on interventions

Effective Approaches Elements of Success: Plan long term, demonstrate short term gains Measure outcomes, monitor performance Make road safety integral to transport policy Competent lead agency coordinates actions by transport, interior, police, health, education etc Ensure adequate financing Good public transport options

Effective proven measures Better road design Remove roadside hazards (trees, poles) Install crash barriers Clear, helpful, safely placed road signs Central islands, “pedestrian refuge” Well-designed pedestrian crossings Separate vehicles from pedestrians and cyclists Audible road edge-lining, seal shoulders, construct passing lanes Better road markings Traffic calming (speed bumps, cameras)

Effective proven measures (2) Improve vehicle safety In-vehicle crash protection (airbags, seatbelts, child car seats) Vehicle licensing and inspection to enforce roadworthy standards Daytime running lights Require and enforce helmet use with bicycles, motorbikes

Effective proven measures (3) Behavior change - education, law/regulation enforcement Lower speed limits: 30 km/hr in residential areas, 50 km/hr in other urban areas Enforcing 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 use Prevention of distracting driving due to use of phones and texting Media coverage, education campaigns + tough sanctions Graduated 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

Cost-effectiveness – depends on risk factors, and distribution of fatalities/injuries by road user group Average cost per disability-adjusted life (DALY) year saved, adjusted for purchasing power parity

Financing Sources Source: Adapted from OECD (2002) and Aeron-Thomas and others (2002), cited in Peden and others (2004); ECORYS (2006). Traditional funding sources: General tax revenues Road 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 levies Earmarked 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)

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 interventions Primary health care providers: medical assessments of elderly/impaired drivers, advice on alcohol use and effects on driving of medications Emergency medical services: communication for rapid response, initial emergency care and stabilization, transport to health facility, well-trained teams with medicines and equipment, quality assurance Safe blood supply &transfusion Rehabilitation services

Current Road Safety Policy – Holistic “Safe Systems” approach Crash Phase Nature of Intervention Human Factors Vehicle and Equipment Factors Environment Factors Pre-crashCrash preventionInformation Training Attitudes Impairment Road-worthiness Lighting, Braking Handling Speed management Road design, signs, markings, maintenance Speed limits Pedestrian facilities CrashInjury prevention during crash Use of restraints Impairment Occupant restraints/ airbags Other safety devices Crash-protective design Crash-protective roadside objects Post-crashLife-sustainingFirst aid skill Access to medical care Ease of access Fire risk Rescue facilities Congestion Haddon’s Matrix for Crash and Injury Prevention Principles: Cannot prevent all road crashes, can reduce traffic injuries Design road traffic systems to take account of human error and vulnerability of human body Responsibility and accountability for road safety shared by road and car designers and road users

ECA Efforts to Prevent Road Transport Injuries Good Examples: Poland: public education on road safety, seat-belt use, drunk driving; training for professional drivers; road signs warning of black spots; improved pre-hospital care Armenia: dramatic improvements in seatbelt use by enforcing seatbelt law Russia: fines for not using a seatbelt increased 10x, new law against crossing into an oncoming lane punishable by revoking driver’s license, anti-alcohol campaigns launched much more is possible Of 29 countries in ECA: 27 have a lead agency for road safety 19 allocate funds in the national budget 19 have a strategy with clear targets, 16 of these are funded 25 set blood alcohol limits at/below recommended level (0.05g/dl) 27 do spot checks for alcohol levels many require formal audits for major new road construction projects and regular audits of existing roads, many promote public transportation, walking, and cycling But Only 8 countries have seatbelt used at least 70% (in front seats) Urban speed limits are 60km/h in 15 countries, 70 km/h in 1 (higher than recommended) Quality of formal, publicly available pre- hospital post-crash care systems varies Enforcement is often lacking

World Bank Support (to date)  Practical guidelines to help countries implement these recommendations  Global Road Safety Facility generates funding and Technical Assistance for country road safety efforts  Road safety management capacity reviews done in many ECA countries  World Bank-supported road safety investments in transport and health projects  Information and policy dialogue

What more could the World Bank do in ECA? 2004 World Report identifies 6 key steps for success: 1. Identify a lead agency in government 2. Assess road traffic injury problems, policies and institutions, and capacity for prevention 3. Prepare a national road safety strategy and plan of action 4. Allocate financial and human resources 5. Implement specific actions and evaluate their impact 6. Support national capacity and international cooperation. Principles: systematic, sustained, successful effort has 3 parts: Institutional management interventions Results

What more could the World Bank do in ECA? (1) 1. Build institutional management capacity Provide training and information for policy makers, practitioners Support existing networks of people responsible for road safety Help countries improve data on RTIs and causes Specify lead agency reforms needed 2. Help countries choose interventions well Review national road safety management capacity - assess the situation, propose strategies and actions with realistic targets and budgets 3. Support a safe system approach + results focus aiming to end road deaths and serious injuries (see next slide for specifics)

What more could the World Bank do in ECA? (2) 3. Support a safe system approach + results focus aiming to end road deaths and serious injuries: Analyze planned road investments for safety, improve design Review road sections where many crashes occur to target investments Lower urban speed limits to 50 km/h; 30 km/h in residential areas; enforce – speed cameras are cost effective Enforce alcohol limits with systematic police enforcement (breath tests, high- visibility random road checks), high-profile media campaigns, and swift severe penalties Enforce use of seat belts – campaigns, penalties, car restraint specifications Reduce young driver risk – graduated licensing scheme, extended training Reduce pedestrian risk – barriers, traffic “calming”, more pedestrian facilities Improve speed and quality of emergency care (at crash site and after) – evaluate, identify and fix weak areas, train Include road safety as a key “performance attribute” of transport Demonstration projects, with strong evaluation

Focus areas for World Bank support that is evidence-based, cost-effective, and follows international best practice: A. Capacity reviews – to ensure country commitment, customization, consensus B. Ensure lead agency has capacity, mandate, and funding to manage for results C. Invest in management capacity to deliver results in stages D. Learn by doing demonstration projects that rapidly achieve safety improvements in high-risk areas, then build on success Key Partners: International Road Assessment Program (iRAP) - engineering safety RoadPOL - traffic police peer-to-peer services International Road Traffic Accident Database Group - data World Health Organization (WHO) - technical support in traffic injury prevention, injury surveillance, emergency trauma services & care Ministries: transport, health, law enforcement, finance, interior, education Private sector: insurance, auto makers, media, regulatory agencies CSOs: consumer organizations, faith-based organizations Parliaments

Effective Road Safety Program Building Blocks Intervention AreaInvestments and actions 1. 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 arrangements Technical assistance for developing/updating legislative framework, policies, strategies and plans with targets to halve RTI fatality rates by Create safer road environments Investments 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 behavior Acquire 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 campaigns Technical 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 services As 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.

 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.  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! Take Away Messages: