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

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, 1980–2007large, 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).

5

10

15

20

25

30

1980 1990 2000 2010

European RegionEU CIS

CIS

European Region

EU-27

RTI Death Rates in WHO-EURO Member Countriesper 100,000 Population, 2007

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

10.4

10.9

12.0

12.3

12.7

13.0

13.2

13.4

13.4

13.6

13.9

13.9

14.1

14.6

14.7

14.7

14.9

15.1

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 100 000 population

High-income countries

Low- and middle-income countries

Source: WHO-EURO, 2009

KazakhstanRussian FederationKyrgyzstanUkraineMontenegroTurkmenistanLatviaGeorgiaBelarusSlovakiaRep. of MoldovaGreeceEstonia PolandSloveniaTajikistanAlbaniaArmeniaCroatiaTurkeyAverage-WHO-EUROBulgariaAzerbaijanRomaniaHungaryCzech RepublicBosnia & HerzegovinaPortugalCyprus

BelgiumIcelandSerbiaUzbekistanItalySpain IrelandAustriaFranceFinlandFmr Yugoslav Rep. of MacedoniaGermanyIsraelUKSwedenNorwaySwitzerlandNetherlandsMaltaSan Marino 302

5

GDP and RTIs mortality in ECA

Alb

an

ia

Arm

en

ia

Aze

rbaij

an

Bela

rus

Bo

sn

ia&

Herz

e.

Bu

lgari

a

Cro

ati

a

Cze

ch

Rep

ub

lic

Esto

nia

Geo

rgia

Hu

ng

ary

Kaza

kh

sta

n

Kyrg

yzs

tan

Latv

ia

Lit

hu

an

ia

Mo

ldo

va

Mo

nte

neg

ro

Po

lan

d

Rep

of

Maced

on

ia

Ro

man

ia

Ru

ssia

Serb

ia

Slo

vakia

Slo

ven

ia

Taji

kis

tan

Tu

rkey

Tu

rkm

en

ista

n

Ukra

ine

Uzb

ekis

tan

0

5000

10000

15000

20000

25000

0

5

10

15

20

25

30

35

GDP Per Capita and Mortality Rate by Country in ECA

GDP per capita US$ Death Rates 2007

GD

P P

er

Capit

a (

US$)

Mortality Rate

Economic development does not lead automatically to lower road fatalities, therefore need for effective road safety management strategy

0 5000 10000 15000 20000 25000 30000 35000 40000 45000 50000

0

5

10

15

20

25

30

35

f(x) = − 0.000134662200849628 x + 16.8168324227779R² = 0.0546057376186149

GDP and Mortality Rates in 39 Countries in 2007

Death Rates 2007 Linear (Death Rates 2007)

GDP Per Capita

Mort

ality

Rate

Source: Elaboration by Authors

The RTI situation in Ukraine (1) Road traffic crashes decrease from 63,000 in 2007 to

51,000 in 2008.

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 2007 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.

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.

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 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

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.

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)

Impact on the Health SystemRTIs 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 0.27 percent of GDP in 2003, or about USD 1.2 billion (World Bank 2005).

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?"

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.

WHAT TO DO?

INTERVENTIONS ALONE WILL NOT SUFFICE

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

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

Haddon`s Matrix

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

Institutional management functions

Delivered by government entities, in partnership with civil society and business entities to achieve RESULTS

RESULT FOCUSA 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

FUNCTIONS (i)Coordination: horizontally and

vertically, partnerships

Legislation: the legal instruments for governance; defines responsibilities, accountabilities, interventions, and related institutional management functions

FUNCTIONS (ii)

Funding and resource allocation: how to finance interventions and related management functions on a sustainable basis

Different mechanisms adopted in various countries

Funding 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)

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

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.

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

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

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

Cost-effectiveness – depends on risk factors, and distribution of fatalities/injuries by road user group

$- $10,000 $20,000 $30,000 $40,000 $50,000 $60,000 $70,000

Enforcement of speed limits (via fixed/mobile cameras)

Drink-drive legislation & enforcement (breath-testing)

Legislation & primary enforcement of seat belt use

Legislation & enforcement of helmet use by motorcyclists

Legislation & enforcement of helmet use by bicyclists

Speed cameras + breath-testing

Seatbelts + motorcycle helmets

Speed cameras + breath-testing + seatbelts

Speed cameras + breath-testing + motorcycle helmets

Seatbelts + motorcycle helmets + breath-testing

Seatbelts + motorcycle helmets + speed cameras

Seatbelts + motorcycle helmets + speed cameras + breath-testing

Seatbelts + motorcycle helmets + speed cameras + breath-testing + bicycle helmets

Average cost per DALY saved

EurB

EurC

Average cost per disability-adjusted life (DALY) year saved, adjusted for purchasing power parity

Safety TargetFinal 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

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.

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.

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.

What could the World Bank do? (ii)

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 could the World Bank do? (iii)

1. 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 needed

2. Help countries choose interventions wellReview 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 could the World Bank do? (iv)

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: 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

Effective Road Safety Program Building Blocks

Intervention Area Investments and actions1. 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.

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!

Take Away Messages: