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establishing multisectoral partnerships to address a silent epidemic

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1 establishing multisectoral partnerships to address a silent epidemic
Confronting “Death on Wheels” Making Roads Safe in Europe and Central Asia establishing multisectoral partnerships to address a silent epidemic PATRICIO MARQUEZ THE WORLD BANK KIEV, MAY 2010

2 Outline: Challenges and Opportunities in Addressing Road Safety in the ECA Region*
The problem: trends, size, characteristics, causes Effective measures to improve road safety Current international road safety policy Possible 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 disparities 5 10 15 20 25 30 1980 1990 2000 2010 European Region EU CIS CIS European Region EU-27 Increasing 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
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 3.2 3.4 4.8 4.9 5.0 5.2 5.4 5.7 6.0 6.9 7.2 7.5 8.3 8.5 9.3 9.6 9.7 9.8 10.0 10.2 10.4 10.9 12.0 12.3 12.7 13.0 13.2 13.4 13.6 13.9 14.1 14.6 14.7 14.9 15.1 15.7 16.8 17.9 18.6 20.4 21.5 22.4 22.8 25.2 30.6 0.0 5 10 15 20 25.0 30.0 35.0 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 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 Source: WHO-EURO, 2009 25 30

5 GDP and RTIs mortality in ECA

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 in Similarly, 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 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

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 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) 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 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?"

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.


16 Current Road Safety Policy – Holistic “Safe Systems” approach
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

17 Effective Approaches Action Areas:
Prevent road traffic crashes and injury Minimize injuries when crashes occur Recovery: reduce injury severity afterwards The Haddon Matrix: a holistic framework for intervention focusing on road transport and its risks Car crashes divided into 3 phases: before, during and after to highlight when crashes can be prevented or their effects minimized Sources for cost effectiveness estimates: ETSC 2003, SWOV 2001, and U.S. National Center for Injury Prevention and Control 2000

18 Haddon`s Matrix Травма – 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 accountability Provides cohesion and direction, strategic orientation linking interventions with results, analyzes what could be achieved over time Sets 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 basis Different mechanisms adopted in various countries

24 Funding Sources 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) 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 interventions Monitoring 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 types Standards and rules Compliance Planning, design, operation and use of the road network Standards 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 network Standards and rules also address vehicle safety standards and driver licensing requirements Recovery and rehabilitation of crash victims from the road network Standards and rules can also be set for the delivery of emergency medical and rehabilitation services to crash victim Source: Bliss, 2004

28 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)

29 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

30 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

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 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

32 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 In 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 travel Intermediate outcomes Intermediate 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. Outputs Outputs 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 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 In 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 government Assess road traffic injury problems, policies and institutions, and capacity for prevention Prepare a national road safety strategy and plan of action Allocate financial and human resources Implement specific actions and evaluate their impact Support national capacity and international cooperation. Principles: systematic, sustained, successful effort has 3 parts: Results Institutional management interventions

38 What could the World Bank do? (iii)
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 Help countries choose interventions well Review national road safety management capacity - assess the situation, propose strategies and actions with realistic targets and budgets Support 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 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

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, consensus Ensure lead agency has capacity, mandate, and funding to manage for results Invest in management capacity to deliver results in stages Learn by doing demonstration projects that rapidly achieve safety improvements in high-risk areas, then build on success Key Partners: Global Road Safety Partnership of the International Red Cross Federation 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

41 Effective Road Safety Program Building Blocks
Intervention Area Investments and actions 1. Institutional capacity building Establish, 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 2020. 3. 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 evaluation Investments 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!

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