51667 "From time to time in human history there comes a killer epidemic "Our work on regional and global public goods will require close that is not recognized for what it is and is not acted against until cooperation with other agencies that have specialized exper- it is almost too late. HIV/AIDS, which is ravaging Sub-Saharan tise...We also must determine the Bank Group's comparative Africa, is one such. Road traffic injuries have the potential to be advantage to best focus our resources through selective, dif- another." ferentiated approaches. Given our specialization in working on ­ Desmond Tutu, development at the national level, our most important operating Emeritus Archbishop of Cape Town, challenge will be to support countries as they determine how Nobel Peace Prize Laureate, 1984 best to integrate public goods policies--and regional and global opportunities--into national programs. These opportunities should draw on private sector entrepreneurs and energies, too." "Beyond the enormous suffering they cause, road traffic crashes ­ Robert Zoellick, can drive a family into poverty as crash survivors and their President, The World Bank families struggle to cope with the long term consequences of the event, including the cost of medical care and rehabilitation and all too often funeral expenses and the loss of the family bread- winner." "Nowadays, a Minister of Health cannot consider his or her job Confronting ­ Margaret Chan, Director-General, World Health Organization done simply by looking at the health care system. It's not enough to have a health policy, you need healthy policies elsewhere. We need to redefine health not as a specialized sector with doctors and nurses, but as a social objective. You need strong policies "Death on Wheels" for empowering women, for promoting a fair justice system that brings perpetrators of violence to justice, and--in the case of Making Roads Safe in Europe and Central Asia "The national economy lost US$175 billion from traffic accidents accidental injury--for safe roads." over the past five years. That is comparable with overall health care expenditures of the same period." ­ Julio Frenk, Former Health Secretary of Mexico Establishing multisectoral partnerships ­ Dmitry Medvedev, President of the Russian Federation, and current Dean of the to address a silent epidemic Harvard School of Public Health The New York Times, August 8, 2009 "All multilateral development banks (MDB's) are committed to "The safe system approach is simple, sustainable, affordable and taking a leading role to address what is becoming one of the effective." most significant public health development priorities of the early ­ Claes Tingvall, 21st century." Architect of Sweden's "Vision Zero" ­ Jamal Saghir, policy and Director of Traffic Safety, Director of Energy, Transport, Swedish Road Administration and Water, The World Bank. "We have the tools, the knowledge, to undertake this work. Now we need to see the political will to implement a Decade of Action. The United Nations has recognized that the global road injury epidemic is serious enough to warrant General Assembly resolu- tions and a first Ministerial-level conference." ­ Lord Robertson of Port Ellen, Former Secretary-General of NATO and Europe and Central Asia Region current Chairman, Commission for Human Development Department (ECSHD) Global Road Safety Sustainable Development Department (ECSSD) Global Road Safety Facility (GRSF) The World Bank World Bank Report No. 51667-ECA Copyright © 2009 Europe and Central Asia Human Development Department/The World Bank 1818 H Street, NW Washington, DC 20433, U.S.A. All rights reserved Manufactured in the United States of America First Printing: November 2009 The full report as well as the Executive Summary in Russian is posted at www.worldbank.org/eca/roadsafety. Library of Congress Cataloging-in-Publication Data has been requested. Confronting "Death on Wheels" Making Roads Safe in Europe and Central Asia Establishing multisectoral partnerships to address a silent epidemic Europe and Central Asia Region Human Development Department (ECSHD) Sustainable Development Department (ECSSD) Global Road Safety Facility (GRSF) The World Bank ii TABLE OF CONTENTS Acknowledgements..................................................................................................................... vii Abbreviations and Acronyms ......................................................................................................viii Executive Summary ..................................................................................................................... xi Chapter I. Introduction ................................................................................................................1 1. Negative transport-related environmental and health impacts ................................................1 2. What is a road traffic injury (RTI)? ............................................................................................2 3. RTIs risks from increasing motorization in LMICs ....................................................................2 4. The broad potential benefits of road safety policies ................................................................3 5. Road safety: The way forward ..................................................................................................3 6. Report objectives .....................................................................................................................4 Chapter II. The Epidemic of Road Traffic Injuries .................................................................7 1. The global context ....................................................................................................................7 2. ECA: A bleak situation and prognosis .................................................................................... 8 3. Country variability ...................................................................................................................11 4. Fatal road traffic injuries by ECA road user type ...................................................................11 5. RTIs among population groups ..............................................................................................15 6. Inequality dimension of RTIs ..................................................................................................15 7. What are the economic and social consequences of RTIs?..................................................16 Chapter III. Interventions and Results: What Is the Evidence?.......................................21 1. Engineering measures that improve road design and make roads safer .............................21 2. Vehicle design and safety equipment ....................................................................................22 3. Education, laws and enforcement ..........................................................................................22 4. Traffic management and reducing risk exposure to RTIs ......................................................26 5. Private sector role and practices to support road safety efforts ...........................................26 6. Cost-effectiveness of selected interventions and financial gains to society .........................27 7. How to finance road safety efforts?........................................................................................28 8. Country experiences: Selected international good practices................................................28 9. Country-level responses in ECA.............................................................................................31 Chapter IV. The Role of Health Systems in Preventing RTIs and Helping Victims .....35 1. Public health actions ..............................................................................................................35 2. The role of primary care services in RTIs prevention ............................................................36 3. Emergency medical care systems to deal with crash victims ...............................................36 4. The importance of blood transfusion services in dealing with RTIs ......................................37 5. Rehabilitation services............................................................................................................38 6. Good practices in organizing emergency medical services .................................................38 iii Chapter V. Road Safety Approaches and Policies ..............................................................41 1. The safe systems approach ...................................................................................................41 2. Policy framework at the international level .............................................................................42 3. Key European Union (EU) Policies and Legislative and Regulatory Framework on Road Safety: A "Safe System Approach" rather than a Group of Parallel Interventions .......42 4. Setting road safety targets .....................................................................................................45 5. Car and road assessments ....................................................................................................46 6. International organizations addressing road safety in ECA (other than the World Bank) .....46 7. Institutional arrangements at the country level ......................................................................48 Chapter VI. World Bank Support for Road Safety Improvements in ECA and in other Regions ....................................................................................................51 1. The Objectives and Scope of Action .....................................................................................51 2. The Global Road Safety Facility .............................................................................................51 3. Road safety management capacity reviews in ECA countries ..............................................52 4. Guidelines for the implementation of the recommendations of the 2004 World Report .........52 5. World Bank-supported road safety projects ..........................................................................52 Chapter VII. Priorities for Intersectoral Work on Road Safety in ECA ...........................59 1. Implementing the recommendations of the 2004 World Report: What needs to be done? ........................................................................................................59 2. Building institutional management functions..........................................................................60 3. Focus on results .....................................................................................................................62 4. Design demonstration projects ..............................................................................................64 Chapter VIII. The Task Ahead: Operationalizing an Effective Response in ECA .........67 1. Framework for action: World Bank future engagement on road safety ................................67 2. Options to support ECA countries in improving road safety .................................................67 3. Building blocks .......................................................................................................................69 4. Partnership arrangements with international agencies at the country, regional, and global levels .....................................................................................................70 5. Implementing arrangements ..................................................................................................70 6. Choice of instruments.............................................................................................................70 7. "Window of opportunity" for advancing the road safety agenda under ECA economic recovery programs ........................................................................................71 8. What could be achieved in a road safety decade? The case for action ...............................72 9. Safety on the roads: Multilateral Development Banks joining forces to save lives ...............72 Epilogue ......................................................................................................................................75 Annexes: The Response in ECA ­ Selected Indicators by Country ...........................................77 Annex 1: Institutional Framework for Road Safety, ECA Countries ............................................77 Annex 2: Road Safety Requirements and Compliance Rates, by ECA Country ........................78 Annex 3: Conference Declaration ...............................................................................................79 References ..................................................................................................................................83 Map of the World Bank Europe and Central Asia (ECA) Region ...............................................91 iv LIST OF FIGURES Figure 1: Estimated External Costs by Mode of Passenger Transport (Excluding Congestion), in the EU in 2002, 15 countries .........................................................2 Figure 2: Standardized Mortality Rates from Road Traffic Injuries in the European Region, EU-27 and CIS Countries, per 100,000, 1980­2007...................................9 Figure 3: RTIs Death Rates in WHO-EURO Member Countries, per 100,000 Populations, 2007 ...............................................................................................12 Figure 4: Trends in Age-standardized Mortality Rates from Transport Injuries among People Aged 0­14 and 15­24 in the European Region, the EU, and CIS Countries, 1980­2005 ..................................................................................14 Figure 5: Cost-effectiveness of Road Traffic Injury Prevention Strategies, in Europe and Central Asia, 2005 ...........................................................................................28 LIST OF TABLES Table 1: Predicted Road Traffic Fatalities, by World Bank Region ..............................................8 Table 2: Leading Causes of Death, All Ages, 2004 and 2030 ....................................................8 Table 3: Road Traffic Deaths and Nonfatal Injuries in ECA, by Country ...................................10 Table 4: Percentage of Fatal Road Traffic Injuries by Road User Type, 2007...........................13 Table 5: Road Traffic Deaths Involving Alcohol in ECA, 2007 ...................................................14 Table 6: Socioeconomic Cost Estimates for Road Injuries in ECA (2008 prices) .....................17 Table 7: Why Should the Private Sector be Interested on Road Safety Issues? .......................26 Table 8: Estimated Financial Savings to Society from Selected Road Safety Interventions ......29 Table 9: Haddon's Matrix for Crash and Injury Prevention ........................................................41 Table 10: Building Blocks for the Implementation of an Effective Road Safety Program..........69 Table 11: Multisectoral Collaboration for Road Safety...............................................................71 LIST OF BOXES Box 1: Sources and Quality of the Statistics and Indicators on Road Traffic Deaths and Injuries in Europe.............................................................................11 Box 2: RTIs Contribute to High Mortality Rates among Working-age Males in Russia and Ukraine .............................................................................16 Box 3: Stepwise Approach to the Choice of Alcohol-control Policies .......................................24 Box 4: Traditional and Alternative Sources of Funding for Road Safety Programs ...................29 Box 5: Selected International Country Experiences ..................................................................30 Box 6: How is Russia Responding to the RTIs Challenge? .......................................................32 Box 7: Seatbelts in Armenia ......................................................................................................32 Box 8: SAMU: France's Emergency Medical Services ..............................................................39 Box 9: Towards Zero: Ambitious Road Safety Targets and the Safe System Approach ...........43 Box 10: World Bank-supported Road Safety Projects in ECA ..................................................53 Box 11: Vietnam's Safe System Road Safety Improvement Project ..........................................55 v ACKNOWLEDGMENTS This report was prepared during May-October 2009 USAID: Paul Holmes, Senior Regional Health Advisor, by Patricio Marquez, Lead Health Specialist, Human Bureau for Europe and Eurasia. Development Department (ECSHD), George Banjo, Senior Transport Specialist, Elena Chesheva, Transport Bloomberg Philanthropies Health Initiative: Kelly Operations Officer, and Stephen Muzira, Young Larson, Health Specialist. Professional, Sustainable Development Department Jill Farrington, Honorary Senior Lecturer, UK Nuffield (ECSSD), Europe and Central Asia (ECA) Region Centre for International Health and Development, of the World Bank. The report also includes valu- University of Leeds, UK, and former Coordinator able contributions and technical advice from Dinesh Noncommunicable Conditions, WHO-EURO. Sethi, Francesca Racioppi, and Francesco Mitis of World Health Organization Regional Office for Europe Albert Figueras, Catalan Pharmacological Institute, (WHO EURO), Rome, Italy, as well as from Daniel H. Barcelona Autonomous University. Chisholm, Health Economist, WHO, Geneva. Diane Stamm, Beth Goodrich, Ekaterina Ushakova, and Additional contributions were made by Christopher Jennifer Manghinang, provided support in editing and R. Bennett, Senior Transport Specialist, and Richard in the production of the report. Martin Humphreys, Transport Program Team Leader, The report was prepared with the support of an ECSSD, the World Bank, and David Silcock, Road Innovations Grant from ECA Vice Presidency (ECAVP) Safety Consultant. under the leadership of Xiaonan Cao, Lead Knowledge The report benefited from comments and sugges- and Learning Officer (ECAVP) World Bank, and a grant tions from specialists of different institutions: from the Global Road Safety Facility administered by the World Bank. World Bank: Tony Bliss, Lead Road Safety Specialist, and Marc Sanford Shotten, Operations Officer, Energy, Overall support for undertaking this task was provided Transport and Water Department; Armin Fidler, by Abdo S. Yazbeck, Sector Manager, Health, Nutrition Lead Advisor Health Policy and Strategy, Human and Population, ECSHD; Henry G. Kerali, Sector Development Network; Sally M. Zeijlon, Manager, Manager, Transport, ECSSD; and Motoo Konishi, ECSCD; Charles Griffin, Senior Adviser, ECAVP; Country Director for the Central Asia Region, ECA, Zeljko Bogetic, Lead Economist, Russia Country World Bank. The support from Tamar Manuelyan Management Unit; Kumari Navaratne, Public Health Atinc, Director ECSHD, Peter D. Thomson, Director, Specialist and Focal Point on Road Safety, HNP, South ECSSD, and Jamal Saghir, Director, Energy, Transport, Asia Region; Vickram Cuttaree, Senior Infrastructure and Water Department, the World Bank, is much appre- Economist, ECSSD; Susanna Hayrapetyan, Senior ciated for this cross-sectoral work. Health Specialist, ECSHD; Joy de Beyer, Health Economist, Global AIDS Program (GAP); and Ben L.J. Eijbergen, Lead Transport Specialist, Sustainable Development Unit, South Asia Region. vii ABBREVIATIONS AND ACRONYMS ADB Asian Development Bank G-8 Canada, France, Germany, Italy, AIDS Acquired immune deficiency syndrome Japan, the Russian Federation, United Kingdom, United States; the EU is APL Adaptable Program Lending represented. AusAID Australian Agency for International GAP Global Aids Council Development GBP Great Britain Pound AusRAP Australian Road Assessment Program g/dl Grams per deciliter (measure of alcohol BAC Blood alcohol concentration concentration in blood) CIS Commonwealth of Independent States GDP Gross domestic product DALYs Disability-adjusted life years GNP Gross National Product dB Decibels GRSF Global Road Safety Facility DCPP Disease Control Priorities Project GRSP Global Road Safety Partnership DRLs Daytime running lights H-MICU Hospital mobile intensive care unit DRUID Driving Under the Influence of Drugs, HIC High-income country Alcohol and Medicines iRAP International Road Assessment Program EC European Commission ITF International Transport Forum ECA Europe and Central Asia km/h Kilometers per hour ECMT European Conference/Council of Ministers of Transport LMICs Low- and middle-income countries ECS Electronic stability control system MDB's Multilateral Development Banks ECSHD Europe and Central Asia Human MDG Millennium Development Goal Development mph Miles per hour ECSSD Europe and Central Asia Sustainable NCAP New car assessment program Development Department NGO Nongovernmental organization ECSCQ Europe and Central Asia Quality NHTSA National Highway Traffic Safety EEA European Environment Agency Administration (United States) EIB European Investment Bank NLTP National Land Transport Program EMS Emergency medical system NRSC National Road Safety Council EMSs Emergency medical services NTSC National Traffic Safety Committee EU European Union NZD New Zealand dollar EU-15 Austria, Belgium, Denmark, Finland, NZRSP New Zealand Road Safety Program France, Germany, Greece, Ireland, Italy, OECD Organization for Economic Co-opera- Luxembourg, the Netherlands, Portugal, tion and Development Spain, Sweden, and the United OECD/IT OECD International Traffic Federation Kingdom OLA Objective data, List of solutions/actions, EuroRAP European Road Assessment Program Addressed action plans FBS Fee-Based Services PHRD Policy and Human Resources FIA Fédération Internationale de Development Fund l'Automobile RSMCR Road safety management capacity review viii RTI Road traffic injury TSPMU Traffic Safety Project Management Unit SAMU Services d'Aide Médicale Urgente, UK United Kingdom Emergency Medical Services UN United Nations SIDA Swedish International Development UNECE United Nations Economic Commission Cooperation Agency for Europe SIL Sector Investment Loan USRAP United States Road Assessment Program SMR Standardized mortality rate UNRSC United Nations Global Road Safety SRSO Swedish Road Safety Office Collaboration SWOV Institute for Road Safety Research VND Vietnam Dollar (The Netherlands) VRA Vietnam Road Administration TB Tuberculosis WHA World Health Assembly TRRL Ltd. Transport and Roads Research WHO World Health Organization Laboratory, Ltd. (United Kingdom; formerly the Road Research Laboratory, WHO EURO World Health Organization Regional RRL) Office for Europe ix Executive Summary Executive Summary "Death on wheels" evokes a bleak image, but an appro- To begin to address the problem of road traffic injuries priate one for countries in the World Bank's Europe and fatalities, country authorities, the World Bank, and and Central Asia (ECA) Region.1 A combination of international partners need to (Saghir 2009): weak road safety management capacity, deteriorated roads, unsafe vehicles, poor driver behavior, and patchy · Recognize that the scale of the public health crisis from death on wheels in low- and middle-income enforcement of road safety laws, alongside exponential countries (LMIC) is unacceptable. growth in the number of vehicles, have contributed to road traffic injuries and fatalities multiplying at a rapid · Commit to implementing road safety measures that pace. are: (a) sustainable, which requires proper sequencing and a long-term commitment; (b) integrated, which This report provides an overview of the challenges and requires multisectoral and multidisciplinary engage- opportunities in addressing road safety in the ECA ment; and (c) inclusive, which takes into account Region. It presents information on the size, characteris- country development objectives and recognizes that tics, and causes of the problem; presents evidence on the poor and those thrust into poverty by road crashes the effectiveness of measures that countries world-wide have rights that deserve protection. have adopted to improve road safety; briefly describes current international road safety policy; and discusses a · Prioritize safe, clean, and affordable transport for range of strategies and actions that could be undertaken development. by the World Bank in coordination and partnership · Accelerate knowledge transfer and scale-up road safety with the World Health Organization (WHO), multilat- engagement and investments. eral development banks, other international agencies and donors, as well as with private and civil society · Understand that the World Bank, in partnership with institutions. other institutions, could play an important role in supporting governments to raise the political impor- A primary audience of this report is internal--particu- tance of road safety as a development priority and in larly managers and staff of the World Bank working in designing and implementing programs and projects the transport, health, education, and governance sectors, over the medium term to achieve road safety targets. to raise awareness about the multisectoral nature of the This in turn will help raise the importance of road road safety challenge and of effective options to address it. safety in country and regional assistance agendas of It proposes ways that the World Bank might engage more other international agencies and among the donor to support ECA countries in tackling this issue, work- community. ing in partnership with other international agencies and donors. The secondary audience is external--policymak- ers, senior analysts, program managers, and their advisers THE NATURE OF THE PROBLEM in the governments of ECA countries, private sector Most passenger and goods traffic uses roads (for exam- officials, and civil society and international organizations ple, close to 80 percent and 50 percent, respectively, in working in this field. The goal is to support discussion the European Union). Rising incomes in many develop- on appropriate choices and instruments for advancing ing countries have led to more motor vehicles and great- the road safety agenda as a top development priority er traffic volumes, but road safety management capacity, over the short and medium term. road infrastructure and enforcement of traffic safety reg- ulations have not kept pace. As a result, road traffic inju- ries (RTIs) have become a major public health challenge 1 Countries of the Former Soviet Union, the Baltics, the Balkans, in many low- and middle-income countries (LMICs), Eastern and Central Europe, and Turkey. xi including in ECA. About 90 percent of the 1.3 million per capita by car. RTI deaths in ECA in 2007 showed deaths and 50 million injuries from road traffic crashes increases ranging from 8 percent to 39 percent. In 2007, worldwide each year occur in LMICs, although these there were an estimated 80,000 reported traffic deaths countries have only 48 percent of the world's registered in ECA countries, where RTIs are already among the vehicles (WHO 2009a). Increasing motorization and top 10 causes of death. Besides deaths, the societal toll urbanization in LMICs could double this toll by 2030. of RTIs in ECA is also reflected in more than 800,000 The difference between low- or middle-income countries nonfatal injuries that occurred in 2007. and high-income countries--where many road deaths still occur--is stunning. RTIs negatively affect economically productive age groups: 55 percent of road traffic deaths in ECA coun- The ECA countries have experienced rapid growth in tries are among people aged 15­44, mostly among those the number of passenger cars on the roads over the last aged 15­29; more than 80 percent of these deaths are two decades. In the Commonwealth of Independent men. Alcohol misuse is linked to increases in traffic States (CIS) there was a 120 percent increase in pas- fatalities and differences in death rates between males senger cars per 1,000 persons from 64 in 1990 to 141 in and females. Children and the elderly are also vulnerable 2003 (UNECE and WHO EURO 2009). Similar trends on the roads, especially as pedestrians, and are seven to are observed in countries in South-Eastern Europe: an nine times more likely to be killed in a road crash than increase from 18 passenger cars per 1,000 persons in car occupants. 1994 to 48 in 2002 in Albania, and from 143 to 276 in Croatia. However, there are still far fewer cars in most The proportion of deaths among different road users ECA countries than the typical range of 400 to 600 in varies from country to country, reflecting differences in Western Europe (UNECE and WHO EURO, 2009). exposure and safety. The majority of road traffic fatalities Increased reliance on private cars for transport in ECA is in ECA occur among motorized four-wheeler occupants. reflected in the smaller increase in the number of buses However, pedestrian fatalities are also very high in sev- (Eurostat 2007). Vehicles in many ECA countries, par- eral ECA countries, accounting for 40 percent or more ticularly in the CIS, tend to be old and have substandard of total road fatalities in Albania, Belarus, Kyrgyzstan, safety features. Cross-border trade in cars considered too Tajikistan, and Ukraine. unsafe, old, or polluting for Western European countries exacerbates this problem. Length of roads (in 1,000 RISK FACTORS km.) and highways (in km.) has also increased since the 1990s, by 18 percent and 157 percent in the CIS, 21 The main risk factors for RTIs are: percent and 75 percent in EU-10 countries2, and 46 · Road design features, including those that expose percent and 144 in South-Eastern Europe, respectively. vulnerable road users when mixing with traffic (for In spite of significant investments in road infrastruc- example, due to lack of crossings or walkways). ture since the 1990s, in some CIS countries the road infrastructure suffers from poor maintenance and under- · Lack of effective regulation and enforcement of investment. The population in the CIS travels 800 km required vehicle condition, driver's education and per capita by car, as compared to more than 12,000 km training, and risky behaviors. per capita in Western Europe. · Driver behavior: speeding; recklessness; drinking and driving; not using seatbelts, helmets, and other While road traffic fatalities have declined steadily in protective equipment; and using mobile phones, espe- Western Europe, to below 6 fatalities per 100,000 in cially texting. the Netherlands, Sweden, Switzerland, Norway, and the United Kingdom (2006), deaths from RTIs have increased in most ECA countries in spite of the smaller ECONOMIC COST OF RTIs car fleet and relatively low number of km travelled The RTI epidemic has negative effects on individuals, societies, and health budgets. Worldwide, the cost of 2 The 10 countries which joined the EU in 2004: Cyprus, the road deaths and injuries is estimated at about 1 percent Czech Republic, Estonia, Hungary, Latvia, Lithuania, Malta, of Gross National Product in low-income countries, 1.5 Poland, Slovakia and Slovenia. xii percent in middle-income countries, and 2 percent in existing roads --many follow the EU Directive mandat- high-income countries. The total costs to governments ing audits for all investments in core road networks-- exceed US$500 billion annually. In ECA, the highest and have policies promoting public transportation, walk- costs are in the large economies with sizeable popula- ing, and cycling. Formal, publicly available pre-hospital tions: Russia (US$34 billion per year), Turkey (US$14 care systems for post-crash medical care are in place, billion), Poland (US$10 billion), and Ukraine (US$5 albeit with varied quality. billion). In addition to death and disability from road crashes, hazardous road conditions restrict citizens' In spite of progress observed in ECA countries, addi- mobility and opportunities to lead healthy, active lives, tional and scaled-up efforts and resources are needed to aggravating the risk of developing non-communicable remedy the significantly worse road safety performance conditions such as cardiovascular diseases and diabetes (including in countries that are now part of the EU) and contributing to increased obesity rates. than their counterparts in Western Europe. Experience from high income countries (HICs) and HOW TO TACKLE THIS PROBLEM? other middle-income countries shows that improving road safety requires a consistent, 20-to-30-year effort An effective road safety strategy requires a multisectoral, to develop and implement comprehensive, integrated "safe system" approach. It needs a lead agency to coor- safe system programs, under the coordination of a well dinate contributions by the many government depart- structured and funded, technically and operational com- ments across which road safety responsibilities tend to be petent, lead agency. Business planning processes diffused: transport, interior, police, health, and educa- and performance monitoring systems must be devel- tion, among others. The goal is to prevent the occur- oped and strengthened to support a long-term strategy, rence of injury, minimize the severity of injury when and the first phase of a strategy should foster consensus traffic injuries occur, and reduce the severity of injury in among stakeholders and public sector agencies on a the aftermath. long-term action plan based on demonstrably successful interventions. A financing plan for implementing the Road safety must be integrated into the design of trans- strategy should be specified. Support should be provided port plans and programs and considered in broader pub- to develop a program of road user education, traffic lic policy discussions that influence people's transport safety enforcement and emergency preparedness along a options and decisions. When road safety becomes an first set of demonstration corridors. Certainly efforts to integral part of transport policy, the benefits of reducing reduce corruption, lack of transparency, and lack of noise and air pollutants, controlling alcohol abuse, and credibility and public trust of road police should promoting walking and cycling become apparent. For improve. example, maintaining lower speeds reduces the costs of injuries and also the costs from air pollution, greenhouse The excessively large numbers of deaths and injuries in gas emissions, noise, and fear-based barriers among ECA countries are evidence of the need for international would-be pedestrians and cyclists. support for implementing a safe systems road safety approach over the short and medium term. ECA EFFORTS TO PREVENT ROAD Scaling up implementation of the recom- TRANSPORT INJURIES mendations of the 2004 World Report on Many ECA countries have structures and processes in Road Safety: what needs to be done in place to address RTIs, including institutional frame- ECA? works where lead agencies coordinate the national The findings of this landmark report (Peden and others response, funding in national budgets, and national road 2004) led to six over-arching recommendations that set safety strategies with measurable targets. National laws out the strategic initiatives necessary to improve country set speed limits, regulate driving under the influence of road safety performance: alcohol, and mandate the use of safety equipment. In addition, many ECA countries require formal audits of · Identify a lead agency in government to guide the major road construction projects and regular audits of national road safety effort. xiii · Assess the problem, policies and institutional settings consequences of injuries; to pinpoint risks for more relating to road traffic injury, and the capacity for effective action; and to evaluate the effectiveness of road traffic injury prevention in each country. those actions. · Prepare a national road safety strategy and plan of · National road safety reviews are a sound basis for action. formulating policies and plans. These reviews help identify main risk groups and exposures to determine · Allocate financial and human resources to address the priorities, set realistic targets, allocate budgets, specify problem. implementation responsibility, and ensure rigorous · Implement specific actions to prevent road traffic evaluation. crashes, minimize injuries and their consequences, and evaluate the impact of these actions. A focus on results requires: · Integrating road safety in all phases of planning, · Support the development of national capacity and design, and operation of road infrastructure. At the international cooperation. planning stage, before project approval, strategic Implementing these recommendations at country level comparative analysis of substantial changes and new requires building capacity, to create the resources and construction need to be conducted to examine the tools necessary to implement target initiatives on a scale network's safety performance. Road safety audits and capable of reducing road deaths and injuries significantly safety impact analyses complement these assessments and sustainably. It also requires an integrated framework focusing on the design characteristics of a road infra- that treats the recommendations of the World Report structure project. In addition, reviews of high road as a totality, and ensures that institutional strengthening traffic crash concentration sections need to be under- initiatives are properly sequenced and adjusted to the taken to help target investments to road sections with absorptive and learning capacity of the country con- the highest crash concentrations and/or the highest cerned (Bliss and Breen, 2009). crash reduction potential. A systematic response is needed. Managing for improved · Reducing speed limits, particularly in urban areas, road safety results at country level must address three and strengthening these efforts with road design, inter-related elements of the road safety management enforcement, publicity, speed cameras and appropri- system: institutional management functions, interven- ate penalties, to generate immediate safety benefits. tions, and results; with prime importance being placed · Reducing drinking and driving. Given the relative on institutional management functions and more specifi- importance of alcohol abuse in some ECA countries, cally the role of the lead agency. Interventions alone will broad alcohol-control policies, fiscal measures, and not suffice. interventions are required to support the long-term sustainability of road safety efforts. Blood alcohol lim- Building institutional management its need to be aligned with international practice and functions requires: priority given to systematic general deterrence-based · Strengthening institutions and governance capacity for police enforcement with severe penalties. RTI prevention, including lead agency capacity, tar- · Increasing seatbelt use through enforcement and geting evidence-based training of senior policymakers, publicity campaigns, revising specifications (at least executive managers in the various relevant sectors, and for new cars), promoting vehicle seatbelt reminder ministry focal points and practitioners, especially in systems, and undertaking periodic surveys to monitor transport, justice, traffic police, and health. Creating front and rear seatbelt usage rates. space for civil society and private sector participation has the potential to galvanize political support on the · Reducing young driver risk through graduated licens- basis of well-articulated social demands from commu- ing schemes and extended training programs. nities that bear the burden of RTIs. · Improving emergency medical systems as part of · Improving nationwide traffic injury surveillance broader health system modernization efforts to reduce systems to better map the causes, risks, extent, and fatalities and mitigate injuries. xiv · Integration of road safety and transport policy. Recent road crash fatalities during 2010­16 by exploring research indicates that improving transportation options to support the identification, selection, design, options (for example, better walking and cycling con- and implementation of actions most likely to prevent ditions, and improved ride sharing and public trans- road crashes and improve road crash emergency and port services) can reduce car collision frequency. rehabilitation services. Some ECA countries, as members of the EU, have the opportunity to deal with the RTI · Designing demonstration projects. Well-designed challenge through that membership. And, since non-EU demonstration projects can support the process of ECA countries may not have the same opportunity, the catching up with best practice in road safety perfor- support that could be provided by the World Bank mance and are an essential part of building capacity. would follow a tailored approach. They can provide useful benchmarks for rolling out a modern road safety program to the rest of the country As seen in ongoing U.S.-supported efforts under the with support from donors and international finance Recovery and Reinvestment Act of 2009, programs organizations. being funded by governments in different countries to reactivate economic growth and employment offer a "window of opportunity" to scale-up and improve road THE WORLD BANK'S ROLE safety in ECA. This implies that investment directed to To advance the road safety agenda, the World Bank co- roads and highways should incorporate safety features founded the Global Road Safety Facility in 2006 with and be coupled with support for implementing existing other partners. The Facility works with international road safety plans. partners to provide funding and technical assistance to On the basis of priorities set by ECA countries and tak- scale-up LMIC capacity to implement cost-effective road ing into account the individual circumstances of each safety programs. country, the World Bank could provide an assistance Road safety is routinely a key component in World program that advocates greater investment in certain Bank road infrastructure projects. For example, recently road safety initiatives, taking into account evidence- approved projects in Bosnia and Herzegovina, Bulgaria, based, cost-effective approaches and international best Georgia, Poland, and Ukraine include pilot measures practices, evidence from modeling exercises, extrapola- (and monitoring), such as road safety reviews, strength- tion of the impact of different interventions for improv- ening capacity of national road safety authorities, ing road safety, and available economic evidence. improving safety features of road infrastructure, tighten- Following the recently-issued World Bank guidelines for ing enforcement, and public campaigns for safer driving. implementing the recommendations of the 2004 World In Vietnam, a World Bank-supported project dedicated Report (Bliss and Breen 2009), programs could concen- to road safety and complementing related initiatives trate on the following areas: supported by other international agencies is enabling the government to achieve good results (for example, Capacity review. The conduct of a safety management unprecedented enforcement of a new law mandat- capacity review is a vital first step in the process of a ing motorcycle helmet use is contributing to reducing country tailoring the World Report recommendations to road traffic fatalities). This example of a multisectoral its unique circumstances. The review can help a country approach includes institution--and capacity strengthen- determine its readiness to commit to the productive and ing, physical road improvements, user education, and sustainable steps necessary to improve road safety out- monitoring and evaluation. The new road projects in comes. It also identifies related institutional responsibili- Georgia are trying to emulate this approach and apply it ties and accountabilities and provides a platform to reach to specific road corridors. World Bank projects in Russia an official consensus on country capacity weaknesses and and other countries have engaged the health sector to how best to overcome them. reorganize and strengthen emergency medical services to improve care for RTI victims. Role of lead agency. The World Report highlights the fundamental role of the lead agency in ensuring the The World Bank, working with international partners, effective and efficient functioning of the road safety could support ECA countries in their effort to reduce management system. Responsible and accountable road xv safety leadership at country, state, provincial and city other with a high rate of road crashes. Particular atten- levels is vital to success. In the absence of such leader- tion could be devoted to exploring links and synergies ship with a sustained focus on results, improvements, with transport policy options to mitigate the effects of for example, in program coordination, decentralization climate change through reduced greenhouse gas emis- and promotion will often be elusive and unsustainable. sions ­ this would garner additional support for policies Likewise, action plans prepared without a designated to reduce speeding and a modal shift toward safer, clean- agency mandated to lead their implementation and a er transport modes. In addition, this is an important area realistic and sustainable funding base are likely to remain for synergy with other health policies and programs, and paper plans and make no positive impact. with other international agencies and donors. Staged investment. Countries wishing to improve The objective of the demonstration projects would be their road safety performance must be well orga- to: (a) field-test a road safety improvement strategy that nized to achieve improved results in a systematic way. implements a combination of preventive safety engineer- Institutional management functions must take the ing measures and legal and regulatory measures to reduce highest priority as the foundation on which road safety urban speed limits to 50 km/h; and (b) encourage local management systems are built: they produce the inter- authorities to impose 30 km/h limits in highly popu- ventions that achieve the desired results. In practice, lated areas and to strictly enforce key safety behaviors institutional strengthening must be staged. During the concerning speed, seatbelts, and alcohol, supported by formative stages, emphasis must be put on improving high-intensity public education campaigns and strength- the focus on results and related inter-agency coordi- ened emergency medical care services. nation. As these institutional management functions become more effective, the remaining management func- Combined with the development of lead agency capacity tions are in turn strengthened. that would operate a continuous, detailed monitoring and evaluation system, the demonstration projects would Learning by doing. Sustained long-term investment is generate benchmark performance measures. This would the key to improving country road safety results. This allow successful interventions to be extended to the rest requires a staged process of investments that address of the country within a reasonable time frame, for exam- revealed capacity weaknesses, first building core capacity ple, five years. In some countries, this effort would also to achieve initial targeted safety outcomes, then scal- require a clearer distinction of what is possible at local, ing up investment to accelerate capacity strengthening regional, and national levels and their respective respon- and achieve improved results across the national road sibilities and related policy options and interventions, network. Building upon the findings of the country particularly since the World Bank is starting to work at capacity review, investment must be grounded in learn- the sub national level. ing by doing, backed with sufficient targeted investment to overcome the barriers presented by weak institutional capacity. WHY NOW? One way to operationalize this approach would be to The time to support concerted efforts to make roads support the design and implementation of safe system safer in ECA has arrived. Growing urbanization, poor demonstration projects that aim to anchor country road conditions, accelerating growth in the number capacity building efforts in systematic, measurable and of vehicles, patchy efforts to legislate and enforce road accountable investment programs that simultaneously safety measures, and increases in the rate of road injuries build management capacity while rapidly achieving safety and fatalities, present a real threat. Investing in effective improvements in targeted high-risk corridors and areas. interventions under a safe systems approach as suggested in this report would reduce premature mortality and dis- Demonstration projects could be located in distinct geo- ability, which contribute significantly to the demograph- graphic areas where road safety issues vary in nature: (a) ic decline in countries such as the Russian Federation in a densely populated urban area within a major city, and Ukraine. It would also support human capital accu- for example, Baku, Kiev, Moscow, St. Petersburg, and mulation, a key factor for sustainable economic growth Tbilisi; and (b) along a high-speed and highly trafficked in ECA and elsewhere. highway, for example, Moscow-St. Petersburg, or any xvi CALL TO ACTION "Safe, Clean and Affordable Transport for Development" (World Bank 2008a), and the new World Bank guide- This report provides evidence that road traffic safety lines for implementing the recommendations of the has tremendous implications for health, social welfare, 2004 World Report (Bliss and Breen 2009c). It also and economic well-being in ECA countries. Road traffic supports the health improvement and poverty alleviation injuries are a major cause of death and disability, in par- objectives outlined in the "Healthy Development" strat- ticular afflicting children, adolescents, working-age men, egy for health, nutrition and population results (World and the elderly. The report argues that accumulated evi- Bank 2007a), These efforts are also consistent with the dence from country experiences worldwide reveals prom- new strategic directions guiding the World Bank's overall ising measures that would strengthen institutions, laws work, particularly those of fostering regional and global and regulations, policies, enforcement mechanisms, and public goods that transcend national boundaries and of health service delivery systems to reverse deteriorating cooperating with other agencies having special expertise road safety conditions, save lives, and prevent injuries in (Zoellick 2008). the ECA countries. The proposed road safety effort is fully consistent with and supports the World Bank's transport strategy of xvii 1 "From time to time in human history there comes a killer epidemic that is not recognized for what it is and is not acted against until it is almost too late. HIV/AIDS, which is ravaging Sub-Saharan Africa, is one such. Road traffic injuries have the potential to be another." ­ Desmond Tutu, Emeritus Archbishop of Cape Town, Nobel Peace Prize Laureate, 1984 Chapter I. Introduction Transport is central to development--it facilitates the 1. Negative transport-related envi- movement of people, goods, and services; enhances ronmental and health impacts employment opportunities; and improves access to health care, education, and other essential services While contributing to economic growth and improv- (World Bank 1996). Most passenger and goods traffic ing living conditions, road traffic may expose people to uses roads (for example, close to 80 percent and 50 per- risks in a number of ways. For example, there may be cent, respectively, in the European Union) (Commission sudden and catastrophic negative impacts on health as of the European Communities 2001). Transport invest- in the case of road traffic deaths, or long term damage ments contribute to economic growth in both densely such as chronic respiratory diseases caused by air pol- populated cities and major corridors and more sparsely lution.3 Road traffic-related emissions of greenhouse populated suburban, rural, and other areas (Banister and gases contribute to climate change, which in turn, can Wright 2005; Straub 2008). In low- and middle-income result in extreme weather events, including floods--with countries (LMICs), transport investments reduce social attendant destruction of vital infrastructure, drought, exclusion by facilitating mobility; increase access to mar- and changes in the habitats of disease vectors that help kets and basic services; and improve health, education, spread communicable diseases such as malaria and den- and quality of life. gue in many regions of the world, including Central Asia. Air pollution costs are estimated at 2 percent of The transport sector is affected by the policy decisions of Gross National Product (GDP) in high-income coun- several other sectors, including fiscal, land use, urban and tries (UNECE and WHO EURO 2009). rural development, energy, and health. These, together with the transportation options available, facilitate or Pervasive traffic noise, congestion, and driver stress tend discourage the use of private cars and otherwise influ- to aggravate psychosocial and mental health problems. ence the choices people make for traveling. Perceptions Recent estimates indicate that in many European Union of whether roads are safe or not also influence people's (EU) countries approximately 30 percent of the popula- transportation choices, as does the social status associ- tion is exposed to traffic noise levels above 55 decibels ated with different modes of transport. For example, in (dB), although World Health Organization (WHO) some countries public transportation guidelines would limit them in residential areas to 55 is perceived as being "for the poor," while luxury cars are dB during the day and 45 dB at night (UNECE/WHO- perceived as being "for important people." The types of EURO 2009). The use of older vehicles and poor vehicle transport available to and chosen by populations maintenance worsens traffic noise in many LMICs, can have a dynamic and complex influence on exposure including former Soviet Union countries. to hazards or risks, with acute and chronic health effects. 3 In Moscow, for example, motor vehicles are the main source of air pollution, accounting for more than 80 percent of pollutants (UNECE and WHO EURO 2009). 1 Overall transport external costs were estimated at about Various time periods after a road crash are used when 8 percent of gross domestic product (GDP) in the EU- defining a road traffic fatality or injury, and other crite- 15 countries4 in 2002. Figure 1 shows that the external ria also vary for nonfatal injuries. In some countries, a costs of car transport (per 1,000 passenger-kilometers serious injury is defined as one requiring hospital atten- traveled) are considerably higher than other transport tion, while in others it is inpatient care for at least 24 modes. The largest cost category is road crashes, fol- hours or longer admission times (WHO 2009a). lowed by air pollution and climate change. The figure suggests that action should be taken to improve road 3. RTI risks from increasing safety, and also that bus and rail transport are likely to be less expensive and safer alternatives to car transport. motorization in LMICs The rapidity with which the risk of road traffic fatalities 2. What is a road traffic injury grows depends on the rate of growth in motorization and the rate of change in fatalities per vehicle (Kopits and (RTI)? Cropper 2003). Over the last 25 years in most LMICs, The current recommended definition of a road traf- the rate of vehicle ownership rose faster than the rate at fic fatality for harmonization of surveillance purposes which fatalities per vehicle fell. In many LMICs, particu- is "any person killed immediately or dying within 30 larly in ECA's transition countries, a dramatic decline days as a result of a road traffic injury" (WHO 2009a). in the quality of public transport has further accelerated private motorization. This decline is due to limited or 4 The EU-15 countries are: Austria, Belgium, Denmark, Finland, reduced public financing of the system and pushes many France, Germany, Greece, Ireland, Italy, Luxembourg, the people to meet their mobility needs through private cars Netherlands, Portugal, Spain, Sweden, and the United Kingdom. or informal public transportation, such as minibuses. Improvements in road infrastructure, Figure 1: Estimated External Costs by Mode of Passenger Transport public transport policies, and gover- (Excluding Congestion), in the EU in 2002, 15 countries nance systems, including enforcement of laws and regulations, have not Passenger transport accompanied increasing motorization. euro/1,000 passenger-km Many of the technical aspects of plan- 100 ning, highway design, traffic engineer- upstream process ing, and traffic management that are the hallmarks of transportation sys- urban effects tems in many high-income countries nature & landscape (HICs) are absent in LMICs (Tiwari, 75 climate change 2000). The lack of enforcement of air pollution speed limits and very high prevalence noise of drunk driving combine with poor 50 road planning factors--such as high accidents traffic in residential areas, schools on busy roads, dangerous passing on two- lane roads, lack of safe crossing points 25 and secure underpasses, and lack of barriers to prevent pedestrian access onto high-speed roads--to create an environment with an extremely high combination of risk factors for RTIs. 0 car bus rail aviation Several factors increase injury severity Source: European Environment Agency (EEA) indicators: http://themes.eea.europa.eu/Sectors_and_ from crashes. Roadside hazards, such activities/transport/indicators/cost/TERM25,2002/index_html. 2 as trees, poles, and road signs are one factor. Lack of benefits, are those that reduce average speeds and the in-vehicle crash protection devices is another. Evidence need for traveling or that substitute short car trips with indicates that many engineering advances made to vehi- pedestrian, bicycle, or public transport trips. cles in HICs are absent in LMICs, due to out-of-date design standards and the fact that most cars are more It is clear, therefore, that a broader approach to promote than 15 years old (UNECE and WHO EURO 2009), as road safety facilitates linkages with other policy initia- is often the case in ECA countries. Failure to use helmets tives and the search for synergies to maximize health by users of motorized two-wheeled vehicles and bicyclists gains in a society (WHO-EURO 2006). is also a significant risk factor for increased severity of injury. 5. Road safety: The way forward Efforts to strengthen emergency medical services also As noted by the Commission for Global Road Safety have lagged in many countries, resulting in failure to (2009), transport safety is the "orphan child of global address RTIs effectively when they occur and contribut- public policy," often falling through the cracks of the ing to rising numbers of deaths and people with dis- development agenda. This is reflected in the minimal abilities. HIC experience shows that at higher incomes, development assistance allocated to RTI prevention with slowing motorization and increasing investments by and the omission of transport and road safety from the governments, civil society, and individuals in road safety, Millennium Development Goals (MDGs). At the coun- RTIs mortality rates decline. try level, road safety responsibilities tend to be diffused across government departments--transport, interior, and police--without coordinated leadership. In large federal 4. The broad potential benefits of countries, lack of national responsibility is usually not road safety policies balanced by subnational efforts. When road safety becomes an integral part of transport The Commission for Global Road Safety (2009) also policy, the benefits of reducing noise and air pollution, notes that while the primary rationale for investing more controlling alcohol abuse, and promoting safe walking than US$4 billion each year in road infrastructure is and cycling become apparent. In addition, the range to improve road transport efficiency to spur economic of strategies available to improve road safety becomes growth, the risk and magnitude of increased societal costs broader and more cost-effective as investments deliver associated with rising RTIs is often overlooked. It warns multiple health benefits unavailable from singularly that unless road safety is integrated at the design stage focused approaches (Yasuf, Nabeshima, and Ha 2007). of road building and repair programs, new road invest- For example, maintaining lower speeds saves the costs of ments will lead "to higher casualty rates as they increase injuries and also the costs from air pollution, greenhouse both the speed and volume of traffic, intensifying injury gas emissions, noise, and fear-based barriers among risk especially to vulnerable road users, such as pedestri- would-be pedestrians and cyclists. In turn, facilitating ans, cyclists and children." walking and commuting by bike could achieve signifi- cant reductions in the health risks associated with seden- RTI prevention is now recognized as a major public tary lifestyles--obesity, non-communicable diseases such health priority worldwide that must be based on societal as heart attacks and strokes, and diabetes (WHO 2006). values (for example, a more balanced car and public transport culture), national policies, and laws and In recent years, policies that can deliver multiple health regulations that are properly enforced. As discussed in "co-benefits" have been increasingly attracting the inter- this report, broadening the effort beyond dealing solely est of policymakers as they face the challenge of reducing with the consequences of traffic crashes requires politi- greenhouse gas emissions from the transport sector.5 cal commitment and the allocation of resources from Policies primarily intended to combat climate change national authorities and the international community to but that can simultaneously result in immediate health support the development of multisectoral strategies and interventions in the short and medium term. This, in 5 An example of this new trend at the international level is the turn, requires the involvement of multiple stakeholders Amsterdam Declaration (UNECE and WHO EURO 2009), and actors (Bakefi 2006). which commits European countries to adopting this approach. 3 6. Report objectives Economic Commission for Europe (UNECE). Data collection was facilitated by the WHO-EURO Rome This report, based on a desk review, provides an overview Center. A wide literature review from scientific publica- of the challenges and opportunities in addressing road tions and other documentation was also conducted. safety in the countries that are part of the World Bank's Europe and Central Asia Region. It presents data and The primary audience is internal--particularly manag- information on the magnitude and characteristics of the ers and staff of the World Bank working in the trans- problem in ECA countries; briefly describes the current port, health, education, and governance sectors, to raise international policy framework on road safety, including awareness about the multisectoral nature of the road support provided by international organizations; offers safety challenge and of effective options to address it. It examples of effective ways that countries worldwide have proposes ways that the World Bank might engage more responded to different dimensions of this epidemic; and to support ECA countries in tackling this issue, working discusses a range of strategies and actions that could be with partner organizations. undertaken by the World Bank's ECA team working in The secondary audience is external--policymakers, coordination and partnership with other units in the senior analysts, program managers, and their advisers in institution and with WHO, multilateral development the governments of ECA countries, and people working banks, and other international agencies and donors, as on health and transport issues in the private sector, inter- well as with private and civil society organizations. The national organizations, and civil society organizations. report argues that road safety is best approached through The goal is to support discussion of appropriate choices intersectoral cooperation and that the transport, health and instruments for advancing the road safety agenda as and policing/ enforcement sectors have key roles to play a top development priority over the short and medium in preventing RTIs and their attendant deaths and dis- term. abilities. This report draws heavily on data and assessments prepared by the WHO, the World Bank, the Disease Control Priorities Project (DCPP), the Commission for Global Road Safety, the EU, and the United Nations 4 2 "Beyond the enormous suffering they cause, road traffic crashes can drive a family into poverty as crash survivors and their families struggle to cope with the long term consequences of the event, including the cost of medical care and rehabilitation and all too often funeral expenses and the loss of the family breadwinner." ­ Margaret Chan, Director-General, World Health Organization "The national economy lost US$175 billion from traffic accidents over the past five years. That is comparable with overall health care expenditures of the same period." ­ Dmitry Medvedev, President of the Russian Federation, The New York Times, August 8, 2009 Chapter II. The Epidemic of Road Traffic Injuries 1. The global context rapid motorization and intensified provision of road How should exposure to RTI risk be measured? With the infrastructure. This is important when considering the growing level of cooperation between the health and expected negative health impact of RTIs in the world transport sectors, deaths--"fatalities per 100,000 popu- (Plasencia and Borrell 2001; Murray and Lopez 1996). lation" are becoming a widely used measure of exposure Road traffic injuries are growing relative to most other to RTI risk (OECD and ECMT, 2006). The use of diseases worldwide (WHO 2004a). Table 2 on the next population as a denominator permits comparisons with page shows that RTIs accounted for about 1.3 mil- other causes of injury or with diseases. lion deaths worldwide in 2004, 2.2% of total deaths, Global road traffic fatalities are growing fast, and most expected to rise to 2.1 million and 3.2% of total deaths occur in low- and middle-income countries (LMICs). by 2030. Other sources estimate another 20 to 50 mil- Table 1 on the next page presents World Bank projec- lion nonfatal road traffic injuries annually (Murray and tions for global road fatalities, predicting they will others 2001; Peden and others 2004). increase by 66 percent between 2000 and 2020 unless RTIs are the leading cause of death for young people aged road safety interventions are intensified. These fatali- 10­24 globally (this group accounts for 30 percent of ties are estimated to increase by 80 percent in LMICs, the world's population), and are forecast by the WHO to while declining by close to 30 percent in HICs. Over 90 become the top cause of disability and premature death percent of RTI deaths occur in LMICs, although these for children aged 5­14 in LMICs by 2015. This would countries have only 48 percent of the world's registered cause far more disability-adjusted life years (DALY) lost vehicles (WHO 2009a). Road traffic fatality rates in than malaria, tuberculosis (TB), or acquired immune LMICs, at about 20 per 100,000 population, are nearly deficiency syndrome (AIDS). double the rate in high-income countries (HICs), at 10.3 per 100,000 (WHO 2009a). Pedestrians, cyclists, and motorized two-wheeler riders and passengers are vulnerable road users, at especially The gaps between poor and rich countries are widen- high risk of having an RTI and of dying from it. They ing. Scaled-up and effective measures are needed to account for about 46 percent of global road traffic reduce the growing vulnerability of LMICs experiencing deaths (WHO 2009a). 7 Table 1: Predicted Road Traffic Fatalities, Table 2: Leading Causes of Death, All Ages, by World Bank Region 2004 and 2030 Region % Change 2000­20 2004 South Asia 144% Deaths % Total East Asia & Pacific 80% Disease or Injury (millions) Deaths Sub-Saharan Africa 80% 1 Ischemic heart disease 7.2 12.2 Middle East and North Africa 68% 2 Cerebrovascular disease 5.7 9.7 Latin America and the Caribbean 48% 3 Lower-respiratory infections 4.2 7.1 Europe and Central Asia 18% 4 Chronic obstructive Subtotal 83% pulmonary disease 3.0 5.1 High-income countries -28% 5 Diarrheal diseases 2.2 3.7 Global Total 66% 6 HIV/AIDS 2.0 3.5 Source: Kopits and Cropper (2003). 7 Tuberculosis 1.5 2.5 8 Trachea, bronchus, lung cancers 1.3 2.3 9 Road traffic crashes 1.3 2.2 Road crashes tend to disproportionately affect low-income groups, and their attendant costs can plunge households 10 Prematurity and low birth weight 1.2 2.0 into poverty due to the loss of breadwinners and the 11 Neonatal infections and other 1.1 1.9 added burden of caring for members disabled by road 12 Diabetes mellitus 1.1 1.9 traffic injuries (Borrell and others 2005; Nantulya and 13 Malaria 1.0 1.7 Reich 2003; Roberts and Power 1996, Peden and others 2004). The population groups exposed to highest risks 14 Hypertensive heart disease 0.9 1.5 of injury and fatality from traffic crashes in low-income 15 Birth asphyxia and birth trauma 0.9 1.5 and middle-income countries--pedestrians, passengers 2030 of buses and trucks, motorcyclists and bicyclists--are Deaths % Total from lower socioeconomic groups because the more Disease or Injury (millions) Deaths affordable modes of transport present higher risks than 1 Ischemic heart disease 9.6 14.2 private cars (Natulya and Reich 2003, and Mock and others 1997). 2 Cerebrovascular disease 8.2 12.1 3 Chronic obstructive pulmonary disease 5.8 8.6 2. ECA: A bleak situation and 4 Lower-respiratory infections 2.8 3.8 prognosis 5 Trachea, bronchus, lung cancers 2.3 3.6 Rapid motorization has occurred without adequate 6 Diabetes mellitus 2.2 3.3 infrastructure and regulation. Transition countries that experienced rapid economic growth since the 1990s, 7 Road traffic crashes 2.1 3.2 such as Kazakhstan and Russia, motorized rapidly but 8 Hypertensive heart disease 1.5 2.2 without adequate infrastructure. Nor have effective regu- 9 Stomach cancer 1.3 1.9 latory controls been put in place--vehicle safety checks, 10 HIV/AIDS 1.2 1.8 particularly for public transport vehicles; drivers' licens- ing systems; and enforcement of speed and alcohol limits 11 Nephritis and nephrosis 1.1 1.6 and seatbelt and helmet use. 12 Self-inflicted injuries 0.98 1.5 13 Liver cancer 0.95 1.4 ECA countries have experienced rapid growth in the number of passenger cars on the roads over the last two 14 Colon and rectum cancer 0.94 1.4 decades. The Commonwealth of Independent States 15 Esophageal cancer 0.88 1.3 (CIS) went from 64 passenger cars per 1,000 persons in Source: WHO (2008a). 8 1990 to 141 in 2003, a 120 percent increase Figure 2: Standarized Mortality Rates from Road Traffic Injuries in the (UNECE and WHO EURO 2009). Similar European Region, EU-27 and CIS Countries, per 100,000, trends are observed in countries in South- 1980­2007 Eastern Europe: in Albania the increase was 30 from 18 passenger cars per 1,000 persons in 1994 to 48 in 2002, and in Croatia CIS from 143 to 276. However, the level of European Region cars in some of the ECA countries is still 25 EU much lower than the typical range of 400 to 600 in Western Europe (UNECE and WHO EURO, 2009). The population in the CIS travel 800 km per capita per year 20 by car, as compared to the population in Western Europe that travels more than 12,000 km per capita by car (passenger cars account for about 80 percent of this total). 15 While still well below Western European levels, increased reliance on private cars for transport in ECA is reflected in the smaller increase in the number of buses (Eurostat 10 2007). Vehicles and road infrastructure are gener- ally in poor condition. Vehicles in many 5 ECA countries, particularly in the CIS, 1980 1990 2000 2010 tend to be old and have substandard safety features. Cross-border trade in cars consid- Note: CIS countries are Armenia, Azerbaijan, Belarus, Georgia, Kazakhstan, ered too unsafe, old, or polluting for Western Kyrgyzstan, the Republic of Moldova, Russia, Tajikistan, Turkmenistan, Ukraine, European countries exacerbates this prob- and Uzbekistan. EU-27 countries are Austria, Belgium, Bulgaria, Cyprus, the Czech lem. Kilometers of roads and highways have Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Ireland, increased since the 1990s, by 18 percent and Italy, Latvia, Lithuania, Luxembourg, Malta, the Netherlands, Poland, Portugal, 157 percent in the CIS, 21 percent and 75 Romania, Slovakia, Slovenia, Spain, Sweden, and the United Kingdom. percent in EU-10 countries 6, and 46 percent Source: WHO EURO Health for All Data Base (2009). and 144 in South-Eastern Europe, respec- tively. But in spite of significant investments in road infrastructure since the 1990s, in some CIS European Countries (CEEC)7 and the CIS achieved countries the road infrastructure suffers from poor main- considerable annual reductions in the 1990s but since tenance and under-investment. about 1997 fatality rates have stabilized in the CEEC and have increased in the CIS (Figure 2), in spite of Changing mortality rates. Road traffic fatalities have the smaller car fleet and the low number of kilometers steadily declined in Western Europe, reaching lev- travelled per capita by car (OECD and ITF, 2008). els below 6 fatalities per 100,000 in 2006 in the While better than in Africa and Asia, ECA residents are Netherlands, Sweden, Switzerland, Norway, and the three times more likely to die from RTI than people in United Kingdom. The annual number of deaths from Western Europe (Sethi and others 2006a; Hyder and RTIs declined in the Western European countries by 61 Aggarwal 2009). Moreover, fatalities from RTIs are just percent over the 1970-2005 period. Central and Eastern 7 Albania, Bosnia and Herzegovina, Bulgaria, Croatia, Czech 6 The 10 countries that joined the EU in 2004: Cyprus, the Czech Republic, Estonia, Hungary, Latvia, Lithuania, Poland, Romania, Republic, Estonia, Hungary, Latvia, Lithuania, Malta, Poland, Serbia, Montenegro, Slovakia, Slovenia, The former Yugoslav Slovakia and Slovenia. Republic of Macedonia. 9 the tip of the iceberg--for every death, more people are 73 percent of the total deaths occured in ECA countries, hospitalized and many more have injuries that require which have only 28 percent of the registered cars in the medical attention. Region. In contrast, only 27 percent of the deaths occur in non-ECA countries, where 72 percent of the cars are Table 3 shows, by ECA country, the rate of increase in registered (WHO 2009a). deaths from 2006 to 2007 and the number of nonfatal Nonfatal injuries in ECA neared 820,000 in 2007, injuries in 2007. Of the estimated 127,000 RTI deaths in the WHO European Region, close to 80,000 deaths or contributing importantly to disabilities (WHO 2009a). For example, a study in Turkey found that of Table 3: Road Traffic Deaths and Nonfatal Injuries in ECA, by Country approximately 95,000 people injured in road traffic crashes in 2005, 13 percent had a sub- Country Deaths Deaths % Change Nonfatal sequent disability (Esiyok and others 2005). In 2006 2007 2006­2007 Injuries, 2007 Auckland, New Zealand, evidence on the bur- Albania 277 384 38.6 1,344 den of disability after motor vehicle crashes in Armenia 332 371 11.7 2,720 a population-based study shows that 43 percent Azerbaijan 1,027 1,107 7.8 3,432 of crash drivers admitted to the hospital and Belarus n.a. 1,517 n.a. 7,991 20 percent of those not admitted reported that their overall health at an 18-month follow-up Bosnia and Herzegovina n.a. 428 n.a. 11,647 was worse than before the crash (Ameratunga Bulgaria n.a. 1,006 n.a. 9,827 and others 2006). The drivers who reported Croatia n.a. 619 n.a. 25,092 worsened health reported both worsened physi- Czech Republic n.a. 1,222 n.a. 23,060 cal and mental health. Estonia n.a. 196 n.a. 3,270 The burden of RTIs can be measured by disabil- Georgia 675 737 9.2 7,349 ity-adjusted life years (DALYs). Supplementing Hungary n.a. 1,232 n.a. 27,452 mortality data, the DALY is an indicator that Kazakhstan n.a. 4,365 n.a. 32,988 captures the full burden of disease or injury. It Kyrgyzstan 1,051 1,252 19.1 6,223 is calculated by summing the years of life lost Latvia n.a. 407 n.a. 5,404 due to premature death (defined as the differ- Lithuania n.a. 759 n.a. 8,254 ence between the actual age of death and the Moldova n.a. 589 n.a. 2,985 life expectancy at that age in a low-mortality population) and the years of fully produc- Montenegro n.a. 122 n.a. 2,796 tive life or full functionality lost because of a Poland n.a. 5,583 n.a. 63,224 disability (Murray 1993; Murray and Lopez Romania n.a. 2,712 n.a. 29,832 1993). For example, each year lived with a dis- Russian Federation 32,724 33,308 1.8 292,206 ability that leaves a person able to perform only Serbia n.a. 962 6.8 half the normal functions of their life would Slovakia n.a. 627 n.a. 11,310 be counted as one-half of a DALY lost. DALYs Slovenia n.a. 293 n.a. 16,449 capture both the fatal and non-fatal effects of Tajikistan n.a. 464 n.a. 2,048 RTIs. Recent estimates indicate that in ECA countries RTIs account for 3.1 percent of total The Former Yugoslav DALYs lost, as compared with 2.4 percent in Republic of Macedonia 140 173 23.6 6,133 EU-15 countries (WHO accessed October 20, Turkey 4,633 5,004 8.0 169,080 2009). Overall, RTIs are the sixth-leading cause Turkmenistan 650 1,606 of DALY losses in ECA compared to ninth Ukraine 7,592 9,921 30.7 40,887 among EU-15 countries (WHO 2005a). Uzbekistan n.a. 2,,034 n.a. n.a. RTI data underestimate and underreport the sit- n.a.= Not available. uation. As explained in Box 1 on the next page, Sources: ITF (2008); WHO (2009a). ECA countries still differ substantially in the 10 availability, quality, and completeness Box 1: Sources and Quality of the Statistics and Indicators on Road of data on mortality and injuries related Traffic Deaths and Injuries in Europe to road traffic crashes. Underestimation and underreporting of RTI data is one In most European countries, the road police, the health sector, the agency responsible of the key institutional building chal- for death certificates and insurance companies are the main actors responsible for lenges that need to be tackled, as argued collecting statistics about road traffic deaths and injuries. States that are members of in Chapter VII of this report. the European Union, the European Council of Ministers of Transport (ECMT), the Organization for Economic Co-operation and Development (OECD), the United 3. Country variability Nations Economic Commission for Europe (UNECE), and the World Health The average mortality rate due to RTIs Organization (WHO) also report their national data, according to internationally in CIS countries (21.8 per 100,000 agreed questionnaires, to these international bodies, which run databases (such as the population) is nearly three times that WHO Health for All Database, statistics on road traffic crashes from the UNECE, the of EU-15 and other Western European International Road Traffic and Accident Database [IRTAD], and the Community Road countries (7.9 per 100,000) (data from Accident Database [CARE]), and publish reports, such as the statistical reports on road WHO 2009a, shown in Figure 3 on crashes of the ECMT, which allow some international comparisons and analyses of the next page). Kazakhstan has by far trends across the Region. the highest mortality rate in ECA (30.6 The statistics on road safety in the European Region are relatively good compared with per 100,000), followed by Russia (25.2 other regions. Nevertheless, countries still differ substantially in the availability, quality, per 100,000) and Kyrgyzstan (22.8 and completeness of data on mortality and injuries related to road traffic crashes, which per 100,000). With 33,308 victims in makes international comparisons difficult. At the international level, the IRTAD and 2007, Russia had the most RTIs deaths CARE adjust the data to the internationally agreed definition. Data on injuries differ in ECA. As crashes tend to increase even more, since there is ample room for discretion in interpreting the definition of with traffic density, urban driving "slightly" versus "seriously" injured. Data on mortality are comparatively more reliable tends to claim more lives per vehicle- and complete than data on nonfatal injuries. The reasons include differences in methods mile than rural driving, although rural and the quality of data collected, differences in definitions used by bodies involved in crashes tend to be more severe because monitoring crash outcomes, and difficulty in reconciling data from different sources. they occur at higher speeds (Janke 1991, BTS 1997). Recent data for sev- Related to this is the important problem of underestimating the real burden of road eral ECA countries indicate that cities, traffic injury because data are underreported. The reasons for underreporting include especially major ones with the largest the public failing to report injuries; the police not recording cases reported to them; concentrations of population and cars, hospitals not reporting cases presenting to them; and certain institutions such as the and inadequate road infrastructure, face military being exempt from reporting directly to the police. Underreporting is not huge challenges with RTIs. In 2008, for exclusive to low- and medium-income countries. Within countries, the numbers of example, 21 percent of Armenia's road reported fatalities and injuries differ between road police records and those of public deaths and 35 percent of injuries were health institutions, such as first aid stations and hospitals. Finally, data collected by in Yerevan; 47 percent of Azerbaijan's insurance companies are often published in the form of representative surveys, to pro- road deaths and 47 percent of its inju- tect information considered commercially sensitive. ries occurred in Baku; and in Georgia, 48 percent of road deaths and 68 per- Source: Adapted from Racioppi and others (2004). cent of injuries were in urban centers (Camos-Daurella and Silcock 2009). mated distribution of fatal injuries by road user category 4. Fatal road traffic injuries by in ECA countries. It shows that the majority of road ECA road user type traffic fatalities in ECA occur among motorized four- wheeler occupants--typically 40 to 75 percent. The proportion of deaths among different road users varies from country to country, reflecting differences in However, in several ECA countries pedestrian fatalities exposure and safety. Table 4 on page 13 presents the esti- are also very high, accounting for 40 percent or more 11 Figure 3: RTI Death Rates in WHO-EURO Member Countries, per 100,000 Populations, 2007 Kazakhstan 30.6 Russian Federation 25.2 Kyrgyzstan 22.8 Lithuania 22.4 Ukraine 21.5 Montenegro 20.4 Turkmenistan 18.6 Latvia 17.9 Georgia 16.8 Belarus 15.7 Slovakia 15.1 Republic of Moldova 15.1 Greece 14.9 Estonia 14.7 Poland 14.7 Slovenia 14.6 High-income countries Tajikistan 14.1 Albania 13.9 Low- and middle-income countries Armenia 13.9 Croatia 13.6 Turkey 13.4 WHO EURO 13.4 Bulgaria 13.2 Azerbaijan 13.0 Romania 12.7 Hungary 12.3 Czech Republic 12.0 Bosnia and Herzegovina 10.9 Portugal 10.4 Cyprus 10.4 Belgium 10.2 Iceland 10.0 Serbia 9.8 Uzbekistan 9.7 Italy 9.6 Spain 9.3 Ireland 8.5 Austria 8.3 France 7.5 Finland 7.2 MKD* 6.9 Germany 6.0 Israel 5.7 United Kingdom 5.4 Sweden 5.2 Norway 5.0 Switzerland 4.9 Netherlands 4.8 Malta 3.4 San Marino 3.2 0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0 Deaths per 1,000 populationn Note: MKD is the international standardized abbreviation for the Former Yugoslav Republic of Macedonia. Source: WHO EURO (2009). of total road fatalities in Albania, Belarus, Kyrgyzstan, fold as the speed of impact with a car increases from 30 Tajikistan, and Ukraine. Road infrastructure in these km/h to 50 km/h. countries lacks features to make roads safer for pedestri- ans (for example, crossings, walkways, and guardrails), Pedestrians, cyclists, and motorcyclists usually suffer the and the speed limits are too high in urban areas. In most most severe RTIs and report more continuing health ECA countries urban speed limits are 60 kilometers per problems that require more assistance. Among pedestri- hour (km/h), whereas good practice advocates 50 km/h ans, children and older people tend to be more affected. in urban area and 30 km/h in residential areas (Racioppi Risk analysis for the EU shows that the fatality risk for and others 2004; UNECE and WHO EURO 2009). people using motorized two-wheeled vehicles is the high- The high limits are also poorly enforced. Speeding est of all modes of transport--on average, 20 times that vehicles are particularly dangerous for pedestrians: the of car occupants. Fatality for cyclists and pedestrians is probability of a pedestrian being killed increases eight- seven to nine times that of people in cars (Racioppi and 12 others 2004; Sethi, Racioppi, Table 4: Percentage of Fatal Road Traffic Injuries by Road User Type, 2007 and Bertollini 2007). Country Pedestrians Bicyclists Motorcyclists Motorized Four-wheelers The impact of RTIs among pedes- Drivers Passengers trians must be stressed since most Albania 40 6 9 24 22 safety interventions historically Armenia 39 1 n.a. 34 26 have focused on protecting vehicle Azerbaijan 38 1 1 28 31 occupants rather than pedestrians. Walking and cycling are more Belarus 40 9 4 24 23 likely to be chosen if people feel Bosnia and Herzegovina 24 6 5 38 23 their safety is assured. In addi- Bulgaria 26 4 n.a. 65 (drivers and passengers) tion to the RTI gains from safer Croatia 20 5 19 29 21 walking and cycling, getting Czech Republic 19 10 11 41 18 people to use these healthier Estonia 19 9 6 39 27 modes of transport and exercis- Georgia 28 1 Unspecified Unspecified Unspecified ing as part of everyday life would achieve important health gains Hungary 23 12 10 34 21 by reducing obesity and other Kazakhstan 37 1 n.a. 23 32 non-communicable conditions Kyrgyzstan 43 1 4 43 n.a. such as cardiovascular diseases Latvia 37 8 4 31 19 and diabetes. Lithuania 32 7 5 28 26 Drunk driving is an important Moldova 34 2 4 25 33 risk factor for all road users, and Montenegro 20 4 48 27 young drivers and riders aged Poland 35 9 5 30 21 18­25 are particularly at risk Romania 11 7 8 52 23 of crashing (Sethi, Racioppi, Russian Federation 36 2 34 28 and Bertollini 2007). As blood Slovakia 34 8 8 32 17 alcohol concentration (BAC) Slovenia 11 6 18 22 43 increases, so does the likelihood of crashing, particularly above Serbia 25 9 6 37 22 a BAC of 0.04 grams per deci- Tajikistan 44 6 1 18 30 liter (g/dl). Increases in alcohol The Former Yugoslav 34 4 11 29 12 consumption in many ECA Republic of Macedonia countries are strongly associated Turkey 19 2 8 24 31 with the region's unprecedented Turkmenistan 29 5 n.a. n.a. rise in mortality due to RTIs. Ukraine 43 9 8 35 n.a. Russia, Ukraine and some Uzbekistan n.a. n.a. n.a. n.a. n.a. Eastern European countries have the highest overall alcohol con- n.a. = Not available. sumption--11.9 liters of pure Source: National sources as reported WHO (2009a). alcohol (100 percent ethanol) per adult per year compared to the worldwide average of 6.2 liters per adult per year (Rehm traffic deaths in Estonia, Georgia, Latvia, and Slovenia in and others 2009). Other areas of Europe also have high 2008, and at least 10 percent in Russia and several other overall alcohol consumption. countries. These figures are influenced by legislative test- ing practices and it has been suggested that the actual The data reported by national sources to WHO (Table figures are much higher in ECA countries as a result of 5) show that alcohol consumption was estimated to be their extremely high alcohol consumption. responsible for more than 30 percent of all reported road 13 Table 5: Road Traffic Deaths Involving Alcohol in ECA, 2007 Reflecting this high drinking pattern, the European region, particularly the countries % of Road % of Road of the former Soviet Union, had the highest Country Traffic Deaths Country Traffic Deaths proportion of alcohol-attributable net deaths Albania 5 Latvia 21 in the world in 2004, with more than one in Armenia 6 Moldova 17 every ten deaths in European men attributed Azerbaijan 3 Poland 14 to alcohol. A recent study in Russia (Zaridze Belarus 13 Romania 2 and others 2009) documenting the impact Bosnia and Herzegovina 7 Slovakia 4 of alcohol on the high and fluctuating adult mortality rates found that among men, RTIs Bulgaria 5 Slovenia 38 are one of the three leading causes accounting Croatia 30 Russian Federation 10 for alcohol-related deaths, particularly among Czech Republic 3 Serbia 6 young adults. Estonia 48 Tajikistan 5 Medicines can also cause road-traffic injuries. Georgia 37 Turkey 2 Many commonly used medicines act on the Hungary 12 Turkmenistan 7 central nervous system and impair cognitive Kazakhstan 3 The Former Yugoslav function (for example, they can result in slow Republic of Macedonia 5 reaction time, somnolence, and dizziness). No data available for Kyrgyzstan, Montenegro, Ukraine and Uzbekistan. There are many examples but the most con- Source: National sources as reported in WHO (2009a). sumed medicines that can produce these effects Figure 4: Trends in Age-standardized Mortality Rates from RTIs among People Aged 0­14 and 15­24 in the European Region, the EU, and CIS Countries, 1980­2005 (100,000 population) 35 Standardized mortality rate per 100,000 population 30 25 20 15 10 5 0 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 Year European Region (15-24 years) EU (15-24 years) CIS (15-24 years) European Region (0-14 years) EU (0-14 years) CIS (0-14 years) Source: WHO EURO (2009). 14 are antidepressant drugs, anti-anxiety drugs and hypnot- fatalities in pedestrians in the European member states ics, and classical antihistamines used for allergies. Mixing of the Organization for Economic Co-operation and such medication and alcohol potentiates the cognitive Development (OECD). As population aging accelerates and motor impairment effects; some research has found in ECA, identifying new strategies that address their a positive association between road injuries and con- mobility, sensory impairment and safety needs are sumption of antidepressants (Hours and others 2008). essential. Working-age population. RTIs are among the main 5. RTIs among population groups causes contributing to premature mortality and disability Children and young adults are highly impacted. among working-age males, particularly in ECA. This is Although RTIs affect all age groups, their impact is most clearly illustrated by the situation in Russia and Ukraine, striking among the young, whose daily lives tend to where adult male mortality levels are as high as in low- carry them from one area to another for school, home, income countries (Box 2 on the next page, World Bank and leisure. Mortality rates for RTIs among children are 2005a, 2009a). highest in Latvia, Moldova, Romania, and the Russian Gender differences. Males are more adversely affected Federation (UNECE 2003). Young drivers, particularly than females by RTIs in ECA. A recent study document- males, have especially high road traffic fatality rates, ed that in 2004, the male predominance of deaths among associated with high-risk behaviours. CIS road traffic young people aged 10-24 years for all causes in ECA death rates are about four times greater among those was largely due to more than a seven-fold rise in injury aged 15­24 than among children aged 0­14. Figure 4 deaths, particularly RTI fatalities, between adolescence on the previous page highlights these striking differences. and young adulthood (from 24 to 179 per 100,000, For both age groups, the average rates for CIS countries which accounted for 65 percent of male deaths and 48 are higher than for the EU. Except for a peak in 1989­ percent of all deaths (Patton and others 2009). In 2007, 91, recent death rates from transport injuries in the two males in all age groups accounted for 74 to 83 percent age groups have declined in the EU but have increased of all road traffic fatalities in ECA countries (WHO in CIS countries since 1997. RTIs are the leading cause 2009a). In the course of their life, women and men play of death among people aged 15­29, and this age group different roles in society, which affect their risk-taking accounts for one-third of total victims (WHO 2002). behavior, exposure to risks and health-seeking behavior The distribution of road deaths by type of road user (WHO EURO, 2006). Although exposure data are not varies with age. For children aged 0­14 in the ECA available, males travel much more in most of these coun- Region, nearly half of the deaths were pedestrians (48 tries, so the relative risk between males and females may percent), followed by car occupants (32 percent), cyclists be much less imbalanced than indicated by the absolute (9 percent), and motorcyclists (6 percent) (UNECE and number of deaths. Heightened alcohol misuse among WHO EURO 2009; Sethi, Racioppi, and Mitis 2007). young males has been linked to high road fatalities and Adolescents aged 15­17 are more likely to die in car other injuries in ECA (McKee and Shkolnikov, 2001, crashes (40 percent) or on motorized two-wheelers (31 Bye 2008). Alcohol-attributable mortality rates in ECA percent) and less likely to die as pedestrians (21 percent) are four times higher among men than among women and cyclists (5 percent). This reflects different risk expo- (Rehm and others 2009). In ECA, extremely high mor- sures, with older children using cars and motorcycles tality levels among working age men shortens the aver- more than walking and cycling. age man's life expectancy by 10-12 years. The elderly are particularly vulnerable. People over age 60 are more vulnerable to road traffic injuries due 6. Inequality dimension of RTIs to fragility and reduced ability to cope with traffic. Across and within countries, lower incomes are associ- Although injuries in those aged 15­29 are a bigger ated with high death rates from injuries. People in public health problem, older people--frequently as low- to middle-income ECA countries are three to six pedestrians and often more frail--have a higher fatality times more likely to die from injuries than people in rate if injured since their injuries tend to be more severe. EU-15 countries (Sethi and others 2006, Mohan 2002a, For example, older people account for nearly half of all 2002b). Even EU-15 and other Western European coun- 15 Box 2: RTIs Contribute to High Mortality Rates among tries have steep social class gradients in pedestrian Working-age Males in Russia and Ukraine injury rates, and it is well established that child pedestrians in lower socioeconomic groups and eth- Road traffic injuries (RTIs) play a major role in reducing life expectancy nic minorities suffer more injuries. among males in Russia and Ukraine. The probability of men surviving to old age in Russia and Ukraine is low compared not only with European 7. What are the economic and Union (EU) countries but with Central European countries. The probabil- social consequences of RTIs? ity is especially low among working-age males, whose death rates are similar to those of men in countries with less than one fifth the Gross National Impact on health systems. RTIs are a major bur- Product per capita. den on health systems worldwide, placing heavy demands on already overburdened facilities, and Russia straining limited budgets. The results from a com- At 25.2 per 100,000 population, Russian road traffic mortality rate is five prehensive review of epidemiological studies show or six times higher than in several Western European countries such as that traffic-related injuries accounted for 30 to 86 Sweden, the Netherlands, Norway, and the United Kingdom, about double percent of all trauma admissions in hospitals, with that in the United States, and higher than in other Eastern European coun- an overall mean length of stay of 20 days. Patients tries such as Poland and Hungary (OECD/EMCT 2008). This difference is who sustained spinal or head injuries or compound even more remarkable considering that Russia has fewer automobiles than fractures were hospitalized for longest--more 60 Western Europe, the United States, or Canada. Russia's traffic mortality rate days in 25% of cases in one study (Odero, Garner, is also higher than in other former Soviet states. In 2007, more than 30,000 and Zwi 1997). This review also found that patients people in Russia--mostly working-age males--died in crashes. Driver fac- with traffic injuries represented 13 to 31 percent of tors are the major causes: intoxication, lack of discipline, and aggressive all injury-related visits to medical facilities, 48 per- driving. In addition, nearly half of all these deaths victimize pedestrians, not cent of bed occupancy in surgical wards, and were drivers or passengers. the most frequent users of operating theaters and intensive care units. By a second, more meaningful measure, fatalities per 10,000 vehicles, Russia's rate of 12.2 is exceptionally high--50 percent higher than the Similar data for Russia indicate that road traffic second highest (the Republic of Korea at 8.2) among reporting countries. victims are seven times more likely to need hospi- The severity of road crashes is often measured by the proportion of fatalities talization compared with victims of other types of to serious injuries. For this measure, Russia is similar to the other transi- trauma; RTIs account for 75 percent of all types of tion countries, with an index of 0.12; that is, 12 percent of people injured injury, with victims of road traffic crashes represent- in road crashes die. Russia's index for the severity of RTIs is 5 to 10 times ing more than 60 percent of the total number of higher than that in most developed countries (which may result partly from severe trauma cases (for example, patients with sus- poor registration of road crashes not leading to deaths or injuries). However tained spinal or head injury or severe and multiple the problem is measured, Russia clearly has a serious problem of road fatali- fractures). The provision of medical services for ties and injuries. traffic injuries and other external causes absorbed approximately 0.27 percent of Russia's gross domes- Ukraine tic product (GDP) in 2003, or about US$1.2 bil- lion (World Bank 2005a). This is about 10 percent Mortality due to road injuries began to decline in Ukraine in 1992 but of total health care expenditures in Russia. started to rise again in 1999. Four years later, it was twice the EU average. In 2007, transport injuries caused 21.5 deaths per 100,000 population The economic cost of RTIs. Globally, RTIs have a (compared to 13 per 100,000 in 1999), representing 14 percent of all significant negative impact on society which occur external causes of death. Again, this rate is even more remarkable consider- through many channels (Peden and others 2004; ing that there are fewer automobiles per capita in Ukraine than in Western Mohan 2002a, 2002b; Jacobs, Aeron-Thomas and Europe. Alcohol consumption plays an important role in RTIs and other Astrop 2000) and disproportionately affect the most injuries, as well as causing increased risk of cirrhosis of the liver, high blood economically productive age groups. Motor vehicle pressure, heart disease, and cancers. crashes and injuries cause direct and indirect costs Source: World Bank (2005a, 2009a). to individuals and to society as a whole, arising 16 from the decline in the general health status of those Estimates indicate that in HICs, 80 percent of the cost injured in motor vehicle crashes (Blincoe and others of RTIs is attributable to nonfatal events, with 2 percent 2002). In estimating the total economic cost of RTIs, of nonfatal crashes accounting for 44 percent of life- the value of the decreased production and consumption time medical costs (NHTSA 1987; Miller, Luchter, and of injured individuals is included, as are the resources Brinkman 1989, as reported in Ameratunga, Higar, and consumed as a result of any injury or crash that might Norton 2006). otherwise have been used for increasing societal well- being. The economic cost of road deaths and injuries globally is estimated at US$518 billion--1 percent of GNP in low- Direct costs include emergency treatment, initial medi- income countries, 1.5 percent in middle-income coun- cal costs, rehabilitation costs, long-term care and treat- tries, and 2 percent in high-income countries (Peden and ment, insurance administration expenses, legal costs, and others 2004; Jacobs, Aaron-Thomas, and Astrop 2000). employer/workplace costs. Indirect costs include pro- ductivity costs in the workplace due to temporary and The cost in ECA. One estimate from Russia suggested permanent disability and decreases in household produc- that the loss from RTIs was as high as 3 percent of tivity emanating from these disabilities. Property damage GDP (ECMT 2006). Using the conservative estimate and travel delay and crash costs are estimated for injury of the economic costs of road crashes in ECA as being and non-injury crashes (Blincoe and others 2002). approximately 1.5 percent GDP, Table 6 presents the results for ECA countries. Of course, human life has The method used to calculate the economic cost of RTIs no price tag, and the results are presented only for eco- does not include costs associated with loss of emotional nomic comparison purposes. The highest costs are in well-being unless it requires medical attention or there the large economies that also have sizeable populations: are permanent losses in functional capacity or earning Russia (US$34 billion per year), Turkey (US$14 billion), capacity. Poland (US$10 billion), and Ukraine (US$5 billion). Table 6: Socioeconomic Cost Estimates for Road Injuries in ECA (2008 prices) Number of Estimated Estimated Unit GDP Per Fatalities per Economic Economic Cost GDP Capita Number of Million Costs per Fatality) Country/Economy (US$b)a (US$) Fatalitiesb Inhabitants (US$b)c (US$)d Russia 2,285 16,161 34,506 246 34.3 1,131,270 Turkey 937 13,447 4,496 59 14.1 941,290 Poland 669 17,560 5,583 145 10.0 1,229,200 Ukraine 350 7,634 6,966 152 5.3 534,380 Romania 273 12,698 2,794 126 4.1 888,860 Czech Republic 266 25,755 1,221 120 4.0 1,802,850 Hungary 199 19,830 1,232 124 3.0 1,388,100 Kazakhstan 180 11,563 3,136 204 2.7 809,140 Belarus 118 12,344 1,688 175 1.8 864,080 Slovakia 120 22,242 627 115 1.8 1,556,940 Bulgaria 94 12,372 1,006 140 1.4 866,040 Azerbaijan 78 8,958 1,027 125 1.2 627,060 Serbia 81 10,911 897 88 1.2 763,770 Croatia 73 16,474 614 137 1.1 1,153,180 Uzbekistan 71 2,606 2,075 75 1.1 182,420 (Continued on next page) 17 Table 6: Socioeconomic Cost Estimates for Road Injuries in ECA (2008 prices) (continued) Number of Estimated Estimated Unit GDP Per Fatalities per Economic Economic Cost GDP Capita Number of Million Costs per Fatality) Country/Economy (US$b)a (US$) Fatalitiesb Inhabitants (US$b)c (US$)d Lithuania 64 18,855 739 208 1.0 1,319,850 Slovenia 58 28,894 292 146 0.9 2,022,580 Latvia 40 17,801 419 188 0.6 1,246,070 Turkmenistan 30 5,765 533 109 0.5 403,550 Bosnia and Herzegovina 30 7,618 436 95 0.5 533,260 Estonia 28 20,754 196 151 0.4 1,452,780 Armenia 19 5,437 259 87 0.3 380,590 Georgia 22 5,001 637 138 0.3 350,070 Albania 22 6,797 277 76 0.3 475,790 The Former Yugoslav 19 9,128 143 69 0.3 638,960 Republic of Macedonia Moldova 11 3,154 391 90 0.2 220,780 Kyrgyz Republic 12 2,174 892 164 0.2 152,180 Tajikistan 13 1,984 483 66 0.2 138,880 Montenegro 7 10,414 122 181 0.1 728,980 Kosovo 5 2,300 152 84 0.1 161,000 a IMF World Economic Outlook Database, October 2008. b Fatalities data: Latest available from WHO, UNECE, EuroStat databases, and World Bank. The statistics used are the average number of fatalities during 2003­05. c Economic costs estimated at 1.5 percent of country GDP at 2008 prices. d To quantify the savings due to lower deaths, a cost to human life has to be approximated. This is referred to as the value of a statistical life (VSL). The literature presents two main approaches: the willingness-to-pay approach and the human capital or lost output approach. In the willingness-to-pay approach, as the name implies, an estimate is made of the value that individuals in a society attach to road safety in terms of the amount of money that they are willing to pay to avoid the risk of loss of life. Either stated preference or revealed preference techniques can be used in this method. In the human capital approach, the main part of the estimate is the discount to present value of a victim's foregone future output or income due to the death resulting from a road crash. Both approaches have a clear linkage to the level of income (GDP per capita). The willingness-to-pay approach is discussed in the literature as being more robust but presents the weakness of requiring intensive and sophisticated surveys. One approach has been devised to estimate the statistical value of a life based on available studies from both approaches; and link- ing simply to the GDP per capita of the country (McMahon and Dahdah, 2008). The estimate of VSL at 70 times GDP per capita has been found to fit most data samples from different countries' estimations of VSL depending on the datasets used. This research is supported by earlier work (European Road Safety Observatory, 2006). In that study, there were wide variations in VSL in the official valuations of road safety fatalities in 23 different countries. However, all the countries with good road safety records were using an official valuation in the range of 60 to 80 times GDP per capita, and confirm the estimation at 70 times GDP per capita recommended in McMahon & Dahdah (2008). Sources: IMF, WHO, UNECE, EuroStat, World Bank; and McMahon and Dahdah (2008). 18 3 "The safe system approach is simple, sustainable, affordable and effective." ­ Claes Tingvall, Architect of Sweden's "Vision Zero" policy and Director of Traffic Safety, Swedish Road Administration Chapter III. Interventions and Results: What Is the Evidence? To prevent the occurrence of road traffic injuries, mini- roadside vegetation, and construction of passing lanes mize their severity when they occur, and reduce the (OECD and ITF 2008). severity of victims' injuries and the impact on others following injury events, various programs and interven- Safety awareness in engineering and road planning, and tions have been designed and implemented in different safety audits, are required in many countries, including countries. There is strong evidence of the effectiveness Australia, Denmark, New Zealand, the Netherlands, of interventions in high income countries, but evidence and the United Kingdom. Macaulay and McInerney from low- and middle-income countries is relatively rare, (2002) found these audits and systematic safety impact so international organizations such as the WHO endorse assessments to have a cost-benefit ratio of 1:20 in New tailoring HIC-proven interventions to LMICs (Peden Zealand. and others 2004, World Bank 2007a). Engineering technologies and road designs to improve This section describes the nature of road, vehicle, and infrastructure--such as better geometric design, intersec- user interventions implemented in many countries, par- tion control, safety (or crash) barriers, signs, markings, ticularly in HICs, to improve road safety. While in most and maintenance--are effective intervention strategies countries these measures have been adopted individually, (World Bank 2003). For example, lighting columns that evidence from good international practice indicates that break away on impact are widely used with cable barri- applying them as part of broader systemic approaches in ers in Denmark, Sweden, Switzerland, and the United combination or as a series of measures is more cost-effec- Kingdom (ETSC 1998). Cirillo and Council (1986) tive (Bliss and Breen 2009). reported that some crash-protective roadside objects, guardrails, crash cushions, and so forth could reduce injuries by 30 percent. Other low-cost traffic engineering 1. Engineering measures that measures that are highly cost-effective are skid-resistant improve road design and make surfacing, central refuges and islands, and signal control roads safer or operation of junctions. The United Kingdom has moved away from a "black spots" to a "whole route" Engineering interventions improve road infrastructure, approach, with a reported significant reduction in introduce safety awareness into the process of planning killed or seriously injured (KSI) casualties on Britain's road networks, incorporate safety features in road design, roads--currently 33 percent below the 1994­1998 and remedy high-risk sites with signs, markings and baselines, against a target of 40 percent by 2010 (DETR preventive measures. HICs have adopted many of these 2007). strategies, and though they have not been examined in rigorously controlled studies, such strategies form the Traffic-calming measures that reduce traffic speeds, such basis of best practice guidelines and manuals for use as speed bumps, that are appropriately incorporated into in LMICs (Ross and others 1991). In the short term, road design also reduce RTIs, especially among pedestri- appropriate measures for safer roads and roadsides ans (Afukar 2003). A systematic review and meta-analy- include targeted improvements that identify and treat sis confirmed that area-wide traffic-calming schemes can the highest crash locations with specific measures such reduce road crash-related deaths and injuries (Bunn and as audible edge-lining, shoulder sealing, clearing of others 2003). 21 A 2004 summary of research findings suggests that auto- DRLs consistently show that they reduce road crashes mated speed enforcement has a significant impact on (Elvik and Vaa 2004). Lights on motorcycles show simi- controlling speeding (ICF Consulting Ltd. and Imperial lar results (Radin, Mackay, and Hills 1996; Yuan 2000). College Centre for Transport Studies 2003). Another meta-analysis found that speed cameras led to a 14 per- Research also indicates that injury protection designs-- cent reduction in fatal crashes and a 6 percent reduction such as installing seatbelts, a known and effective safer- in nonfatal crashes in HICs (Elvik and Vaa 2004). vehicle measure--helps to reduce traffic deaths and serious injuries when crashes occur. Studies show that seatbelt use in cars by drivers and passengers in HICs 2. Vehicle design and safety reduces fatal injuries an average of 11 percent and seri- equipment ous injuries 18 percent (Elvik and Vaa 2004). Another study found an average reduction of 9 percent in fatal Strategies focusing on safer vehicles include improving injuries (Dinh-Zarr and others 2001). A review in the vehicle visibility (for example, daytime running lights United Kingdom found that crash protection improve- [DRLs]), incorporating crash protective design into ments reduced casualties 15 percent compared with 11 vehicles (for example, seatbelts and airbags), and promot- percent for drunk-driving measures and 6.5 percent for ing further development of "intelligent" vehicles for active road safety engineering measures (Broughton and oth- crash avoidance (for example, adoption of electronic sta- ers 2000). The relative difference safety measures make bility control systems [ESCs] 8, which the U.S. National depends on the exposure to risks in different settings. Highway Traffic Safety Administration (NHTSA) has already announced its intention to require all vehicle manufacturers to include as part of the standard equip- 3. Education, laws and enforcement ment list for every vehicle by the start of the 2012 model Intervention strategies aimed at improving road user year). However, in LMICs, more basic strategies have the behavior increasingly focus on combining education potential to be cost-effective, such as ensuring regular interventions with the introduction and enforcement of maintenance of older vehicles and removing "clunk- relevant legislation (ETSC 2003a). Research by Poli de ers" (vehicles that are not roadworthy) from the roads, Figueiredo and others (2001) in Brazil indicates that and vehicle licensing and inspection (Peden and others media coverage, increasing fines, and suspending drivers' 2004). Likewise, installing seatbelts in cars that lack licenses reduced RTIs and deaths. Graduated driving them will help improve passenger safety; the WHO esti- licenses along with extended training during the learner mated in 2008 that 20 percent of cars in HICs and 50 period are effective in reducing deaths among young percent in lower-income countries lack seatbelts. drivers (OECD and ITF 2008). For example, notable Measures to make vehicles safer help drivers avoid crashes, success in the United States has been achieved by gradu- and protect drivers, passengers and others when crashes ated driving permits for teens, requiring six months do occur. Meta-analyses of the effects of automatic with a learner's permit, a curfew against driving between midnight and 5:00 a.m., and restrictions on the number of passengers in the vehicle for the first year after acquir- 8 An ESC helps maintain the direction of a vehicle if it begins to ing a license. The Texas Transportation Institute reported drift beyond the driver s intended path. For example, if the driver misjudges the speed reduction required when entering that the rate of fatal teen crashes in Texas dropped from a sharp curve in the road, there is a good chance the vehicle could 625 deaths in 2002 to 419 in 2007 after these measures skid out of control. To prevent the vehicle from rolling over or were adopted (Linderberger 2009). spinning out of control, the ESC takes over and sends comput- erized commands, applicable to the situation, which apply the Public communication and advertising campaigns have brakes to one or more wheels and/or reduce engine throttle. The been used to influence driver's attitudes toward speed and reduction in engine power enables maximum traction and helps keep the vehicle under control and on course. ESC uses a com- speeding behaviors (OECD and ITF 2008). Evidence puter that communicates with a series of sensors that detect wheel on the impact of these measures indicates that high spin, steering angle, wheel speed, and sideways motion. ESC does levels of recognition and understanding are achieved, not actually increase the available traction, but it does highly increase the chances of keeping the vehicle on the road and under as in the case of the United Kingdom's Department of control in high-risk situations (Carseek webpage: http://www. Environment and Transport (DETR) "Kill Your Speed" carseek.com/articles/electronic-stability-control.html#). campaign. 22 There is also strong evidence that laws requiring the use Measures to control speeding, drunk driving, and cell of seatbelts and child restraints reduce occupant deaths phone use while driving have also proved effective. and injuries. However, such laws have not been intro- International experience and research have proven that duced in all LMICs (Peden and others 2004). Wearing behavior measures to limit speed, blood alcohol concen- a seatbelt can reduce the risk of RTIs by 40 to 65 per- tration (BAC) levels and, lately, cell phone use are also cent (Peden and others 2004), and if combined with effective, especially with good enforcement (Elvik and airbags, they can reduce deaths by an additional 8 to Vaa 2004). 14 percent (Cummings and others 2002). Mandatory seatbelt-use laws accompanied by strict police enforce- Evidence from different studies indicates that increased ment and intensive mass-media programs are successful vehicle speeds are associated with an increased risk in preventing deaths, as demonstrated in a 30-year study of crash and injury, both for motor vehicle occupants in Finland and the United Kingdom (ETSC 1996; and for vulnerable road users, particularly pedestrians Ashton, Mackay, and Camm 1983). Countries of the (Jamison and others 2006). Enforcement of existing European Union (EU) and elsewhere in Europe have speed limits can provide immediate safety benefits, seatbelt enforcement laws allowing the police to stop a perhaps more quickly than any other single safety mea- motorist for not wearing a seatbelt (primary enforce- sure (OECD and ITF 2008). A large body of research, ment), increasing the laws' effectiveness (Dinh-Zarr and although little of it in LMICs, shows that setting and others 2001). Mandatory, enforced seatbelt use in the enforcing speed limits reduces RTIs by up to 34 percent, EU increased use from 37 percent to 95 percent and particularly among vulnerable road users (pedestrians, quickly resulted in a 35 percent reduction in hospital cyclists, and motorcyclists). Urban speed limits should admissions for RTIs. Aggressive seatbelt use campaigns not exceed 50 kilometers per hour (km/h) and should be in Malta helped bring seatbelt use compliance rates to lower near schools and in residential areas. As noted ear- 99 percent for drivers, 93 percent for front seat adult lier, the probability of a pedestrian being killed increases passengers, and 43 percent for backseat adult passengers. eightfold as the speed of the impact car increases from Malta also introduced speed cameras, improving road 30 kilometers per hour (km/h) to 50 km/h. Reducing traffic enforcement. speed limits by 10 km/h on rural roads could reduce traffic-related deaths by 6 percent, and reducing them Motorcycle and bicycle helmets provide significant protec- by about 14 km/h on highways could reduce deaths by tion against injuries when they meet a recognized safety 21 percent (Racioppi and others 2004). Recognizing standard and are used correctly. Although education can speed as a major contributory factor in about a third of increase helmet use among riders of motorized two- road crashes, and being one of the best performers on wheelers, the effect is greater when combined with laws road safety in Europe (second to Sweden in terms of and enforcement. The enactment and enforcement of fatalities), the United Kingdom has adopted effective helmet laws in Malaysia and Thailand led, respectively, measures, including: (a) increased publicity and aware- to 56 percent and 30 percent reductions in road traffic ness programs; (b) speed limits appropriate to location fatalities (Ichikawa, Chadbunchachai and Marui 2003; and road function (70 mph limits on motorways and Supramaniam, Belle, and Sung 1984). A meta-analysis dual carriageways and 30 mph in urban areas); local showed that motorcycle helmet use is associated with a authorities are allowed to introduce 20 mph zones and 36 percent reduction in fatal injuries and a72 percent rural speed limits of 60 mph on single carriageways; (c) reduction in nonfatal injuries (Liu and others 2004). targeted use of speed cameras at high-crash areas; and (d) Bicycle helmet use also reduces the risk of injury. A improved signage (DETR 2000). 1999 meta-analysis found that helmets reduced fatal head injuries by 69 percent (Thompson, Rivara, and Alcohol consumption among both drivers and pedestrians Thompson 2000). The use of child restraints--infant also increases the risk of road crashes and injuries. The seats, child seats, and booster seats--is estimated to pre- dose-response gradient is clear: the likelihood of a crash vent 70 percent of deaths among infants and 54 to 80 rises as blood alcohol concentration (BAC) increases. At percent of deaths among small children in the event of a a BAC of 0.06 grams per deciliter (g/dl), drivers were car crash (WHO 2009). twice as likely as sober drivers to cause a road crash, and at 0.10 g/dl they were six times as likely (Levine 2003). 23 Driving under the influence of Box 3: Stepwise Approach to the Choice of Alcohol-control Policies drugs is another risk factor, and mixing drugs and alcohol amplifies Core impairment. Affordability: Excise tax graded by volume of ethanol, inflation-adjusted Setting and enforcing blood alcohol taxes. limits has proved highly effective in Availability: Regulation of all production and sale, licensing of places for reducing RTIs. Most countries set sale and consumption, licensing of days and hours of sale, and minimum the legal limit at 0.05 g/dl. A BAC purchase age. limit of 0.05 g/dl or less is recom- mended for the general popula- Regulation of marketing: Regulation of all marketing, including sponsor- tion; if enforced, 5 to 40 percent ship, content restricted with no lifestyle advertisements, bans on sponsor- of traffic-related deaths could be ship, placement restricted by volume and media (for example, no electronic eliminated (ETSC 1996, 2003a). media). Research also shows that RTIs are Drunk-driving: Limit on blood alcohol concentration established in law, reduced by varying magnitudes by sobriety checkpoints. setting and enforcing BAC limits and minimum drinking-age laws, Treatment: Brief intervention. using checkpoints to randomly stop drivers to detect alcohol, and run- Expanded ning mass media campaigns aimed Availability: Bans on sales and drinking in public places, enforce laws at reducing drinking and driving against serving intoxicated customers and minors, different availability based (Peden and others 2004). Random on volume of alcohol. breath testing has been found to Regulation of marketing: No pricing promotions or discounts, no promo- be twice as effective as selective tions using competitions or gifts. checkpoints (Henstridge, Homel and Mackay 1997). Enforcement Drunk-driving: Random breath testing, administrative license suspension. is most effective when backed by extensive publicity, with tough Optimum sanctions for repeat offenders Affordability: Minimum price. (OECD and ITF 2008). In the Availability: Mass media campaigns supporting availability policy. United States some state legislatures are considering measures to further Regulation of marketing: Restrictions on packaging and product design, reduce drunk driving. For example, ban advertising of corporate philanthropy, ban all forms of product California and Wisconsin are marketing. considering legislation to require Drunk-driving: Mass media campaigns supporting policy; for example, people convicted of drunk driving drunk driving, mandatory treatment for repeat drinking drivers. to use an "ignition interlock"; that is, drivers blow into a device that Treatment: Detoxification, cognitive-behavioral therapies, pharmacological measures BAC; if it is too high, treatments. the car will not start. Fourteen Source: Adapted from Casswell and Thamarangsi (2009). states routinely use this technol- ogy, which experts say could reduce drunk-driving offenses by up to 64 in a recent study (Casswell and Thamarangsi 2009), percent (Wallwork, Winik and Massey 2009). despite clear evidence of the major contribution alcohol Given the relative importance of alcohol abuse in some makes to the global burden of disease and its substantial ECA countries, broader alcohol control policies and economic costs, focus on alcohol control is inadequate interventions are required to support the long-term sus- internationally. Certainly this is the case in most ECA tainability of road safety efforts. As clearly articulated countries, particularly in Russia, Ukraine, and other 24 former Soviet Union (FSU) republics. Industrial produc- teenagers. Early results from car drivers are similar to tion of alcohol is expanding and aggressive marketing those of truck drivers (see below) with texting associ- is increasing alcohol use, both in emerging markets and ated with an enormous increase in risk of a crash or among young people in mature alcohol markets. near-crash. As shown in Box 3, cost-effective and affordable inter- For heavy vehicles and trucks risk estimates were: ventions to restrict harm do exist and are in urgent · Placing a call on a cell phone made the risk of a crash need of scaling-up. There is a need to overcome factors or near-crash event 5.9 times higher than non-dis- impeding progress, such as lack of political will, unhelp- tracted driving. ful participation of the alcohol industry in the policy process, and increasing difficulty in free-trade environ- · Talking or listening on a cell phone made no differ- ments to respond adequately at a national level. ence to the risk of a crash or near-crash event com- pared to non-distracted driving. Other driver-related factors that increase the risk of road crashes include fatigue and stress caused by stifling levels · Use of or reaching for an electronic device made the of traffic congestion that influence aggressive driving, risk of a crash or near-crash event 6.7 times higher inadequate visibility of vulnerable road users and, more than non-distracted driving. recently, the use of handheld mobile telephones and tex- · Text messaging made the risk of a crash or near-crash ting devices. A recent survey in Great Britain revealed event 23.2 times higher than non-distracted driv- that 45 percent of drivers use short message services ing (large trucks made up 8 percent of all vehicles (SMS), particularly young drivers, and complementary involved in fatal crashes in 2008 in the United research found that drivers were significantly impaired States). According to the study, drivers spend five sec- in their performance when both reading and writing onds out of a six-second window looking away from text messages, with the latter producing the greatest the road when they are engaged with an electronic impairment (Reed 2008). It was also noticed that when device. Clearly, keeping the driver's eyes on the road texting, drivers slowed significantly, indicating that they significantly improves safety. recognized the impairment caused by their texting activi- ties and were attempting to mitigate risk by reducing Measures adopted at the state level in the United States to speed. Recent studies in the United States (Box 2009) outlaw the use of cell phones by young drivers are starting monitored light-vehicle and truck drivers as they manip- to generate positive results. Besides the tougher laws, peer ulated phones, such as dialing and texting. Findings influence programs and other measures have reinforced indicate these behaviors pose a substantial increase in the rules and contributed to Texas' success in reducing the risk of being involved in a safety-critical event, such fatal crashes involving teen drivers. For example, since as a crash or near crash. However, talking or listening 2003, 300 school districts have been implementing an increased risk much less for light vehicles and not at all innovative program, called "Teens in the Driver Seat," for trucks. The studies estimate risk for light vehicles and which starts teens talking to peers about driving risks cars as follows: (Linderberger 2009). · Placing a call on a cell phone made the risk of a crash Finally, to alert users of certain prescription drugs about or near-crash event 2.8 times higher than non-dis- their side effects that could impair the capacity to drive tracted driving. or to use other machines, drug companies include leaflets · Talking on or listening on a cell phone made the risk in the packages. However, most people do not read the of crash or near-crash event 1.3 times higher than leaflets. Several initiatives propose including pictograms non-distracted driving. outside the boxes of these medicines (Goullé and others 2008) to alert users to possible dangers. It is also impor- · Reaching for an object such as an electronic device tant to highlight that the use of alcohol and illicit drugs made the risk of a crash or near-crash event 1.4 times in combination with prescription drugs could further higher than non-distracted driving. impair reaction time. Specific studies on these points · A study on texting while driving in light-duty vehicles should be encouraged as should active interventions to is currently underway, and is looking specifically at reduce risks. 25 4. Traffic management and reducing 5. Private sector role and practices risk exposure to RTIs to support road safety efforts The least-used and least-evaluated road safety interven- Table 7 illustrates how effective measures to address RTIs tion strategies are those that aim to reduce exposure to not only save lives but are also good for business. Private risk of RTIs. Estimates in high-income countries indicate sector firms working in partnership with governments that under certain conditions, for each 1 percent reduc- and civil society organizations have a vital role to play tion in distance traveled, the corresponding reduction in advocating and supporting road safety policies and in crash incidence is 1.4 to 1.8 percent (Litman 2000; strategies. Effective partnerships have been established in Edlin 2002). It follows that governments should improve a variety of countries with multiple, related aims: Brazil transport networks and land use to reduce distances and (safety for schools), Poland (driving education, black the need to travel. Steps include providing shorter, safer spot treatment), Hungary (improving the visibility and routes; better management of commuter transport; bet- safety of black spots), Vietnam (motorcycle helmets), ter mass transit; and prioritizing or restricting access to and Thailand (safer school zones and better discipline, parts of road networks (preventing pedestrian and cyclist improved vehicle visibility), and South Africa (respon- access to motorways and keeping vehicles out of pedes- sible alcohol use, pedestrian safety and visibility) (Bekefi trian zones). Well-designed and positioned crossings and 2006). These country experiences--and a recent example improved signal-controlled junctions are also important. in India where strong business and management skills The United Kingdom has adopted child safety measures coupled with sound public health programming helped as well, such as improving school travel safety, child road boost health outcomes (Kusek, Wilson, and Thomas safety audits, local transport plans for traffic calming in 2009)--clearly illustrate the potential benefits of apply- school areas, safer crossing facilities and speed cameras ing private sector business practices to improve road on roads prone to crashes; and training children in basic safety and the delivery of related services in pedestrian skills. ECA. What can car insurers do to improve Table 7: Why Should the Private Sector be Interested on Road Safety Issues? road safety? As shown by experience in the United States and other HICs Industry Type Area of Interest where car insurance compliance is Auto Safe product development and use, protection of customer base, over 90 percent, insurance policies regulatory costs. that offer premium discounts for Oil and gas, chemical Product transport is key to business, and better road transport good driving records, good student management reduces safety and environmental risks. records, and driver training, and Alcoholic and other Safe product use serves market and safeguards "good product safe driver discounts or premium beverage image." Safe transport of product to guarantee supply. increases for vehicle offenses offer a promising private sector mechanism Fleet operators, To achieve reliable services and high fleet productivity, protect especially transport cargo investment, safety of drivers, welfare of their families, liability to encourage safe driving, particu- and delivery and medical costs, and community relations. larly among teenagers. Little evidence Diversified technology Market for goods. has accumulated, however, to show that these measures work. Other Consumer device Safe product use (cell phones, handheld devices) to safeguard ways that the industry can contribute market. to road safety are: helping to shape Construction Transport of materials, safety of workers. policy, financing road safety inter- Agribusiness/forestry Product transport is key to business, and better road transport ventions, providing education and management reduces probability of damage to their products communication about road crashes Banking and insurance Bear burden of insuring for crashes. and their associated risk factors, and Tourism Safe transport of tourists to sites, creating positive image of locale promoting research on road safety to attract visitors. (Global Road Safety Partnership online). Source: Adapted from Bekefi (2006). 26 6. Cost-effectiveness of selected (pedestrians, bicyclists, motorcyclists, car occupants, and bus/lorry drivers and occupants), and also on various risk interventions and financial gains factors that are the target for interventions (speeding, to society drunk driving, and not wearing seatbelts or helmets). The call for greater effort in road safety must include In ECA--covered by the WHO subregions EurB and the cost of paying for interventions within a country's EurC10--pedestrians are particularly vulnerable road budgetary constraints. The allocation of additional funds users (31 to 38 percent of fatal RTIs), along with driv- and/or the reallocation of existing funds to finance ers and passengers of cars (43 percent and 24 percent, expanded road safety programs will depend on a clear respectively). Of the risk factors specifically considered, policy decision by governments to assign greater priority excessive speed (21 to 22 percent) and driving under the to these efforts. One approach for priority setting is the influence of alcohol (16 to 21 percent) contribute the comparison of the likely costs and impacts of single and most to the overall death toll: 97 per 1 million and 248 combined interventions. Since the costs of, responses to, per 1 million population (in each case, the first number and effects of interventions differ substantially among refers to subregion EurB, the second to EurC). countries, this should be seen only as an attempt to Looking at the cost-effectiveness of particular interven- provide a "sense of priority" among various road safety tions addressing exposure to these risk factors and com- interventions and not as a prescription on how to ratio- pared to the situation of no intervention, legislation and nalize the allocation of public resources in ECA. enforcement of bicycle helmet use by children is the most A recent analysis of the cost-effectiveness of RTI preven- cost-effective strategy in EurB (I$10,395 per DALY tion strategies in different regions was carried out as part saved), followed by roadside breath testing for alcohol- of the WHO's CHOICE work program (Chisholm and impaired driving (I$12,691 per DALY saved). In EurC, Naci 2008). Results are expressed in terms of the cost of breath testing is the most cost-effective strategy (I$5,825 achieving one additional year of healthy life (or averting per DALY saved). Results for all single and combined one disability-adjusted life year).9 Costs are in inter- interventions are shown in Figure 5 on the next page. national dollars (I$), which account for differences in Combining roadside enforcement strategies--against purchasing power among countries and therefore provide alcohol-impaired driving, speeding, and non-use of seat- a more suitable basis for international comparisons. A belts, for example--offers the prospect of major syner- selected set of interventions for reducing the burden of gies on the cost side, making it an attractive proposition. road traffic injuries was assessed: enforcement of speed The investment costs to gain a year of healthy life is limits via handheld speed cameras; drunk-driving legisla- less than the respective per capita annual income of the tion and enforcement by breath-testing campaigns; leg- selected populations, a threshold used internationally to islation and primary enforcement of seatbelt use in cars; determine whether an intervention is cost-effective. It legislation and enforcement of helmet use by motorcy- could be concluded, therefore, that the evidence and costs clists; and legislation and enforcement of helmet use by indicate that an integrated, systemic approach is a prom- bicyclists under age 15. ising approach to effectively address RTIs. Estimates of what works best in a given country or Society's financial gains from selected road safety inter- region depend crucially on the underlying distribution ventions. Although the size of a cost-benefit ratio may be of fatal crashes and non-fatal RTIs by road user group country specific, the measures in Table 8 on page 29 and those mentioned in Table 2 have been proven to provide value for money (ETSC 2003, SWOV 2001, and U.S. 9 The costs of RTI prevention span a wide array of resource inputs, including engineering and design of roads and vehicles, safety devices and technology, and ambulance and trauma care services. 10 Countries in the WHO European Region with low child and The intervention costs in the WHO study are those that are adult mortality (EurB) are: Albania, Armenia, Azerbaijan, incurred at a more programmatic level (not at health-facility Bosnia and Herzegovina, Bulgaria, Georgia, Kyrgyzstan, Poland, level), and include the resource costs associated with legislation, Romania, Slovakia, Tajikistan, The Former Yugoslav Republic of program management, and law enforcement, coupled with the Macedonia, Turkey, Turkmenistan, and Uzbekistan. Countries in privately borne costs to bicycle and motorcycle owners of buying the WHO European Region with low child and high adult mor- helmets and the cost of fitting front and rear seatbelts in cars that tality (EurC) are: Belarus, Estonia, Hungary, Kazakhstan, Latvia, lack them. Lithuania, Republic of Moldova, Russia, and Ukraine. 27 Figure 5: Cost-effectiveness of Road Traffic Injury Prevention Strategies, in Europe and Central Asia, 2005 Enforcement of speed limits (via fixed/mobile cameras) Drink-drive legislation & enforcement (breath-testing) Legislation & primary enforcement of seatbelt use Legislation & enforcement of helmet use by motorcyclists Legislation & enforcement of helmet use by bicyclists Speed cameras + breath-testing EurB EurC 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 $0 $10,000 $20,000 $30,000 $40,000 $50,000 $60,000 $70,000 Average Cost per DALY Saved Note: International dollars per DALY saved. EurB (countries with low child and adult mortality) = Albania, Armenia, Azerbaijan, Bosnia and Herzegovina, Bulgaria, Georgia, Kyrgyzstan, Poland, Romania, Serbia and Montenegro, Slovakia, Tajikistan, the former Yugoslav Republic of Macedonia, Turkey, Turkmenistan and Uzbekistan. EurC (countries with low child and high adult mortality) = Belarus, Estonia, Hungary, Kazakhstan, Latvia, Lithuania, the Republic of Moldova, the Russian Federation, and Ukraine. Source: Chisholm and Naci (2008). National Center for Injury Prevention and Control targets in the medium and longer terms. The traditional 2000). For example, one measure shows that every US$1 and alternative funding sources presented in Box 4 may spent on random breath testing for alcohol control saves be relevant for the ECA context since some of them US$36. Affordability of personal safety equipment is individually or in combination have been adopted with important and depends on price relative to disposable success in some countries (OECD/ITF 2006, 2008). income. A combination of free-market competitive pric- ing and subsidies may be required to achieve affordabil- 8. Country experiences: Selected ity (Hendrie and others 2004). international good practices 7. How to finance road safety Box 5 on page 30 describes policies, strategies, funding arrangements and interventions in a sample of countries efforts? that have achieved good road safety results. Clearly, One of the main challenges facing governments in many these experiences show that at the root of these good countries is how to fund necessary investments and other practices is a firm and sustained commitment by govern- program costs of a road safety initiative to help achieve ment, including proper allocation of funding, over many 28 Table 8: Estimated Financial Savings Box 4: Traditional and Alternative Sources of Funding for to Society from Selected Road Safety Programs Road Safety Interventions Savings Traditional funding sources: Intervention (US$ per US$1) General tax revenues: As part of the national budgeting processes, specific road Road Design safety components are embedded within larger engineering, enforcement, and Simple road markings 1.5 education programs. Upgrading marked pedestrian crossings 14.0 Road funds: Revenue sources for road funds typically come from fuel taxes, vehicle registration and licensing fees, and road user charges for heavy vehicles. Pedestrian bridges or underpasses 2.5 User fees: Regulatory services associated with driver's licensing, vehicle inspec- Guardrails along the roadside 10.4 tion, and operator licensing are directly funded from road user fees, paid to Removal of roadside obstacles 19.3 either the government agencies responsible or private sector agencies working on Median guardrail 10.3 their behalf. User fees are usually collected on a cost-recovery basis. Signing of hazardous curves 3.5 Insurance levies: Some countries levy a fee on vehicle insurance premiums to Area wide speed and traffic help fund road safety programs, but the amount of funding raised is often small management 9.7 and used to fund education and publicity initiatives to improve road user aware- Conspicuousness ness of road safety risks. Daytime running lights Earmarked charges: Various taxes and user charges are being channeled to road (normal bulbs) 4.4 funds for a variety of purposes. For example, revenue from traffic fines is used to Roadside lighting 10.7 finance road safety activities in some countries. Alcohol control Random breath testing 36.0 Alternative financing sources: Car Restraints More recently, the following alternative options to complement the traditional Audible seatbelt reminders 6.0 funding sources are being discussed in various countries (ECORYS 2006): Child restraints 32.0 Price/tax policy: This includes fiscal incentives to encourage private and busi- Seatbelt enforcement programs 3.0 ness investments in safety measures and to promote the design of safer infrastruc- Helmets ture and vehicles. The incentives could relate to certain categories of equipment Bicycle helmets 29.0 with proven safety effectiveness (for example, production of safety belt reminders Motorcycle helmets 1.0 for retrofitting in existing vehicles). Sources: ETSC (2003b); SWOV (2001); and Insurance premiums: Behavior that reduces safety on roads could be discour- U.S. National Center for Injury Prevention and aged by adjusting premiums to: (a) ensure that road safety gets prominent atten- Control (2000). tion within companies (for example, through safe fleet management practices); (b) match travel speeds through pay-as-you-drive or pay-as-you-speed mecha- nisms; (c) spread the costs of risks associated with crashes causing bodily injuries decades. One key lesson that comes out of more fairly; and (d) assign the total costs of a car crash from society to the per- these experiences is that road safety needs to son who caused the crash. be approached in a very systematic manner, building upon research and enhanced institu- Financial options: Using financial and fiscal incentives to change the behavior tional capacity in different sectors to formu- of road users and to stimulate safety measures by car manufacturers and infra- late effective programs that can be monitored structure managers has the advantage of using market principles and might and adjusted as implementation progresses. be more acceptable than direct interference by governments: unsafe behavior Some of these experiences are relevant for becomes more expensive while safe behavior is rewarded. ECA since they provide evidence that RTIs can be reduced and that they make good Source: Adapted from OECD (2002) and Aeron-Thomas and others (2002), as cited in economic sense. Peden and others (2004); ECORYS (2006). 29 Box 5: Selected International Country Experiences Policies and Strategies Sweden is a world leader in road safety. Since the mid-1990s, it has implemented a bold road safety initiative known as "Vision Zero," which aims to eliminate deaths and serious injuries. Road fatality numbers have plum- meted since the 1990s to 4.3 fatalities per 100,000, about half the European Union average. The main strategic principles guiding the road safety effort are: (i) the traffic system has to adapt to take better account of the needs, mistakes and vulnerabilities of road users; (ii) the level of violence that the human body can tolerate without being killed or seriously injured forms the basic parameter in the design of the road transport system; and (iii) vehicle speed is the most important regulating factor for safe road traffic. It should be determined by the technical stan- dard of roads and vehicles so as not to exceed the level of violence that the human body can tolerate. The action strategy aims to: (i) prevent crashes leading to serious injury especially by limiting exposure to risk; (ii) reduce the severity of injury in a crash through crash protective design and protective clothing; and (iii) ensure that the sever- ity of injuries received is minimized through efficient rescue service, health and rehabilitation. The Netherlands has one of the lowest fatality rates in the world at 4.6 per 100,000 inhabitants. The Dutch Sustainable Safe Traffic System's main components are: (i) infrastructure adapted to human limitations through proper road design; (ii) vehicles equipped to make driving easier and to offer good crash protection; and (iii) road users provided with adequate information and education and, where necessary, deterred from undesirable or dan- gerous behavior. The strategic principles are: (i) re-classifying the road network according to road function, includ- ing the flow function to enable high speeds of long-distance traffic and large volumes; the distribution function, serving districts and regions as containing scattered destinations, and the access function, enabling direct access to properties alongside a road or street; (ii) establishing speed limits according to road function; and (iii) ensuring compatibility through design in function, layout and use to prevent unintended use, large discrepancies in speed, direction and mass at moderate and high speeds, and uncertainty amongst road users by making the road course more predictable. Funding Approaches Australia. The federal government directs its fuel tax revenues to the states to make significant investment to upgrade the national highway system and for black spot programs. Each state raises its own revenues for invest- ment in its own roads and for enforcement, regulatory, and educational activity. Injury insurers also play a grow- ing role in safety investment, particularly in Victoria, where insurers have invested heavily in educational and infrastructure projects. Road fatalities have fallen significantly since the 1970s through mandatory seatbelt wearing and random breath testing for alcohol, improvements in vehicle safety, increases in speed enforcement supported by major public education and publicity, bicycle helmet wearing (mandated in 1990), graduated licensing, and, since 2001, lower traffic speed limits (50 kilometers per hour [km/h] on urban roads and 40 km/h near schools and shopping centers), increased penalties, increased enforcement, and continuing public service announcements. Infrastructure improvement contributes as an ongoing commitment. New Zealand. Specific road safety budgets and allocation processes have been critical elements in improving road safety in New Zealand since 1990. Revenue from fuel taxes (New Zealand dollars [NZD] 1.315 billion) and vehicle registration and licensing fees (NZD222 million) were directed to a National Land Transport Fund in May 2004. These funds, channeled through the New Zealand Road Safety Program (NZRSP), have financed the national road policing program, national road safety education, national publicity and awareness campaigns, and national strategy management and coordination processes. National and local low-cost safety engineering mea- sures and general road network investments that contribute to improved road safety outcomes have been financed through the National Land Transport Program (NLTP). The NZRSP and the NLTP complement local govern- (Continued on next page) 30 Box 5: Selected International Country Experiences (Continued) ment activity. In addition, a compulsory injury insurance scheme, the Motor Vehicle Account (NZD583 mil- lion), charges road users premiums to meet injury treatment, rehabilitation, and compensation costs from crashes. While most of this income is directed to injury management and rehabilitation, the insurer applies a portion of this account to safety promotion programs. Selected Interventions Germany. The number of fatalities on German roads fell more than 50 percent during 1991­2005: from 11,300 to 5,361. This resulted from (a) active and passive safety features of vehicles (for example, seatbelts, front passen- ger airbags, side protection systems); and (b) development and implementation of governmental road safety pro- grams that prioritize developing a safe road culture, protecting vulnerable road users, making novice drivers less prone to collisions, reducing the danger posed by heavy-duty vehicles, and raising road safety on rural roads. United Kingdom. The number of deaths and serious injuries in London from road traffic crashes fell 45 percent during 1994­2005, well ahead of the national target of 40 percent by 2010. The success is attributed to: (a) hav- ing strong political support from the mayor; (b) a new London Road Safety Unit established to coordinate road safety activities; (c) large budget increases; and (d) applying a full range of known infrastructural and behavioral interventions. Enforcement activities include use of over 600 cameras, which helped reduce by over 40 percent serious casualties at camera sites where speed had caused collisions. Direct expenditure on road safety rose sharply from GBP10 million a year in 2000 and 2001 to GBP39 million in 2005. Mexico. A key investment for Mexico's road safety improvements has been the modernization of 14 central road corridors. By 2006, this program had upgraded 17,320 kilometers of the most important highways in the country, 90 percent of the total length of the 14 corridors. United States. Since 40 percent of all fatal crashes are alcohol related in the United States, laws governing blood alcohol concentration (BAC) levels for law enforcement have been enacted by all states. All have enacted zero-tol- erance laws that make it illegal for drivers under age 21 to have any detectable alcohol on their breath. By 2005, all 50 states, the District of Columbia, and Puerto Rico had enacted 0.08 BAC laws. This, along with strict police enforcement, has helped reduce highway deaths from 43,384 in 2007 to 39,397 in 2008. Source: OECD/ITF (2008); OECD/ECMT (2006); Breen, Howard, and Bliss (2008); and Halsey (2009). 9. Country-level responses in ECA audits of existing road infrastructure, and have national policies to promote public transportation, walking, and Annex 1 shows that many ECA countries now have cycling. Formal, publicly available pre-hospital care sys- structures and processes to address the RTIs epidemic. tems for post-crash care are available in ECA countries, These structures range from institutional frameworks but their quality varies significantly. that include lead agencies to coordinate the national response funded by national budgets and national road Significant progress has been achieved in Poland for safety strategies with measurable targets, to laws that example, with public education on road safety and safe- set speed limits, regulate driving under the influence of driving training for professional drivers, campaigns to alcohol, and mandate the use of motorcycle helmets, increase seatbelt use, programs to reduce alcohol abuse, seatbelts, and child restraints. special cautionary road signs to warn drivers of black spots, and improved pre-hospital care. Russia, too, has In addition, many ECA countries require formal audits had some recent success in health promotion to reduce for major new road construction projects and regular 31 RTIs, the details of which are presented in Box 6. and magnitude of RTIs and their associated risk factors Armenia has seen dramatic improvements in seatbelt use (World Bank 2004). as a result of its decision to enforce its seatbelt law, as described in Box 7. In spite of progress observed in ECA, additional and scaled-up efforts and resources are needed to remedy the Enforcement of road safety laws and regulations, how- ever, is often lacking, for example: Georgia's seat-belt Box 7: Seat belts in Armenia law, Kyrgyzstan's drunk-driving law, Moldova and Serbia's drunk-driving and motorcycle helmet laws, and Armenia has had a law since 2007 requiring all car Tajikistan's seatbelt law (WHO 2009a). Due in large passengers to wear seatbelts. However, the law was measure to deteriorated epidemiological surveillance sys- widely ignored and not enforced. Casual observa- tems, few ECA countries have reliable data on the level tion suggested very low usage rates in urban areas and only a small proportion of drivers and front-seat passengers wearing seatbelts on inter-urban roads. Box 6: How is Russia responding to the RTIs Challenge? In 2008, the World Bank funded the preparation The Government of the Russian Federation is implementing the of a road safety strategy and a five-year action plan "Federal Targeted Program for Ensuring Road Traffic Safety 2006­ which, among other things, stressed the case for 2012," aimed at decreasing the number of road crashes by 15 enforcing the law. percent and reducing the number of people killed on the country's On August 13, 2009, the government formally roads by 15-20 percent by 2010. The Department of Road Traffic approved the strategy and action plan. On the same Safety within the Ministry of Internal Affairs (MIA) is coordinating day, the Prime Minister and Minister of Transport this program with the participation of the Transport, Emergency appeared on television to express their support for Situations, Health and Social Development Ministries, other fed- action on road safety, and both personally pledged eral agencies, and regional and municipal governments. to wear seatbelts. They announced that the law The main components of the program are roads modernization would be enforced. The police immediately began and education and information campaigns. Also, several promis- stopping drivers but initially only gave advice to ing measures were recently adopted: fines for driving without a drivers, pointing out that the law would soon be seatbelt were increased tenfold, a law was enacted to make cross- strictly enforced. ing into an oncoming lane an offense punishable by revocation of Now, the law is enforced and the impact has been driver's license, and anti-alcohol campaigns have been launched, in dramatic. While systematic surveys are yet to be some cases with the participation of the Russian Orthodox Church undertaken, it is clear that usage rates have increased (Parfitt 2009). As a result of these efforts a positive trend in RTIs dramatically--casual observations suggest that over was observed during 2007­08. 90 percent of drivers and front-seat passengers now However, road conditions in Russia are still very dangerous. As "belt-up" in the capital, Yerevan, and that higher President Medvedev emphasized in a national speech on August rates prevail on highways. 6, 2009, poor road infrastructure, bad organization of road traffic, Political endorsement at the highest level has been and insufficient efforts at the regional and local levels, hinder fur- vital in this, both in high-profile personal commit- ther improvements. This situation is aggravated by the absence of ment to wear seatbelts, and in giving the police the effective education programs for drivers, particularly young drivers, security of knowing that their enforcement effort and a limited road police purview which concentrates on collect- has strong backing. The Prime Minister made it ing penalties and not on preventing road crashes. Road fatalities clear in his television speech that the government, and disability among car crash victims also occur due to the weak and in particular members of the cabinet, should organization and limited resources that constrain the timely and lead by example. The effect can now be seen on the effective operation of emergency medical services and of rehabilita- streets of Yerevan. tion services at the facility and community levels upon discharge of the patient. Source: Camos-Daurella and Silcock (2009). 32 significantly worse road safety performance (including in on demonstrably successful interventions. A financing countries that are now part of the EU) compared with plan for implementing the strategy should also be speci- their counterparts in the EU. fied using a staged approach to address revealed capacity weaknesses. This requires building core capacity to bring Experience from HICs and other middle-income targeted safety outcomes under control, then scaling up countries shows that improving road safety requires a investment to accelerate this capacity building strength- consistent, 20-to-30-year effort to develop and imple- ening and the achievement of improved results across ment comprehensive, integrated safe system programs, the national road network. Support should be provided under the coordination of a well structured and funded, to develop a program of infrastructure safety improve- technically and operational competent, lead agency. ments, road user education, traffic safety enforcement Business planning processes and performance monitor- and emergency preparedness along a first set of demon- ing systems must be developed and strengthened to stration corridors, with successful measures being rolled support a long-term strategy, and the first phase of the out across the remaining network (Bliss and Breen, strategy should foster consensus among stakeholders and 2009). public sector agencies on a long-term action plan based 33 4 "He went to him and bandaged his wounds, pouring on oil and wine. Then he put the man on his own donkey, took him to an inn and took care of him." ­ Parable of the Good Samaritan, New Testament Luke 10:34 Chapter IV. The Role of Health Systems in Preventing RTIs and Helping Victims In accordance with the vision outlined in "The Tallinn among different agencies, including centralized data Charter: Health Systems for Health and Wealth" (WHO- repositories at coordinating agencies, first responders, EURO 2008b), strengthened health systems have a major and medical care providers. Reliable RTIs statistics role to play as part of a multisectoral effort to improve are fundamental for identifying trends and priority road safety and other health conditions. The quality and interventions, designing programs and managing their effectiveness of the health system have a direct bearing implementation , allocating resources efficiently, and on achieving road safety goals. monitoring and evaluating the cost-effectiveness of programs and interventions. It is reported that police Health system activities that effectively contribute to data significantly underestimate fatal and non-fatal reducing the burden of RTIs could be grouped into four RTIs (Racioppi and others (2004). broad categories: (a) public health, (b) primary health care, (c) post-impact medical care, including (d) blood · Research into the causes of traffic crashes and injuries, transfusion services, and (e) rehabilitation. Each of these factors that increase or decrease risk, and factors that categories is discussed in detail in this chapter. might be modifiable through interventions. · Advocacy. This involves efforts to persuade policy 1. Public health actions makers and decision makers of the necessity of addressing injuries in general as a major issue and of The public health approach to RTIs involves a logical the importance of adopting improved approaches to sequence of actions including (a) identifying the size road traffic safety. of the problem; (b) analyzing the associated risk factors; (c) finding out what preventive measures work; and · Policy. This involves translating effective science-based (d) designing, implementing, and evaluating programs information into policies and practices that protect (Sethi 2007; WHO Regional Committee for Europe pedestrians, cyclists, and the occupants of vehicles. resolution 2005; Krug, Sharma, and Lozano 2000). The scope of these actions encompasses the following: · Population-based prevention and control interven- tions. The overall objective is to prevent the occur- · Monitoring and Evaluation. This includes assessing, rence of RTIs by changing related behaviors and through injury surveillance and surveys, all aspects lifestyles, environmental factors, and their social and of road crash injury--by systematically collecting economic determinants in an entire population (for data on the magnitude, scope, characteristics, and example, information and communication programs consequences of road traffic crashes. Data collection addressing the risks of RTIs, excise and other taxes for road safety requires well-organized and well-run aimed to reduce alcohol abuse). The main argument epidemiological surveillance systems, with standards for these interventions is that they target a high pro- and guidelines; well-trained data management per- portion of the population at risk of RTIs; 70 percent sonnel; and robust information systems to ensure or the majority of the population (Rose 1992). This the connectivity and flow of data and information approach offers an opportunity for synergy with other 35 programs and interventions targeting risk factors that 3. Emergency medical care systems are associated with the onset of non-communicable to deal with crash victims conditions such as cardiovascular diseases, diabetes and obesity. The aim of medical care after crashes is to avoid death and disability, limit the severity and suffering from 2. The role of primary care services injuries, and ensure optimal functioning of the survivors and reintegration into the community (Peden and others in RTI prevention 2004). The term emergency medical services (EMSs) has Recent and ongoing reforms of primary health care servic- evolved from referring to a simple transportation system es aim to secure healthier communities by strengthening (ambulance service) to an interconnected pre-hospital the response to complex health challenges that are associ- and facility-based medical care system. ated with growing urbanization, aging of the popula- The first step toward the modern organization of tion, and changing lifestyles (WHO 2008c). The reality emergency medical assistance was taken by Dominique of individuals facing multiple symptoms, illnesses, and Larrey, surgeon-in-chief of Napoleon Bonaparte's Grande injuries demands that service delivery be more integrated Armée, in the late 18th century, in treating casualties and comprehensive for effective case management. As rapidly on the spot. An emergency medical system such, well-structured and well-run primary care services (EMS) is "a comprehensive system that provides the can provide a "place to which people can bring a wide arrangements of personnel, facilities and equipment for range of health problems," and be a "hub from which the effective, coordinated and timely delivery of health patients are guided through the health system," and that and safety services" to victims of RTIs (Moore 1999). "opens opportunities for disease and injury prevention These services comprise a "continuum of care" from and health promotion." first contact with a victim until he or she is stabilized Primary health care services have an important role to (communication systems, transport systems, paramedic play in helping address RTIs ­ they are an integral part teams), to medical care provided at different trauma care of a community-based health care delivery system that facilities of varying technological capacity, to the reha- brings together promotion and prevention, treatment, bilitation of victims in health facilities and in communi- and care services. For example, general practitioners ties after discharge. (GPs) or family medicine teams provide medical A major review of worldwide evidence summarized the assessments of drivers who may be in special categories, components of an emergency medical service (Kobusingye have underlying medical conditions, or who are over and others 2006) as follows: age 70. The primary-care level also provides an opportu- nity for health interventions concerning alcohol abuse Pre-hospital care for initial emergency care and stabili- or the collateral effects on driving of using certain zation of road traffic victims. This component encom- prescribed medications. For example, there is evidence passes: (a) a first tier that involves care provided by the of the cost-effectiveness of advice given by a physician community at the injury scene to arrival at a formal in a brief encounter in primary care and emergency health care facility, and (b) a second tier that involves department settings about the harmful effects of alcohol. trained paramedic personnel who use dedicated vehicles Since leading risk factors for RTIs such as alcohol and equipment to get to patients and take them to hos- misuse are also associated with other leading causes of pitals within the shortest possible time. Effectiveness has death and disability (for example, cardiovascular diseas- also been demonstrated of well-placed dispatch sites in es), health gains can be maximized by simultaneously urban populations, where vehicles and personnel can be implementing population-level health promotion and optimized. Shorter pre-hospital times are an important disease prevention programs targeting multiple risk parameter of the quality of pre-hospital care. These times factors and groups and individual at high risk, while have the following components: enhancing population coverage of effective treatment and care. · Notification time is the time from injury occurrence or recognition of injury until the EMSs are notified. 36 · Response time is the time from notification until ter), a district hospital with generalists, or a health center arrival of an emergency unit to the injured person. with competent clinicians, depending on the country. The recommended ratio of one emergency unit for The triage or screening process--in the pre-hospital sub- 50,000 people (McSwain 1991) results in response system or receiving area of a fixed facility--should deter- times as low as four to six minutes, although traf- mine the appropriate facility to transport patients to, fic congestion, poor maps, and poor signage may rather than sending them to the nearest facility. Precious increase the time. Monterrey, Mexico has an aver- time and lives may be lost when patients are taken to age response time of 10 minutes with one unit per facilities unable to offer appropriate care. Equipment 100,000 people. Hanoi, Vietnam, with one unit for and supplies at each level should match the knowledge 3 million people, has an average response time of 30 and skills of the personnel available to use them. minutes (Mock and others 1998). Systems organization. Emergency care must be planned · Scene time is the time pre-hospital providers take and implemented carefully. The various EMS compo- from arrival at the scene until departure from it. nents should be linked to ensure that the entire system operates as a unit. · Transport time is the time from leaving the scene until arrival at a treatment facility. Health financing for emergency care. Direct payment of costs for transportation, medical treatment, and drugs Traditional and innovative communications systems. erects a barrier between the poor and EMSs everywhere. Nowhere is efficient communication and rapid trans- Emergencies can financially devastate individuals and portation more critical than in emergency medical care. families, often for many years. Financial protection The best teams equipped with the best technology and for emergency health care is a necessity in low-income supplies are wasted if they cannot be reached quickly or countries and has lacked adequate attention. The goal lack contact with health care facilities. Radio communi- is to ensure that individuals and families do not spiral cation is one solution in low-income settings. Cellular down to abject poverty as a result of interacting with the telephones may offer better communications to com- national health system. In some ECA countries, the sys- munities that are remote from standard communications tem of co-payments or informal payments disadvantages infrastructure. the poor. Medicines and equipment for the care of people that have Quality assurance. For an EMS to maintain and improve suffered traffic injuries. Medicines and equipment for the care of patients, systematic documentation and peri- emergency care play an important role in stabilizing and odic audits or other processes to ensure quality of care saving the life of an injured person. Training ambulance must be incorporated. Quality management systems that drivers and paramedic and medical personnel in the are simple and continuous and allow for rapid changes administration of first responder care (for example, for in the system must be implemented. shock, appropriate use of intravenous fluids) is vital. Proper emphasis on essential medicines and equipment to be included in first aid kits to attend the needs of 4. The importance of blood people with multiple injuries, hypovolemia (low blood transfusion services in dealing volume due to blood loss), and other conditions, is with RTIs required. Training in trauma triage11 is also important. Blood transfusions, coupled with safe medical procedures, Health-facility-based subsystem. This subsystem within save lives after a road traffic injury. Life-saving transfu- the health care system delivers definitive care. It may be sions of blood or blood-based products are an indicated a regional hospital with specialists (major trauma cen- procedure for situations involving massive blood loss due to trauma or surgery . Blood is also needed for people 11 Triage is a process of prioritizing patients based on the severity requiring complicated surgical procedures that result of their condition. Triage helps determine the order and priority from trauma events. of emergency treatment, the order and priority of emergency transport, and the transport destination for the patient after an Blood transfusion services are responsible for ensuring RTI. safe and sufficient quantities of blood in a health system. 37 Blood service organizations educate, recruit, and select However, particularly in Central Asia, existing blood donors, collect and process their blood, prepare blood services are in dire need of reorganization and upgrad- products,12 screen blood donations for various infec- ing, with particular emphasis on strengthening the con- tious markers, and do other tests in a quality-controlled trol systems that would ensure the quality and safety of fashion, and, in coordination with health service provid- transfusion therapy (Marquez, 2008). ers, follow up on the safe and appropriate use of blood and blood products. Whole blood and its products must To protect RTI victims from contaminated blood be stored and maintained under proper refrigeration, transfusions and related unsafe medical practices, a well- requiring an accurate and reliable cold chain.13 organized blood transfusion service, with quality control systems in all areas, must be secured as part of scaling-up In 2004, blood services in 172 countries collected a total road safety efforts in ECA. of 81 million units of blood, according to the World Health Organization (WHO) global database. However, only 1 percent was collected in low-income countries, 5. Rehabilitation services where about 37 percent of the world population lives; 44 In many LMICs, rehabilitation services are in short sup- percent were collected in medium-income countries; and ply, and their strengthening needs to be considered as part 55 percent in high-income countries (HICs). In addi- of health system reform and improvement efforts, particu- tion, 94 percent of blood collected in HICs is donated larly to help RTIs victims avoid lasting disabilities. In without pay, whereas 43 percent of blood in low- and HICs, a variety of specialists--physical therapists, occu- middle-income countries is donated for pay or is from pational therapists, prosthetics specialists, neurologists, replacement donors.14 psychological counselors, and speech therapists--provide rehabilitation (Peden and other others 2004). Services The problem of blood supply shortages and increasing and equipment are also provided at home. Building up safety concerns are particularly acute in low- and middle- rehabilitation services would also be useful for the proper income countries (LMICs). Of the 53 WHO European management of stroke victims and other non-communi- Member States (which include the ECA countries), only cable conditions. 26 have national programs for voluntary blood donation. Standard blood safety principles prescribe that blood 6. Good practices in organizing services screen blood and blood products for at least HIV, emergency medical services hepatitis B and C, and syphilis contamination (The Lancet 2007). However, complete and accurate data on Different countries have initiated programs and made testing of donated blood is not available in many LMICs related investments to improve pre-hospital care systems (WHO 2007a). In many FSU countries, blood services and strengthen health-facility-based subsystems. Recent are functioning well and providing safe transfusions. noteworthy experience in the United States indicates that by 2005, 31 states had established formal trauma care systems, up from eight in 1980 (Haider 2007). 12 The WHO definition of blood products includes blood compo- Trauma systems are organized on the basis of different nents (labile) and stable blood fractions resulting from plasma levels of care: Level 1 centers offer the highest level of processing. The European Union blood directive has different care (major trauma center) plus research and a com- definitions and considers only the stable fractions as blood prod- mitment to injury prevention, Level 2 centers offer the ucts. second-highest level of care and can manage most emer- 13 Different blood products require different storage temperatures gencies, Level 3 centers are smaller and can handle only (from +21° C to -40° C according to type of product). moderate injuries, and Level 4 centers need to transfer 14 Where health facilities have blood supply shortages, patients any significantly injured patients to a higher level. needing transfusions recruit friends and family members for donations before the patient undergoes a procedure requiring Multiple studies have shown that state trauma systems a transfusion. These family replacement donations are seen as improved outcomes and survival among RTIs victims. essential and as far safer than paid blood donors, but not as safe Increased survival was found to result from better pre- as blood from those who donate for the public good (Carolan and García 2005). hospital care (expedited access) and improved in-hospital 38 care processes (quality of care), Box 8: SAMU: France's Emergency Medical Services revealing the potential for an EMS to address the growing The principles of Service d'Aide Médicale Urgente (SAMU) hold that emergency medical assis- burden of trauma and injuries tance is the first (and therefore a key) step in the provision of medical care. Interventions in the through improvements in field must be speedy and efficient and use suitable resources. The approach to each individual both pre-hospital and hospi- case is simultaneously medical (to provide care), operational (movement is necessary, so distance, tal-based care. time, weather, and so forth are considerations), and human (patient dignity and comfort must be Another good example in this primary concerns). The responsibilities and detailed arrangements for coordination among those field is France's Service d'Aide involved must be regulated by a set of working rules. Results depend in large measure on the skill Médicale Urgente (Emergency of those involved. Preventive action must complement emergency action. Medical Services, SAMU). Organizational and operational elements include integration of fire departments and private Formally begun in the 1960s ambulance networks. Services are activated by a call to a SAMU call center, where a physician with the support of the French and staff determine the most suitable response and implement it by giving information or advice Ministry of Transport, SAMU or by sending appropriate help. Call centers are situated at hospitals, usually next to the hospital is now part of the health mobile intensive care unit (H-MICU). Hospitals are pivotal, managing the call centers, coordi- sector. It contributed to the nating staff in the pre-hospital phase, managing H-MICUs, and receiving patients. H-MICUs development of the first pilot are hospital units operating in close collaboration with the hospital departments responsible for hospital mobile intensive care receiving emergency patients. The H-MICU transport system includes light rapid-intervention units (H-MICUs) (Box 8). vehicles, ambulances, and helicopters. The vehicles are equipped with essential resuscitation and intensive care equipment. Source: France's SAMU online. 39 5 "We have the tools, the knowledge, to undertake this work. Now we need to see the political will to implement a Decade of Action. The United Nations has recognized that the global road injury epidemic is serious enough to warrant General Assembly resolutions and a first Ministerial-level conference." ­ Lord Robertson of Port Ellen, Former Secretary-General of NATO and current Chairman, Commission for Global Road Safety Chapter V. Road Safety Approaches and Policies The approach to road safety has evolved in recent decades vehicle safety, and legislation and enforcement of laws to from "blaming the victim" to "safe systems." In the 1950s ensure road users' compliance with safety measures. The and 1960s, road safety policies emphasized the role of Haddon Matrix in Table 9 is a framework for holistically individual responsibility and used legislation, traffic addressing road transport and its risks. It divides a car management, drivers' licensing and vehicle inspections, crash into three phases--before, during, and after--to and information and communication to change road highlight the times when crashes can be prevented or users' behaviors. Little progress was made in reducing their effects minimized. Each phase involves three fac- road injuries. This chapter describes the more system- tors--human, vehicles and equipment, and environ- atic "safe systems" approach that has evolved, which ment--and each of the nine resulting cells in the matrix identifies the risk factors that contribute to crashes and outline possible areas for intervention. This holistic, sys- injuries, and then discusses interventions that reduce tems approach--operationalized through action-focused the risks associated with those factors (Peden and others plans with numerical outcome targets, broad packages of 2004, OECD/ITF, 2008; and Bliss and Breen, 2009). system wide measures, close monitoring and evaluation of performance, and development and application of new knowledge--helped reverse the rising trend in road 1. The safe systems approach facilities in high-income countries (HICs) in the 1980s Blaming the victims has given way to strategies emphasiz- and 1990s. By the late 1990s, this holistic approach had ing a systems approach to intervention. This approach evolved into the `safe system' approach that highlights embraces improvements in road infrastructure and the shared responsibility and accountability by all parties Table 9: Haddon's Matrix for Crash and Injury Prevention Nature of Factor Phase Intervention Human Vehicles and Equipment Environment Pre-crash Crash prevention Information/training Road-worthiness Road design, signs, Attitudes/impairment Lighting markings, maintenance Police enforcement Braking Speed limits Handling Pedestrian facilities Speed management Crash Injury prevention Use of restraints Occupant restraints/ Crash-protective during crash Impairment airbags roadside objects Other safety devices Crash-protective design Post-crash Life-sustaining First aid skill Ease of access Rescue facilities Access to medical care Fire risk Congestion Source: Commission for Global Road Safety (2006). 41 to the road transport system for improved road safety Organization (WHO) to coordinate (in collaboration performance. with the UN regional commissions) road safety issues within the UN system. A safe system approach has as its goal the elimination of death and serious injuries, and this influences how inter- United Nations World Health Assembly Resolution ventions are designed. The guiding principles of the safe WHA 57.10 on Road Safety and Health, May 22, 2004, system approach are: recognizes that road traffic injuries (RTIs) are a major but neglected public health problem causing significant · Not all road crashes can be prevented, but traffic inju- mortality and morbidity and considerable social and eco- ries can be reduced. nomic costs and requiring urgent action (WHA 2004). · Road traffic systems should be designed and operated It offers countries several recommendations to reduce to cope with human error and take better account of RTIs. The resolution urges Member States to integrate the vulnerability of the human body. RTIs prevention into public health programs; establish · Responsibility and accountability for road safety is government leadership in road safety; facilitate multi- shared by road and car designers and road users. sectoral collaboration across ministries, communities, and society; assess the national situation and ensure that Proven approaches fall into four categories: (a) vehicle available resources are commensurate with the size of the design and safety equipment (helmets and seatbelts, road safety problem; prepare and implement a national daytime running lights, airbags); (b) road user measures strategy on road injury prevention; and take specific and their enforcement (for example, speed limits, seat- measures to prevent mortality and morbidity and evalu- belts, restrictions on drinking and driving and cell phone ate their impacts. The resolution requests the WHO use); (c) engineering measures that improve road design Director-General to collaborate with Member States to (intersection control, safety and crash barriers, clear undertake further research, build capacity, advocate road markings and signs); and (d) traffic management and injury prevention, raise awareness about the risk factors reducing exposure (providing shorter, safer routes, better related to road traffic collisions, and strengthen pre-hos- mass transit, and reducing mixing between pedestrians pital and trauma care for survivors. and cyclists and motorized traffic). Also, when preven- tion fails, effective post-crash emergency medical and The World Report on Road Traffic Injury Prevention rehabilitation services are important to reduce both the (Peden and others 2004) emphasizes the role of public number of fatalities and the length and severity of sur- health in preventing RTIs. It covers the fundamental viving victims' disability. concepts and prerequisites of RTI prevention, the inten- sity and impact of RTIs, key determinants and risk fac- "Towards Zero: Ambitious Road Safety Targets and tors, intervention strategies, and recommendations. the Safe System Approach" was released by an inter- national group of safety experts under the aegis of UN Resolution A/62/L.43 on Easing the Global Road the Organization for Economic Co-operation and Safety Crisis and the call for the First UN Ministerial Development (OECD) and the International Transport Summit of Road Safety, hosted by Russia in November Forum (ITF) (OECD/ITF 2008). As detailed in Box 9, 2009, are further raising the policy profile of road safety the report sets out a policy framework for pursuing road globally. safety targets, one that has been adopted by many coun- tries worldwide. 3. Key European Union (EU) Policies and Legislative and Regulatory 2. Policy framework at the Framework on Road Safety: international level A "Safe System Approach" The last decade witnessed several international policy Rather than a Group of Parallel developments on road safety, raising the policy profile Interventions of road safety worldwide. In April 2004, UN General Assembly Resolution A/Res/58/289 on "Improving The current comprehensive EU policies and legislation Global Road Safety" mandated the World Health and other measures to deal with RTIs are already insti- 42 Box 9: Towards Zero: Ambitious Road Safety Targets and the Safe System Approach 1. Adopt a highly ambitious vision for road safety. outcomes (also called safety performance indicators and All countries are advised to adopt and promote a level including mean speeds, seatbelt wearing, drunk driving, of ambition that seeks in the long term to eliminate and vehicle and infrastructure safety ratings); institu- death and serious injury arising from use of the road tional delivery outputs (including different categories of transport system. Adopting such a vision will reverse enforcement effort); socioeconomic costs associated with people's view of the inevitability of road trauma, alter road trauma; and underlying economic factors (includ- institutional and societal responsibilities and account- ing new vehicle sales). Careful data analysis should be ability, and reshape road interventions. used to improve understanding of crash and other trends to inform different intervention mixes and intensities. 2. Set interim targets to move systematically toward the vision. All countries should adopt ambitious, 6. Strengthen the road safety management system. achievable, and empirically derived road safety targets All countries should commit to ensuring an effective to drive improved performance and accountability. The road safety management system and in particular foster targets should be developed in a way that links inter- a strong results focus through institutional arrange- ventions and institutional outputs with intermediate ments. A results focus requires the identification of a and final outcomes to develop achievable targets for dif- lead agency, the core group of government ministries ferent intervention options. and agencies and their roles and responsibilities, and performance targets for institutional outputs and inter- 3. Develop a safe system approach, essential for mediate and final outcomes to be achieved within a achieving ambitious targets. All countries, regard- defined strategy. less of their level of road safety performance, should adopt a safe system approach. This approach builds on 7. Accelerate knowledge transfer. Knowledge transfer existing road safety interventions but reframes the way initiatives must be supported with adequate investment road safety is viewed and managed in the community. in targeted programs and projects and be designed to It addresses all elements of the road transport system overcome institutional capacity weaknesses, especially in an integrated way with the aim of ensuring crash by creating sustainable learning opportunities in the energy levels are below what would cause fatal or seri- countries concerned. Strong and sustained interna- ous injury. It requires system designers and road users tional cooperation will be required to mobilize required to share responsibility and accountability. It stimulates resources. the development of innovative interventions and new partnerships that are necessary to achieve ambitious 8. Invest in road safety. Most countries need to better understand the costs of road crashes, both by govern- long term-targets. ment and personal injury insurance companies, and the 4. Exploit proven interventions for early gains. value of investment in road safety. Opportunities for Countries experiencing difficulty in improving their road safety investments with competitive returns are road safety performance should urgently conduct high- available; the business case for this investment needs to level reviews of their safety management capacity and be developed. prepare long-term investment strategies and related programs and projects to overcome capacity weaknesses 9. Foster commitment at the highest levels of gov- revealed through such reviews. ernment. Sustained government commitment at the highest levels is essential for improving road safety. 5. Conduct sufficient data collection and analysis To secure this, road safety managers must develop to understand crash risks and current performance. evidence-based road safety programs and advocate All countries should develop data collection procedures strategies that reflect an understanding of political con- to cover: final outcomes (including at least deaths and straints, such as the electoral cycle. serious injuries by road users); exposure measures (for example, relating outcomes to population levels, num- Source: Joint Research Centre of the OECD and ITF (2008). bers of licensed drivers, distances traveled); intermediate 43 tutionalizing a "safe system approach", rather than a comparative analysis of substantial changes and new group of parallel interventions. Taking into account that construction to examine the network's safety perfor- ECA is a mixed group of non-EU and EU countries, mance. The purpose is to know the implication for current EU policies and legislative measures offer a clear road safety of different alternatives to ensure that road framework to recently ascended countries and candidates safety is weighed carefully in decisions. for ascension for adjusting their policies and programs. The EU approach focuses on three pillars, briefly termed · Road safety audit. An audit is an independent, detailed, systematic, and technical safety check relat- "infrastructure," "vehicles," and "user behavior." ing to the design characteristics of a road infrastruc- The White Paper, "European Transport Policy for 2010: ture project. It covers all stages from planning to early Time to Decide" (EC 2001) approved by the European operation in order to identify and detail any unsafe Commission (EC) in September 2001, set the ambitious features of such project. goal of reducing the number of fatalities on European · Rankings of high crash concentration sections. This roads by 50 percent by 2010. This target was recon- review examines sections of the road network in use firmed in 2003 with the European Road Safety Action for more than three years where a large proportion program, "Halving the Number of Road Accident of crashes have occurred. It then identifies, analyzes, Victims in the European Union by 2010: A Shared and classifies parts of the network according to their Responsibility" (EC 2003). (The fourth European Road potential for safety development and crash cost sav- Safety Action Program 2011­2020 is under prepara- ings. It helps target investments to road sections with tion.) A European Road Safety Observatory15 was set up the highest accident concentrations and/or the highest to disseminate information, best practices, and findings crash reduction potential. of research on road safety, and to collect and analyze data. · Safety inspections are a preventive tool to identify defects that require attention. The current EU program aims to improve road infra- structure, make vehicles safer, and encourage better road Member States are expected to bring into force the laws, user behavior. The program proposes that all concerned regulations, and administrative provisions necessary to parties, whether public or private, should subscribe to comply with the directive by December 2010; ensure a European Road Safety Charter.16 EU Road Safety that guidelines (measures describing the steps to be fol- Program managers recently approved directives to lowed and the elements to be considered in applying improve all three pillars. the safety procedures) are in place by then; and ensure that, if they do not already exist, training curriculums A. Road infrastructure for road safety auditors are adopted. Member States may The EU approach integrates road safety in all phases of also apply the provisions of the directive to national planning, design, and operation of road infrastructure. road transport infrastructure not included in the trans- For example, Directive 2008/96/EC of 19 November European road network but constructed with commu- 2008 introduces a comprehensive system of road infra- nity funding. structure safety management (EC 2008a). It addresses substantial changes to the existing network and new B. Vehicle safety construction that affect the traffic flow within the trans- Vehicle safety is addressed through EC directives such as European road network. It focuses on four procedures to those cited in this section and the eSafety initiative pro- address safety concerns relative to road infrastructure: moting intelligent vehicle systems. · Road safety impact assessment. Undertake--at the Seatbelt use. Directive 2003/20/EC made seatbelt and planning stage, before project approval--strategic child restraint use compulsory after May 2006 in all cat- egories of vehicles and on all seats fitted with belts (EC 15 The observatory Website is http://ec.europa.eu/transport/wcm/ 2003a). road_safety/erso/index-2.html. 16 The charter is available at: http://www.erscharter.eu/. 44 Blind spot mirrors. Directive 2003/97/EC required all D. Post-crash care new, heavy-duty vehicles above 3.5 tons to be equipped Improved response and care in the event of road crashes with blind spot mirrors as of January 2007 (EC 2003b). could save several thousand lives. However, emergency Directive 2007/38/EC requires mirrors to be retrofitted medical services appear to have a secondary role in the to heavy-duty vehicles registered in the Community (EC mechanisms for disaster preparedness and response in 2007). many EU countries, including in road safety approaches Daytime running lights (DRLs). Directive 2008/89/EC (WHO EURO 2008c). To address this situation, the makes these lights mandatory after February 2011 for all European Inter-Ministerial Panel on Emergency Health new cars and light vans and after August 2012 for other Care--a group of experts in the field of emergency new vehicles (EC 2008b). medical services--has been established with the support of all Ministries of Health, with the goal of meeting Roadworthiness. Directive 96/96/EC, effective in March regularly and exchanging and analyzing information on 1997, requires periodic roadworthiness tests for vehicles emergency medical services. This panel is expected to be registered on European territory (EC 2008a). Directive instrumental in developing and sustaining a continuous 2000/30/EC, effective in August 2000, provides for process of risk and crisis management at the EU level. technical roadside checks on commercial vehicles in the community. In addition, guidelines will address securing cargo and abnormal transport (EC 2000). 4. Setting road safety targets A long-term policy vision and system-wide strategies need eSafety. This refers to the Intelligent Car Initiative sup- to be complemented by interim targets to raise society's ported by the EC, industry, and other stakeholders. It interest in road safety and guide policymaking and strat- aims to accelerate the development, deployment, and use egy development. International experience indicates that of intelligent vehicle safety systems that use information setting quantitative targets in road safety programs can and communication technologies to increase road safety lead to better programs, more effective use of resources, and reduce the number of road crashes (EC 2009). and improved road safety performance. A prerequisite C. Human behavior for setting targets is data on injuries and fatalities and information on traffic trends. The EC is involved in four initiatives to improve behav- ior: (i) regulating the conditions for issuing drivers' Targets for reducing road fatalities have been set by licenses; (ii) cooperating in, coordinating, and co-fund- individual countries and internationally. For example, ing European campaigns for road safety; (iii) training at the intergovernmental level within OECD, the and education through legislative work and projects; and International Transport Forum (ITF), (formerly known (iv) enforcing traffic rules. as the European Conference of Ministers of Transport [ECMT]), unanimously adopted a target for all 43 Legislation becoming effective in January 2013 will con- member countries to reduce the number of road deaths vert 110 European models of driver's licenses to a single by 50 percent by 2012 from 2000 levels (ECMT 2002). model. Also anticipated are antifraud measures, harmo- Monitoring procedures were set in 2004 (ECMT 2004). nization of five-year medical checks for professional driv- Data from 2006 on progress toward the target indicated ers, minimum requirements for the training of examin- that the only countries on track to achieve the target ers, and better harmonization of license categories. on time were Luxembourg, France, Portugal, Denmark, The research project "DRUID" (Driving Under the Netherlands, Norway, Germany and Belgium Influence of Drugs, Alcohol and Medicines) is expected (OECD and ECMT, 2006, ITF 2008). Although to provide a solid base to generate harmonized, EU-wide this is only a handful of countries, it shows that targeted regulations for driving under the influence of these sub- reductions can be achieved with adequate political will, stances, fix thresholds for driving a power-driven vehicle, institutional organization, and sufficient allocation of evaluate tracking devices, define strategies for driving resources. bans and rehabilitation schemes for drivers, and define doctors' legal responsibility (FHRI 2007). 45 5. Car and road assessments health-friendly transport; (b) managing more sustainable mobility by better coordinating land use and transport New car assessment programs (NCAPs) subject new cars planning; (c) improving road safety and the infrastruc- to crash tests and rate their performance using a "star" ture for walking and cycling; and (d) reducing emis- system. These assessments are a resource for consum- sions of transport-related greenhouse gases and noise by ers, promote safety, and motivate car manufactures to investing in alternative sources of transport. focus on safety. They have led to substantial improve- ments in car design over and above legal requirements. The United States established the first NCAP in 1978; 6. International organizations Australia followed suit in 1992 and EuroNCAP in 1996. addressing road safety in ECA The International Road Assessment Program (iRAP (other than the World Bank) 2008) is an international association created to develop The World Health Organization coordinates road safety independent safety ratings for road infrastructure. These issues in the United Nations system and plays a leading programs are underway in Australia (AusRAP), Europe role by helping to integrate road safety into public health (EuroRAP), and the United States (USRAP). iRAP road programs worldwide. The WHO uses a public health safety plans in Chile, Costa Rica, Malaysia, and South approach, combining epidemiology, prevention, and Africa have identified opportunities to prevent 73,000 advocacy, aimed particularly at low- and middle-income road deaths and injuries and save US$7 billion. Several countries (LMICs). The WHO objectives for road safety components form the core of the iRAP approach and are to: (a) incorporate road traffic injury prevention and programs: (a) partnerships among organizations involved control into public health agendas around the world; (b) in making roads safe (for example, governments, auto- build capacity at the national and local level to moni- mobile associations, funding agencies); (b) roads inspec- tor the magnitude, severity, and burden of road traffic tions using specially equipped cars, software, and trained injuries; and (c) promote action-oriented strategies and analysts to focus on design features that influence crashes advocate for prevention and control of road traffic and their severity (for example, intersection design, injuries. crossing sections and markings, footpaths, bicycle lanes); (c) star ratings based on road inspection data that pro- The United Nations Global Road Safety Collaboration vide an objective measure of the level of safety that is (UNRSC) was established by the WHO as a follow-up built into roads; (d) targeted road safety plans for road to UN General Assembly Resolution A/Res/58/289 improvements; (e) risk mapping to document the num- (United Nations General Assembly 2004). UNRSC ber of deaths and injuries on a road network; (f) perfor- members include all UN Regional Commissions, inter- mance tracking based on measuring and reporting road national finance agencies including the World Bank, and safety outcomes; and (g) support and capacity building a number of national road safety agencies and key deliv- of stakeholder organizations (iRAP 2008). ery organizations in global road safety such as the Global Road Safety Partnership (GRSP). Under the auspices Coordinated policies for sustainable transport and land of the UNRSC, World Bank, WHO, GRSP, and the use. The Amsterdam Declaration of the Third High- Foundation for the Automobile and Society are publish- Level Meeting on Transport, Health and Environment ing a series of good practice manuals to guide actions. issued in January 2009 generated a good reference To date, manuals on helmets, drinking and driving, framework for action, articulating the importance of a speed management, and seatbelts have been published. coordinated approach to sustainable transport and land Manuals on data systems and fleet management are in use policy. It was adopted by representatives of European preparation. These manuals provide a basis for action on countries in attendance. The declaration recognizes the the key risk factors in road safety. opportunity provided by the current financial crisis to rethink investments in transport policies and opportuni- In 2006, a Commission for Global Road Safety, led by ties for economic growth provided by investments in Lord Robertson, was created to advocate for the recom- sustainable transport policies. In particular, it sets four mendations of the World Report on Road Traffic Injury priority goals: (a) contributing to sustainable economic Prevention, propose sources of funding to implement development by directly investing in environment- and the recommendations, raise political awareness, and 46 make the connections between road safety and the wider OECD and ITF Transport Research Center was created development agenda. in January 2004 (ITF 2008). The Commission's 2009 report, "Make Roads Safe," The United Nations Economic Commission for Europe endorsed by the world's leading road experts, recommends (UNECE), established in 1947, aims to promote pan- that: European economic integration. UNECE brings togeth- er 56 countries in the EU; non-EU countries in Western · The UN should approve a Decade of Action for Road and Eastern Europe, South-East Europe, and the CIS; Safety, and governments should collectively commit and North America. These countries dialogue and coop- to reducing the forecast 2020 level of road deaths by erate under UNECE's aegis on economic and sectoral 50 percent (from 1.9 million to below 1 million a issues, including road safety. year). The decade would have a status similar to that of the UN's Decade to Roll Back Malaria. Achieving The European Bank for Reconstruction and the 2020 target could save up to 5 million lives and Development, the European Investment Bank, and the prevent 50 million serious injuries. Asian Development Bank (ADB) are committed to pro- · During the decade, the international community mote and support road safety features in road infrastruc- should invest in a US$300 million action plan to ture projects in ECA. For example, by adopting an inte- catalyze traffic injury prevention and refocus national grated multisectoral approach, the ADB seeks to assist road safety policies and budgets. its developing country members in formulating and implementing comprehensive approaches to enhance · Interim targets and strategies should be established to road safety, and provides funding for such activities. promote 100 percent helmet and seatbelt use in every country by 2020, together with road safety interven- The Global Road Safety Partnership (GRSP) is a global tions. partnership of businesses, civil society, and govern- ments dedicated to the sustainable reduction of death · The World Bank, regional development banks, and and injury on the roads in developing and transition other donors should dedicate at least 10 percent of countries. By creating and strengthening links between their road investment budgets to road safety and partners, GRSP aims to increase awareness of road safety adopt a harmonized policy on dealing with road as an issue affecting all sectors of society. GRSP was safety within their programs. established at the end of 1999 under the World Bank's · The UN Secretary General should appoint a Special Business Partners for Development Program and now Envoy for Road Safety to raise the issue's profile. operates in 20 countries around the world. · Governments attending the Moscow conference are The Foundation for the Automobile and Society is an urged to support the Decade of Action for Road independent, U.K.-registered charity that manages and Safety. supports an international program promoting road safety, environmental protection, and sustainable mobil- The International Transport Forum, formerly the ity, and funds specialist motor sport safety research. European Conference of Ministers of Transport, is an The foundation was established in 2001 with a US$300 intergovernmental organization within the OECD million donation from the Fédération Internationale de comprising Ministers of Transport of member coun- l'Automobile (FIA), a nonprofit federation of motoring tries. Established in Brussels in 1953, it has 43 member organizations and the governing body of world motor countries: EU countries and the countries of Central sport. and Eastern Europe, Russia, and Turkey. It also has seven associate member countries: Australia, Canada, Japan, The foundation works with the UN Economic Mexico, New Zealand, the Republic of Korea, and the and Social Council, is a regular participant in the United States. The ITF's main objective is to provide Working Party on Traffic Safety and the World Forum a forum for ministers to discuss policies and set joint on Harmonization of Vehicle Standards at the UN approaches and actions. The ECMT led the setting of Economic Commission for Europe, and is a leading par- international fatality reduction targets and convened ticipant in the UN Global Road Safety Collaboration. important policy discussions on road safety. A Joint The foundation works with a range of international 47 agencies including WHO, the World Bank, and the traffic safety and driver behavior. Similarly, the Swedish United Nations Environment Program on road safety Roads Administration has been the lead agency for road and environmental issues. safety since 1993 in charge of well-coordinated and well-funded multisectoral interventions that have helped 7. Institutional arrangements at make Sweden a world leader in road safety with one of the lowest death rates globally (Breen, Howard, and the country level Bliss 2008). The 2004 World Report highlighted the Improving road safety requires the concerted action, par- fundamental role of a lead agency in ensuring the effec- ticipation, and support of many different stakeholders tive and efficient functioning of the road safety manage- in various sectors. It is a shared responsibility of govern- ment system. The effective delivery of core institutional ments and citizens. It is important to designate a lead management functions can be achieved with varied lead agency, with clearly defined institutional management agency structural and procedural forms and no preferred functions, organizational arrangements, and processes, model for this can be identified and promoted (Bliss and and to develop institutional capacity across a range of Breen, 2009). sectors to facilitate intersectoral coordination, backed by Successful implementation of comprehensive road safety strong political commitment and adequate and sustain- programs requires coordination under a lead agency of able resources (Peden and others 2004). the multiple government entities responsible for transport, Institutional arrangements for road safety management infrastructure, urban planning, health, education, and in countries have evolved together with the maturation law enforcement. The main role can be assigned either to of thinking about road safety. With the sharp increases a lead ministry, a national road safety council, or a com- in motorization in the 1960s and deteriorating road mission. In any case, the lead agency should have a clear safety conditions, road traffic safety agencies, and regula- mandate, high-level support, and sustainable funding. If tory and management arrangements were established a national road safety council is created to lead concerted in many countries. In some countries, responsibilities efforts in a country, then its multidisciplinary body for road safety are assigned to different levels of govern- should be headed by a high-ranking official and support- ment. For example, in the United Sates, the federal ed by a permanent secretariat of road safety specialists. government establishes national road safety goals, devel- Sustained commitment at the highest levels is crucial ops and enforces vehicle and commercial driver safety for the success of such programs as was recently dem- regulations, and influences actions by the states through onstrated in France under the leadership of President funding and national initiatives. The states oversee and Jacques Chirac, who declared road safety as one of three implement road safety operational programs and enact top national priorities for his presidency and spearhead- conforming state laws on important state initiatives, ed a new road safety action plan with good results in such as seatbelt use, vehicle inspections, speed limits, decreased road traffic injuries and fatalities (Observatoire and impaired driving. National Interministeriel de Securité Routière 2004). Organizational arrangements for road safety management Over the three last decades, road safety policy making differ across countries; having a lead agency is important. was strengthened by the creation of national techni- Experience indicates that better results were achieved in cal and scientific support bodies in some countries. implementing road injury prevention strategies where These include the Swedish National Road and Traffic a separate government agency had been created with a Research Institute, the United Kingdom Road Research clear mandate and adequate budget. Examples include Laboratory (now TRRL Ltd), and the Australia Road creation of the Swedish Road Safety Office (SRSO) Research Board. The United States established both in the 1960s and the U.S. National Highway Traffic the National Transportation Safety Board and the Safety Administration (NHTSA) in the 1970s. NHTSA Transportation Research Board. The combination of developed the first set of vehicle safety standards, and road safety institutions and scientific research has led to its new approach to traffic safety helped reduce road some major changes and innovations in the approaches deaths and injuries. It sets and enforces safety perfor- adopted to improve road safety. mance standards for motor vehicles, provides grants for local road safety programs, and conducts research on 48 Members of parliaments can also be instrumental in and enforcing them quickly and efficiently. This ele- advancing the road safety agenda. For example, in the ment of road safety requires improvement in many ECA Australian state of Victoria, political action and a report countries. by a parliamentary committee led to the world's first laws on the compulsory use of front seatbelts. The law Creating space for civil society participation helps gal- came into effect in early 1971, and by the end of the vanize political support on the basis of well-articulated year, car occupant deaths had fallen by 18 percent, and social demands from communities that bear the burden of by 1975, by 26 percent (Heiman 1988). In other coun- RTIs. A good example of a successful grassroots advocacy tries, committees in parliament monitor the performance group is the U.S. nonprofit organization Mothers Against of national road safety agencies. Drunk Driving (MADD). This organization, established in 1980, has been effective in promoting and support- Road safety management should focus on results, set goals, ing initiatives to stop drunk driving, assisting those and assign responsibilities. Ambitious but achievable affected by drunk driving, preventing underage drinking, targets provide an important stimulus for developing and making an overall push for stricter alcohol policy new approaches and facilitate better implementation of (MADD 2009). For example, MADD was involved road safety strategies. They need to be supported by key in lobbying to reduce the legal limit for blood alcohol performance indicators. To monitor the impact of road from a blood alcohol concentration (BAC) of .10 grams safety measures and interventions, it is very important per deciliter (g/dl) to .08 g/dl, which was approved by to have a reliable system of data collection and analysis, the United States Congress in 2000 and adopted by all maintenance of a crash database, and crash investigation. state governments. These measures have contributed to decreasing traffic fatalities in alcohol-impaired driving Increased institutional capacity is required to develop crashes in the United States by nearly 10 percent, from strategies, a policy framework, and research and interven- 13,041 in 2007 to 11,773 in 2008 (NHTSA 2008). tions, and to implement road safety action plans and In addition, MADD efforts have helped make public sustain improved performance. Laws and enforcement attitudes more negative toward drunk driving than they are also essential. Effective enforcement requires ensur- were in the early 1980s. Organizations active in the ECA ing that the perceived risk of punishment for violations countries include the Red Cross national bodies. remains high by making the penalties sufficiently severe 49 6 "Our work on regional and global public goods will require close cooperation with other agencies that have specialized expertise...We also must determine the Bank Group's comparative advantage to best focus our resources through selective, differentiated approaches. Given our specialization in working on development at the national level, our most important operating challenge will be to support countries as they determine how best to integrate public goods policies--and regional and global opportunities-- into national programs. These opportunities should draw on private sector entrepre- neurs and energies, too." ­ Robert Zoellick, President, The World Bank Chapter VI. World Bank Support for Road Safety Improvements in ECA and in other Regions With an understanding of what Europe and Central Asia doing and to scale-up and roll out successful initiatives (ECA) countries are doing and could do to improve road incrementally across the road network. safety, it is appropriate to examine the World Bank's road safety work, which has been underway for more than two The 2004 World Report on Road Traffic Injury decades. This chapter presents an overview of that work, Prevention, jointly produced by the World Health with special emphasis on efforts in ECA and the lessons Organization (WHO) and the World Bank, summarized the World Bank has learned through various country what is known about the magnitude, risk factors, and projects. impact of road traffic injuries (RTIs) (Peden and others 2004). It provides a framework for guiding institutional efforts to support countries in preventing and lessening 1. Objectives and Scope of Action the impact of road crashes. The World Bank's mission The World Bank promotes better road safety outcomes in this area is to help countries accelerate their imple- in low- and middle-income countries (LMICs) as a mentation of the report's recommendations, emphasizing global development priority. In the past, relatively mod- building their capacity to invest in road safety and mobi- est road safety initiatives were embedded in large-scale lizing global partnerships. road investment projects and were part of so-called "1st Generation" road safety improvement projects. Since 2. The Global Road Safety Facility 2000, the World Bank has shifted to "2nd Generation" The Global Road Safety Facility was established in 2006 or "Safe System" road safety improvement approaches, to generate funding and technical assistance for global, as components of road projects or in projects specifically regional, and country-level activities to accelerate and dedicated to road safety. scale-up LMIC efforts to build scientific, technologi- Safe system projects emphasize government "ownership" cal, and managerial capacity to prepare and implement and agency "accountability," with a clear focus on mea- cost-effective road safety programs. The facility is funded surable safety outcomes. Safe systems road safety projects through the World Bank Development Grant Facility are multisectoral and address all elements of the safety and funding from external donors. In partnership with management system: institutional management func- its founding donors--the Fédération Internationale de tions, interventions, and targeted results. They are the l'Automobile (FIA) Foundation, the government of the foundation of a process designed to foster learning by Netherlands, the Swedish International Development 51 Cooperation Agency (SIDA), and the Australian Agency community groups, private sector organizations and all for International Development (AusAID)--the facility is other global, regional and country partners and stake- seeking additional donor support to sustain funding in holders supporting country road safety efforts. the longer term. During FY06­FY09 (July 2005­June 2009), the facility disbursed more than US$7 million in 5. World Bank-supported road safety grants. projects Beginning in 2009, the Facility is partnering with inter- national leaders of police agencies to develop a police A. Examples of transport projects in ECA engagement model designed to improve the governance Several ongoing transport projects in ECA countries of road safety enforcement in LMICs. This model aims include interventions to help improve road safety. to target police chief/commissioner/executive leader- They include: (i) development of a results-based road ship in police agencies through a global police network, safety strategy and pilot tests of risky road sections in RoadPol. Bosnia and Herzegovina; (ii) eliminating black spots in Ukraine; (iii) engineering works, consultancy services, training, and equipment projects in Georgia; (iv) tech- 3. Road safety management nical assistance in preparing plans, campaigns, legal capacity reviews in ECA countries aspects, enforcement improvements, emergency service The World Bank has been involved in road safety man- responses, and infrastructure improvements in Bulgaria; agement capacity reviews (RSMCRs) in ECA countries and (v) and road safety improvements as part of the supported under the Facility. These reviews report cur- Western Europe-Western China corridor upgrade and rent status and institutional arrangements and recom- rehabilitation project in Kazakhstan. The World Bank mend strategies and action plans for short-, medium-, also has worked with the European Commission and the and long-term investment priorities. RSMCRs in European Investment Bank (EIB) to establish a National ECA countries were undertaken during 2006­08 in Road Safety Council (NRSC) in Poland, contributing to Armenia, Bosnia and Herzegovina, Bulgaria, Kazakhstan, road safety campaigns on seatbelts, alcohol and driving, Montenegro, Serbia, and Ukraine. The iRAP survey in speeding, safety of children and pedestrians, and techni- Serbia and in Montenegro was recently funded as well. A cal assistance. Several of these projects are described in broad review was also supported in Russia in partnership Box 10. with other international organizations, and the road safe- ty performance review report launched in 2006 (ECMT, B. World Bank-supported health projects WHO EURO, World Bank, and OECD 2006). and other related initiatives A number of World Bank-funded health sector projects have supported implementation of road-safety-related 4. Guidelines for implementing the health promotion and prevention activities. These recommendations of the 2004 include information, education, and communication World Report activities to reduce risky behaviors, and strengthen- ing of emergency medical services--pre-hospital and The purpose of these guidelines (Bliss and Breen 2009) facility-based treatment, care, and rehabilitation. They is to promote a safe system approach to road safety are part of larger health system reform and modern- management, and specify a management and investment ization projects, as exemplified by the Russia Health framework to support successful implementation of the Reform Implementation Project and Chuvash Republic World Report recommendations. The guidelines are a Subnational Lending Health Project. revised and expanded version of an earlier World Bank Transport Note (Bliss, 2004) and provide practical proce- Within this US$30 million project implemented during dures designed to be applied at country level to accelerate 2004­08, support was provided to strengthen emergency knowledge transfer and sustainably scale up investment medical services in the Chuvash Republic and Voronezh to improve road safety results. They have been prepared Oblast. Investments included development of automated to assist country road safety professionals, World Bank central dispatcher networks and communication systems, and regional development staff, international consultants, reorganized transport systems and purchase of new 52 Box 10: World Bank-supported Road Safety Projects in ECA Albania Transport Project. This project, which began Bosnia and Herzegovina Road Infrastructure and implementation in September 2007, includes a signifi- Safety Project. This project, begun in 2008, emanates cant component to develop and implement a results- from a 2007 road safety management capacity review focused Road Safety Strategy and Action Plan. The (RSMCR). A US$2.6 million equivalent results- component started in October 2008 and is planned to focused road safety subcomponent is implementing take 16 months. It builds on the Action Plan prepared a road safety strategy with multisector coordination by the National Road Safety Council, and the compo- among the various ministries of the Federation and nent in the earlier Road Maintenance Project, which Srpska Republic. It is also helping develop the capacity closed in December 2006. It involves, among other of road authorities, interior ministries, the police, and things: (a) provision of technical assistance to develop the health and education sectors. Support is also given and implement a results-focused Road Safety Strategy for action plans for road safety measures related to seat- and Action Plan, including assistance to implement belt use, speed, alcohol, and monitoring. changes in the primary and secondary legislation and to collect baseline survey data; (b) analysis of statistics, A US$2.5 million equivalent test pilot subcomponent black spot identification, and extension of the Accident aims to pilot interventions in high-risk areas. Pilots Information System; (c) undertaking a road safety could include high-traffic, linear development sec- inspection on the Tirana to Durrës highway, which tion interventions, such as pedestrian safety at urban would result in an action plan for road safety improve- arterials. Typical interventions would be procurement ments and is intended to have a significant demonstra- of police equipment, road signs, small works imple- tion effect; (d) the provision and operational introduc- mentation, user surveys, data collection, local promo- tion of essential equipment, speed radar guns, and tion campaigns, and multisector crash investigations. breathalyzers, for the Traffic Police within the Ministry If effective, these measures will be scaled to the entire of Interior; and (e) strengthening education curricula road network by local authorities. and awareness of road safety issues. Bulgaria Road Infrastructure Rehabilitation Armenia Local Roads Improvement Project. The Project. This project will (a) provide technical assis- recently approved additional financing to this project tance in preparing road safety plans, public awareness of US$1.6 million provides for implementation of the campaigns, legal foundations for road safety, new road safety program, which will include development enforcement approaches, and a focus on the timeliness of a road safety audit manual tailored to Armenia's of emergency medical services (EMSs); and (b) finance conditions to provide checklists for assessing designs priority road safety improvements to eliminate black and inspecting project sites throughout different phases spots and improve areas with high traffic conflicts, and of a road project development, including assessments associated technical assistance. of existing roads. This financing will also cover imple- Georgia Second East-West Highway Improvement mentation of the "safe villages" pilot program, which Project. This project's roads safety component budget will support rural communities in implementing road of US$2.13 million funds engineering improvements safety measures recommended by the road safety audit addressing black spots, guardrails, and signing and and the National Road Safety Strategy, which was marking. It is also strengthening the capacity of the approved by the government in August 2009. The Road Directorate to deal with black spots and develop World Bank has also secured a US$50,000 grant from new standards for road safety (signs, marking, and the Global Road Safety Facility to support the National traffic management, among others). The project sup- Road Safety Secretariat, which is charged with imple- ports development of Road Safety Audit Guidelines mentation of the strategy and action plan. for Georgia, training in their application, and devel- Azerbaijan Highway 2 Improvement Project. This opment of a road crash database. The project also project will finance development of a national road aims to strengthen the Road Safety Unit of the Roads safety strategy and action plan. Department. (Continued on next page) 53 Box 10: World Bank-supported Road Safety Projects in ECA (Continued) Two new Georgia transport operations were approved of primary and secondary roads, conducted with in 2009 that include road safety components: the the support of the GRSF in Serbia in 2008. A new Third East-West Highway Project and the Kakheti Road Safety Law (RSL) was adopted by the Serbian Regional Roads Improvement Project. These Parliament on 29 May 2009, the first major legisla- projects will test the holistic approach to traffic safety tive update since the 1980s, and incorporates many along the selected road corridors consisting not only aspects of the acquis communautaire (the body of of black spot removal, but also integrating ambulance law of the European Union). The new law, which services, police, first aid training, and other safety comes into force in December 2009 to allow time to measures under the corridor safety management plan complete the necessary secondary legislation, envisions with the target of reducing fatalities in these corridors the establishment of a new state multisectoral coor- by 30 percent by project end. dinating body, the National Road Safety Council, to bring together the key government stakeholders. The Kazakhstan. Road safety improvements are part of component in the project will support plans for: (a) the Western Europe-Western China corridor upgrade road safety capacity building to support the establish- and rehabilitation project. ment of the National Road Safety Council (NRSC) as Poland Third Road Maintenance and lead agency; (b) creation of a road safety performance Rehabilitation Project. This World Bank support framework; (c) development and launching of a builds on the success of two previous road project results-focused national road safety strategy; (d) prepa- safety components under the National Road Safety ration and piloting of two multisectoral road safety Council (NRSC). The project supports road safety pilots; and (e) procurement and establishment of a campaigns on alcohol and drunk driving, speed- road safety database and other road safety equipment ing, and child and pedestrian safety. It also finances Ukraine Roads and Safety Improvement Project. technical assistance to the NRSC Secretariat and This project aims to support the government's efforts contributes to the program of road safety initiatives in collaboration with the European Union. It includes co-financed by the European Commission and the a road safety component to remove 110 black spots. European Investment Bank. Measures will eliminate or reduce road safety hazards Serbia Corridor X Highway Project. This project at intersections; install guardrails and modern crash is expected to become effective in late 2009 and barriers, and so forth; and make pedestrian crossings involves a substantial road safety component, build- safer. ing on the earlier Road Safety Management Capacity Sources: Elaboration of authors on the basis of World Review (conducted in 2007) and the International Bank documentation. Road Assessment Program (iRAP) survey of a sample ambulances, development of guidelines and protocols strengthening of trauma services at ambulatory facilities for trauma care, and training of paramedics and medical and hospitals. personnel on basic and advanced life support systems. These investments complemented government health The conference "Meeting the Challenge of Non-com- promotion efforts to: (i) improve the legal framework municable Diseases and Injuries (NCDI) in the for and enforcement of crash-minimizing regulations; Commonwealth of Independent States (CIS) Countries," (ii) develop information, education, and communication which was jointly organized by WHO-EURO and the about risky behaviors; and (iii) strengthen anti-alcohol- World Bank and hosted by the Russian Government, on abuse programs. In 2009, under subnational lending 30­31 October 2007 in Moscow, is a good example of arrangements, a follow-on loan of US$7 million to a multisectoral approach that could be followed to sup- the Chuvash Republic is funding the rehabiliation and port regional efforts to tackle RTIs as part of a broader 54 initiative to address non-communicable Box 11: Vietnam's Safe System Road Safety Improvement Project conditions in ECA (WHO-EURO and World Bank 2007). The conference was With a population of 83.6 million and a GDP of US$52.8 billion, attended by high-level representatives Vietnam is experiencing increasing industrialization, urbanization, from ministries of health, finance, and and motorization. Road traffic fatalities soared from 4,907 in 1994 to transport and from the parliaments of 11,534 in 2005. Initial public sector efforts to reduce accident rates Armenia, Azerbaijan, Belarus, Georgia, through drivers' licensing, vehicle inspections, and registrations had Kazakhstan, Kyrgyz Republic, Moldova, limited impact. Tajikistan, Turkmenistan, Russian Federation, Ukraine, and Uzbekistan, Risk factors include non-use of helmets by two-wheeler users, speed, and observers from the Baltic countries, poor road conditions, traffic mix, alcohol use, and poor visibility of Mongolia, Romania, and leading inter- road users. Many partners, including the World Health Organization national organizations. The conference (WHO), are collaborating with the Ministries of Health and Transport stressed the gravity and urgency of the to improve the situation. For example, the Traffic Injury Prevention NCDI situation and the need to adopt Project, supported by Bloomberg Philanthropies, WHO, and other a multisectoral approach to deal with it partners, focuses on helmet use and drunk driving. as a top development priority, because these conditions are the leading causes The Bank supports a stand-alone road safety project specifically of premature death, ill health, and dis- designed to reduce the rate of crashes, injury, and death associated with ability. road transport, through physical improvement works and institutional development to strengthen the management of road transport safety (World Bank 2005b). C. World Bank support outside ECA: Selected The first component, an institutional and capacity-building program examples (US$7.8 million), provides technical assistance to (a) strengthen the There is a broad regional program in management and technical capacity of the National Traffic Safety the Latin America and the Caribbean Committee (NTSC) Executive Office and the Traffic Safety Project (LAC) Region. Work in urban transport Management Unit, and (b) prepare a national road safety strategy. reform--carried out and supported in The second component, a road safety demonstration and awareness Argentina, Brazil, Columbia, Mexico, program (US$20.9 million), assists the government in developing and Peru, and other countries--is improv- implementing safety programs, including enhancing road safety audit- ing safety with dedicated bus lanes, safer ing processes and funding black spot treatments for three high-risk access to transport, and the removal of road demonstration corridors. It is also implementing a program of unsafe or inefficient public transporta- road user education, traffic safety enforcement, and emergency services tion vehicles from the roads (Cox 2009). preparedness (materials, equipment, and training) along these cor- ridors. The third component, a road safety monitoring and evaluation Recent work in Argentina and Peru in program (US$6.2 million), supports development of a national road key road corridors targets road curvature, crash database system for the Vietnam Road Administration to identify road signs, and facilities for pedestrians. and treat black spots, and a program of the Ministry of Public Safety to These programs will also tackle regula- improve enforcement strategies. tory issues, such as licensing of drivers and vehicles. Source: World Bank (2009b). The World Bank is also moving toward preparing multisectoral road safety projects in demon- Vietnam offers an example of a stand-alone safe systems stration corridors in LAC where infrastructure improve- road safety improvement project. Cofinanced by the ments along with enhanced enforcement are deployed. World Bank and the Government of Vietnam, this proj- Collaboration with the health sector will enhance emer- ect budget is US$35 million. Approved in May 2005, gency response mechanisms along the demonstration it aims to reduce the rate of crashes, injury, and death corridor. associated with road transport through physical improve- 55 ment and institutional development to strengthen the programs should be developed and approved that will management of road transport safety (Box 11). Useful reduce the number of road deaths over a defined period. lessons from this project could be adapted to help each Current country programs must be seen as the first ECA country address its unique challenges. phase of a long-term (20-to-30 year) strategy. A first step would be establishing the business-planning processes, D. Lessons learned from World financial management, and performance-monitoring sys- Bank-funded programs tems needed to support such a plan. Important limita- A review of worldwide experiences as well as World tions are the lack of methods for setting priorities and of Bank-supported country programs in different regions an effective monitoring and evaluation framework. The revealed several challenges that may be relevant for work first action phase should develop a consensus among key in the ECA Region (World Bank 2008b, 2009b, Bliss stakeholders and commitment at the highest political and Breen 2009). level to support progress. A national agency must coordi- nate the multisectoral response. A key challenge concerns the need to strengthen countries' institutional capacity and governance for road safety, Increasing inter-institutional coordination and account- including aspects of accountability and transparency, and ability. The most challenging aspect of the road safety to improve institutional arrangements to facilitate multi- problem in most World Bank-supported countries is the sectoral and multi-jurisdictional interventions in order to need to foster inter-institutional and multi-jurisdictional implement the actions proposed by national programs. A interventions among the agencies responsible for deliver- key limitation is the common failure to link action plans ing and overseeing road safety policies and programs. to (i) specific, measurable outcomes to be achieved; or This challenge is more acute in federal countries with (ii) investment/funding flows. Also, action plans often different levels of government. The complex division of fail to identify the risks associated with multisectoral responsibilities for road safety among these levels results and multi-jurisdictional interventions, to propose mea- in blurred lines of accountability and failure to monitor sures to lower the risks or factor in other weaknesses, results. These shortcomings lead to fragmented delivery for example, in the enforcement system. Thus, moving and diffused accountability. The country agencies need forward on the ECA road safety agenda will require con- to build their institutional capacity, financial resources, centrating on the following challenges: and skills to ensure sound coordination of the various actors, to enable them to lead strategic investments and Moving away from ineffective plans. There has been a interventions, achieve measurable results in the short tendency for past technical assistance support provided term, and gain credibility by coordinating interventions to LMICs to prepare national action plans which simply across sectoral jurisdictions, including different levels of detail the interventions that should be made to reduce government, the private sector, and nongovernmental road deaths and injuries with little consideration given organizations. Issues that are difficult to address but can- to the institutional capacity and funding needed to not be ignored are good governance of the law enforce- deliver them. This is neither appropriate nor effective. ment system and widespread corruption of the road Countries are becoming more sensitized to the road police. Any effective program would have to confront safety problems they must address, aware that they must this disturbing reality head-on because in many coun- improve the safety of road infrastructure, vehicles and tries it plays an important role in the lack of progress emergency medical response services, as well as road user made in improving road safety. behavior, and are now seeking advice on how to do it. This underscores the emphasis on mobilizing financial Strengthening national capacity. Low- and middle- and human resources for capacity strengthening, as income countries (LMICs) need investments in a cadre country priorities are becoming more focused on build- of road safety practitioners from different disciplines: ing sustainable management systems and related financ- policymakers, police, public health providers, and engi- ing functions. neers. Educational curriculums could be tailored for ECA countries to support specialized training at univer- Creating political commitment to strive for quantified sities and institutes of higher learning for these practitio- results. Building on both positive and negative lessons ners, and providers of continuous professional develop- learned from international experiences, national target ment should be encouraged to adopt such curriculums. 56 Identifying a large-scale pilot project along high-risk cor- promote safe road design. Enforcement and good gover- ridors and in urban areas to demonstrate the adaptation nance are critical features of a culture of road safety, and and transfer of international best practice offers promise this is particularly important in many ECA countries for building national capacity. These opportunities for where they are believed to be less than optimal (WHO improving training and knowledge among practitioners 2009a). should be seized. Strengthening data collection systems to improve decision Building a culture of safe road use and design. Over 60 making, program management, and impact evaluation. percent of crashes are attributed to driver and pedestrian Efficient systems for collecting, managing, and analyzing behavior. Educational programs targeting students and crash data and providing feedback must be developed to media campaigns targeting drivers and pedestrians are correct ineffective programs. Such strengthening must needed alongside strict enforcement. In addition, safer be done at different levels of government, with sufficient road infrastructure must be targeted through programs financial resources and appropriate coordination of such as road safety audits and adoption of standards that responsibilities. 57 7 "Nowadays, a Minister of Health cannot consider his or her job done simply by look- ing at the health care system. It's not enough to have a health policy, you need healthy policies elsewhere. We need to redefine health not as a specialized sector with doctors and nurses, but as a social objective. You need strong policies for empowering women, for promoting a fair justice system that brings perpetrators of violence to justice, and--in the case of accidental injury--for safe roads." ­ Julio Frenk, Former Health Secretary of Mexico and current Dean of the Harvard School of Public Health Chapter VII. Priorities for Intersectoral Work on Road Safety in ECA International good practice suggests effective RTIs pre- · Allocate financial and human resources. vention in ECA countries would need to be implemented systematically over the short and medium terms, with a · Implement specific actions to prevent road traffic crashes, minimize injuries and their consequences, high level of committed political support and funding and evaluate the impact of these actions. under the stewardship of a lead agency to ensure sustain- ability, tailored to the individual circumstances of each · Support the development of national capacity and country, sequencing the interventions over time, and in international cooperation. accordance with consistent and harmonized policies and strategies across sectors and disciplines. Building on that Implementing these recommendations at country level knowledge, this chapter outlines broad strategic themes requires capacity building to create the resources and to use to set priorities for moving the road safety agenda tools necessary for target initiatives on a scale capable forward in ECA. of reducing road deaths and injuries significantly and sustainably. Also, it requires an integrated framework that treats the recommendations of the World Report 1. Implementing the recommenda- as a totality and ensures that institutional strengthening tions of the 2004 World Report: initiatives are properly sequenced and adjusted to the What needs to be done? absorptive and learning capacity of the country con- cerned (Bliss and Breen 2009). The findings in this landmark report (Peden and others 2004) led to six over-arching recommendations that set A systematic response is needed. Managing for improved out the strategic initiatives necessary to improve country road safety results at the country level must address three road safety performance: inter-related elements of the road safety management sys- tem: institutional management functions, interventions, · Identify a lead agency in government to guide the and results. Institutional management functions and spe- national road safety effort. cifically the role of the lead agency are of prime impor- tance. Addressing interventions alone will not suffice. · Assess the problems, policies and institutional settings relating to road traffic injury and the capacity for road traffic injury prevention in each country. · Prepare a national road safety strategy and plan of action. 59 2. Building institutional management ing alternative funding arrangements; (iii) resource allocation mechanisms to target priority areas; and functions (iv) different governance models and policy options A. Strengthen political commitment, for safer roads. The courses would leverage consensus building to strengthen capacity for intersectoral work funding, and institutional capacity for and promote discussion of safety among the different road safety sectors. Adapted to national and local needs, such The first and most important factor in improving road courses could bring together participants from dif- safety is government recognition of the problem, followed ferent countries to promote and facilitate exchanges by commitment and champions at the highest politi- during different stages of road safety development. cal levels. These need to be converted into sustainable institutional and funding arrangements under a lead · Conducting workshops for executive managers from agency in charge of coordinating the different sectoral different sectors to strengthen their knowledge and efforts. In addition, as the 2004 World Report argues, skills related to road safety, and facilitate their role multisectoral, high-level planning is a cornerstone of in ensuring that policy reforms are implemented. effective governance for crash prevention. Planning is Workshops should be interactive and include national essential to ensure effective implementation, and also to case studies that apply knowledge and skills to real engage the various sectors to set priorities and prepare scenarios. If designed well, the training exercises to work collaboratively. Many countries have begun would contribute to actual planning. Subregional such planning but restricted it to a few sectors, orga- workshops involving countries that share similar pol- nizing efforts vertically and failing to exploit the full icy structures and issues (for example, rapid develop- potential of intersectoral engagement. In particular, the ment of motorization) should be considered in order potential contributions of the health sector tend to be to stimulate exchange of knowledge and experiences. overlooked. National road safety committees or bodies Study tours and exchanges could be organized and operating as a lead agency with strong political lever- mentoring encouraged. age and well-defined institutional management func- · Leveraging existing networks of focal persons for road tions and organizational arrangements can advance the safety. Further investment is needed to build capacity agenda, coordinating effort horizontally across sectors in the networks that have responsibility for road safe- and vertically to involve different levels of government, ty. Sectoral ministry focal persons for injury preven- as well as civil society. A recent review identified coun- tion and for road safety in almost every ECA country tries with functioning national road safety bodies that participate on multisectoral teams with a road safety could make stronger multisectoral investments in safety. mandate. These regional networks are a conduit for Unfortunately, these committees tend to lack technical transmitting and implementing evidence-based prac- capacity, and vertical organization and difficulties in tices and policies. Investment should be made in the working across sectors compound the problem. capacity of these networks to implement evidence- based actions. To maximize adaptation and transfer Specific actions. Political commitment and institutional of best practices, regional networks of trainers should and governance reforms for national road traffic injury be developed to exchange expertise and knowledge on (RTI) prevention policies must be supported by asser- how to build capacity in road safety across the disci- tive advocacy and creation of institutional and technical plines. capacity to lead and sustain reform. Capacity building must occur at all decision-making levels and during · Courses for practitioners from the health, transport, implementation of policy reforms. The main actions for and justice sectors should support the deployment capacity building include: of national policies and the sharing of objectives and understanding of the roles and responsibilities of · Conducting short courses targeting senior policy- different sectors. A critical mass must be developed makers at national and subnational levels specifically in each target country, achievable by mainstreaming tailored to expose policymakers to: (i) the nature and the curriculums in the higher professional training of characteristics of the problem; (ii) alternative evi- health and other frontline staff (for example, traffic dence-based options to address the problem, includ- police and road safety engineers). Such capacity build- 60 ing should be designed to meet the specific needs tion need is to better delineate fatal and non-fatal RTIs of each country. Curriculums that advocate the use by risk factor (the study by Chisholm and Naci 2008 of evidence-based safety programs include WHO's tried to isolate the fraction of total RTIs attributable to TEACH-VIP (WHO 2007) and the Road Traffic a sample of risk factors (speeding, alcohol, not wearing a Injury Prevention: Training Manual, available in helmet or seatbelt) but this is just a subset of the relevant Russian. risk factors. Interactions between risk factors are a major challenge­ for example, being under the influence of B. Enhance nationwide RTI information alcohol increases the chance of excessive speed and not systems wearing a seatbelt. This is a priority for more informa- tion and research in the years ahead in ECA ­ without Datasets are a foundation for measuring a problem and a good understanding of the underlying distribution of enabling rigorous program evaluation. RTI informa- risk exposure, it is difficult to target effective responses tion systems vary in quality, and poor systems result in appropriately. underestimates of the problem and leave program man- agers unable to pinpoint risks and evaluate the effective- It is important to acquiring better knowledge and under- ness of preventive interventions. In addition, mortality standing of the joint nature of RTI risk exposure and and injury rates in some countries may reflect under- intervention effectiveness. One of the key conclusions of reporting, especially in the Central Asian republics, the recent research (Chisholm and Naci 2008) is that major Caucasus countries, and some countries in the Balkans synergies can be obtained in the costs of enforcement region. Some countries may under-register deaths by strategies, which makes combined interventions increas- as much as 20 percent. Many countries have not yet ingly cost-effective. But this needs to be complemented adopted the standard definition of a road traffic death as by compiling better evidence on effectiveness. one that occurs within 30 days of a crash (rather than on the scene, within 24 hours, or within 7 days, as in some C. Support national policy reform by ECA countries; these definitions underestimate mortal- undertaking national road safety ity). Problems related to validity and reliability of non- management capacity reviews and fatal injury data also result in underestimates. Reliance specifying lead agency reforms, on traffic police information systems can lead to under- investment strategies and safe system estimates of almost 50 percent. Data on blood alcohol projects concentrations (BACs) and road crashes should be more reliable and could be collected at emergency departments National policy reform for RTI prevention should be and linked to brief physician advice interventions. based on a reliable assessment of the current road safety situation. This needs to be supported by accurate infor- Specific actions. Nationwide road crash monitoring and mation from different sectors, both governmental and analysis tools should be developed. These tools should private, regarding the magnitude of problems, risk fac- integrate data from health and traffic police information tors, the groups at risk, existing policy frameworks, insti- systems. Health information systems should capture tutional arrangements, and roles and capacities. data on the causes, risks, extent, and consequences of injuries so they can be mapped. The WHO injury sur- Specific actions. National road safety management veillance guidelines describe a methodology that includes capacity reviews should be undertaken in targeted ECA information on external cause coding and risk factors. countries with a view to contributing to national road This template should be adapted and used to include safety planning and policy reforms. World Bank guide- a module on injury surveillance in electronic health lines provide a comprehensive framework and checklists information systems in ECA countries. This information for conducting such reviews (Bliss and Breen 2009). must be readily accessible to be used meaningfully for Different stakeholders from transport, justice/interior, planning and evaluation and to share with civil society. health, insurance, nongovernmental organizations, There is a need to share anonymized data describing and international agencies need to be engaged in these levels of fatal and nonfatal road traffic injuries across sec- reviews. The reviews would identify priority areas for tors to improve the completeness and reliability of data lead agency reform and related institutional strengthen- and target and evaluate interventions. A major informa- ing, and specify long-term investment strategies and 61 related safe system projects to implement the strate- road network, the conditions under which vehicles and gies. Stock should be taken of existing national policy. road users can safely use it, and the safe recovery and Essential baseline information has already been collected rehabilitation of crash victims, and set specific standards, in many ECA countries but should be enhanced. The rules and enforcement mechanisms to achieve these contribution of international experts would be invalu- aims. able in conducting such reviews. Data collected would contribute to the development of national road safety A. Safe planning design of the road strategies and related action plans. The plans would: network (i) address road safety across the board, identify at-risk Road safety needs to be integrated in all phases of plan- groups, major risk factors, and exposures; and (ii) pro- ning, design, and operation of road infrastructure. pose comprehensive strategies and evidence-based actions in targeted high-risk corridors and areas to tackle them Specific actions. At the planning stage, before project in a staged learning by doing process. Targets should be approval, strategic comparative analysis of substantial realistic, with sufficient budgets for activities allocated changes and new construction need to be conducted to to the different stakeholders concerned with implemen- examine the network's safety performance. The purpose tation. Interim indicators would need to be measured is to know the implication for road safety of different using a rigorous evaluation framework to ensure that alternatives to ensure that road safety is weighed care- actors were implementing programs. These initiatives fully in decisions. Safety rating tools can be used to should be developed in tandem with transport, land use, achieve this. Road safety audits complement these assess- and urban policies. ments. These are independent, detailed, systematic, and technical exercises that focus on the design characteris- tics of a road infrastructure project. They cover all stages 3. Focus on results from planning to early operation in order to identify In managing for improved road safety results, the fore- and detail any unsafe features of a project. In addition, most and pivotal institutional management function reviews of high road traffic crash concentration sections is results focus (Bliss and Breen 2009). All the other need to be undertaken. As noted earlier, these reviews institutional management functions are subordinate to examine sections of the road network in use for more this function and contribute to its achievement. In the than three years where large proportions of crashes have absence of a clear focus on results all other institutional occurred. They identify, analyze, and classify parts of the functions and related interventions lack cohesion and network according to their potential for safety develop- direction and the efficiency and effectiveness of safety ment and crash cost savings. This helps target invest- initiatives can be undermined. There would be great ments to road sections with the highest crash concentra- potential benefits from a rapid shift by ECA countries tions and/or the highest crash reduction potential. to a safe system approach with a results focus which aims to eliminate road deaths and serious injuries. A B. Address excessive speeding, particularly safe system approach would be well attuned to the high in urban areas priority global, regional and country development goals Urban speed limits in most ECA countries are 60 kilo- of sustainability, harmonization and inclusiveness. Its meters per hour (km/h), and speed enforcement is inef- focus on safer and reduced speeds harmonizes with fective in many. This puts pedestrians and bicyclists at efforts to reduce local air pollution, greenhouse gases high risk. Many interventions have proved effective in and energy consumption. And its priority to protecting reducing speeding with associated reductions in road all road users is inclusive of the most vulnerable at-risk traffic mortality. groups such as pedestrians, young and old, cyclists and motorcyclists. These co-benefits of shifting to a safe sys- Specific actions. Road safety plans must call for legisla- tem approach further strengthen the business case for its tion lowering most speed limits to 50 km/h and to 30 implementation. km/h in residential areas. Effective implementation com- bines publicity, road design, engineering, and enforce- To achieve desired results, interventions need to concen- ment measures, such as speed cameras and penalty point trate on safe planning design, operation and use of the systems. Many ECA countries do not use speed cameras 62 for enforcement and the legal framework (for example, ECA countries. A penalty system would be an effective fines for speeders), capacity and equipment would need deterrent. Audible and visual seatbelt reminders in new to be established. Well-publicized, area-wide speed cam- cars should be a minimum safety standard. Car restraint era operations are cost-effective in reducing speed. specifications need to match the latest EU safety stan- dards, and the health sector could help by implementing C. Implement drunk-driving and broader community-based car restraint loan programs through alcohol control policies obstetric and midwifery services. Occasional surveys Driving under the influence of alcohol affects all groups, should measure levels of seatbelt and car restraint use but male, youth, and novice drivers are at highest risk. to determine compliance levels. Police should record Most ECA countries set BAC limits for drivers in accor- whether seatbelts were worn at the time of crashes. dance with international norms, but enforcement needs to be significantly improved to prevent alcohol-related E. Reduce young driver risk and protect road traffic fatalities. pedestrians Young drivers and pedestrians are disproportionately Specific actions. There is good evidence on what works affected by crashes. Graduated licensing schemes and to prevent drunk driving. A BAC level of 0.05 grams per extended training are effective in reducing deaths among deciliter (g/dl) is sensible paired with a limit of 0.02 mil- young drivers. Pedestrians' risk can be lowered through ligrams per deciliter (mg/dl) for novice and young driv- better infrastructure and lower speeds in urban areas ers; however, cultural factors in some countries may pre- (safe and frequent crossings, safe underpasses, pavements clude these low limits. Many countries need legislation and lightening, traffic calming, and low speeds in resi- allowing mandatory BAC and evidential roadside alcohol dential areas). breath testing and high-visibility random road checks for alcohol. These are more effective if accompanied by Specific actions. Reduced young driver risk can be high-profile media campaigns. Systematic police enforce- achieved through graduated licensing schemes and ment with severe penalties for offenders is paramount extended training programs during the learner period. and should be well publicized. A swift and efficient Document and increase awareness of pedestrian vulner- execution of penalties of adequate severity is needed to ability, and improve vocational and academic training deter risky behavior. Brief counseling interventions in to address the perception that pedestrians cause crashes; emergency wards reduce alcohol-related injuries. Road require the development and/or rehabilitation/improve- safety plans need to address legislative, capacity, and ment of infrastructure for pedestrians as a systematic implementation issues. Broader alcohol control policies, requirement of any transport infrastructure intervention; such as taxation, licensing hours, legal age limits, train- pilot-test traffic-calming schemes in residential areas ing for bar staff, providing nighttime public transport, and near attractors of large numbers of pedestrians (for and preventing alcohol sales near highway exit ramps example, schools, playgrounds, health care facilities, and would help reduce alcohol-related crashes, as well as public transportation stations). Implement projects that violence and acute and chronic alcohol-induced disease, increase the inherent safety of trips, such as "safe routes major causes of premature mortality in ECA countries. to school." Separate pedestrians from high-speed traffic and create more pedestrian facilities. D. Increase seatbelt use Studies indicate that seatbelt use halves the risk of fatal F. Develop high-quality emergency medical injury in car crashes. Levels of front and rear seatbelt use systems as part of health system reform are low in most ECA countries, and compliance must be and improvement efforts raised. Few reliable surveys exist to guide future enforce- Rapid response and high-quality emergency pre-hospital ment activities. The problem is compounded by the high and hospital care require readiness and a coordinated volume of old cars that lack rear seatbelts. response by emergency services. Appropriate and timely management of victims is critical to outcomes. Little Specific actions. Enforcement combined with public- information is available on the quality and organiza- ity campaigns, shown to be cost-effective in European tion of emergency services in many ECA countries, and Union (EU) countries, should be undertaken in most 63 injury severity scales, essential for evaluation, are seldom ride sharing and public transport services) could reduce used. European literature suggests that about 50 percent car collision frequency by 14 percent (total) and 15 of deaths occur at the scene, about 15 percent in the first (severe) (Lovegrove and Litman, 2008). four hours after a crash, and about 35 percent thereafter. Opportunities are available in ECA countries to influ- Specific actions. Integrate RTI prevention into poli- ence the chain of events based on evidence and evalua- cies for sustainable transport. This will be assisted by tion of emergency care. increased use of cost-effectiveness analysis of sustain- able transport and safety interventions that emphasize Specific actions. Collect data on coverage and response benefits across a range of sectors. Take advantage of the times of emergency services to identify gaps and measure commitment to and investments in policies to reduce such times, which may be overlong, especially in rural greenhouse gases to develop the evidence and advocate areas. Injury surveillance systems based on the WHO for policies that provide health "co-benefits," including Injury Surveillance Guidelines must be strengthened so road safety improvements. that preventive programs and service quality can be eval- uated. Optimize the organization of emergency care, and 4. Design demonstration projects retrain staff, especially in rural areas, in emergency care. Training materials, protocols, and guidelines--WHO's As discussed in detail in Chapter VII, well-designed dem- Essential Trauma Care Guidelines, Pre-hospital Trauma onstration projects can support the process of catching up Care Systems, and Guidelines for Trauma Quality with best practice in road safety performance and are an Improvement Programs--can be adapted to local needs essential part of building capacity. They can provide use- based on the Advanced Trauma Life Support training ful benchmarks for rolling out a modern road safety pro- course. gram in the rest of the country with the support from donors and international finance organizations. G. Put road safety at the center of Specific actions. Opportunities should be pursued for sustainable transport policies demonstration projects in urban areas and high-risk Road safety needs to be reframed as an attribute of trans- corridors, including road infrastructure improvements. port, along with other performance indicators. If road These should be multisectoral and well resourced and safety is seen as separate from the other "performance use international expertise to promote the transfer of attributes" of transport systems, it is more difficult to best practice. Demonstration projects should be part also "judge" the performance of transport in terms of of the process of building national capacity through safety, and ministries of infrastructure/ transport will be enhancing the knowledge and skills of professionals. "rewarded" more for kilometers of new roads than for These projects require careful evaluation and monitoring road capacity to protect life. Also, recent research indi- using appropriate methodologies and tools. cates that improving transportation options (for exam- ple, better walking and cycling conditions, and improved 64 8 "Cowardice asks the question ­ Is it safe? Expedience asks the question ­ Is it politic? Vanity asks the question ­ Is it popular? But conscience asks the question ­ Is it right? And there comes a time when one must take the position that is neither safe, nor politic, nor popular, but one must take it because it is right." ­ Martin Luther King, Nobel Peace Prize Laureate, 1964 "All multilateral development banks (MDB's) are committed to taking a leading role to address what is becoming one of the most significant public health development priori- ties of the early 21st century." ­ Jamal Saghir, Director of Energy, Transport, and Water, The World Bank Chapter VIII. The Task Ahead: Operationalizing an Effective Response in ECA 1. Framework for action: World Bank · Safe, clean, and affordable transport for development future engagement on road safety needs to be prioritized. Drawing from lessons worldwide, the following key con- · Knowledge transfer and the scale-up of road safety engagement and investments need to be accelerated. siderations have been offered to guide World Bank efforts on road safety, working in partnership with governments, international agencies, private sector entities, and civil 2. Options to support ECA countries society organizations (Saghir 2009): in improving road safety · The scale of the public health crisis from road traf- The World Bank, working with other international part- fic fatalities in low- and middle- income countries ners, could support ECA governments in the selection, (LMICs) is unacceptable. design, and implementation of safe system programs to · Commitment is needed to implementing road safety reduce road crash fatalities during 2010­16. It should measures that are: (a) sustainable, which requires also be clear, as noted, that some ECA countries, as proper sequencing and a long-term commitment members of the EU, have the opportunity to deal with that is systematic and at scale; (b) integrated, which the RTI challenge through that membership. And, since requires multisectoral and multidisciplinary engage- the opportunity it affords may be different from that ment to focus on the varied, related dimensions of of non-EU ECA countries, the support that could be the phenomenon: urbanization, increasing wealth, provided by the World Bank should follow a tailored demographic maturation, poor behaviors, insufficient approach. (sometimes corrupted) resources, human frailty, and On the basis of priorities set by ECA governments and perhaps a host of other variables; and (c) inclusive, taking into account the individual circumstances of each which takes into account country development objec- country, the World Bank could structure an assistance tives and recognizes that the poor and those thrust program that takes into account evidence-based, cost- into poverty by road crashes have rights that deserve effective approaches and international best practices, evi- protection. 67 dence from modeling exercises based on assumptions and D. Learning by doing. Sustained long-term invest- extrapolation of the impact of different interventions for ment is the key to improving country road safety improving road safety, and available economic evidence results. This requires staged investments that address on the basis of which to advocate for greater investment revealed capacity weaknesses by first building core in certain road safety initiatives. Following the recently- capacity to achieve targeted safety outcomes, then issued guidelines for implementing the recommendations scaling up investment to accelerate this capacity of the World Report (Bliss and Breen 2009), programs strengthening and the achievement of improved could concentrate on the following areas: results across the national road network. Building upon the findings of the country capacity review, A. Capacity review. A safety management capacity investments must be grounded in a learning by review is a vital first step in the process of a country doing process, with sufficient targeted investment taking the necessary actions to tailor the World to overcome the barriers presented by weak institu- Report recommendations to its unique circum- tional capacity. stances, and in determining its readiness to commit to the steps needed to improve its road safety out- One way to operationalize this approach will be to comes. It also serves to identify related institutional support the design and implementation of dem- responsibilities and accountabilities and provides a onstration projects which aim to anchor country platform to reach an official consensus on country capacity building efforts in systematic, measurable capacity weaknesses and how best to overcome and accountable investment programs that simul- them. taneously build management capacity while rapidly achieving safety improvements in targeted high-risk B. Role of lead agency. The World Report high- corridors and areas. lights the fundamental role of the lead agency in ensuring the effective and efficient functioning of These demonstration projects could be located in the road safety management system. Responsible distinct geographic areas where road safety issues and accountable road safety leadership at country, vary in nature: (i) in a densely populated urban state, provincial and city levels is vital to success. area within a major city, for example, Baku, Kiev, In the absence of such leadership with a sustained Moscow, St. Petersburg, and Tbilisi; and (ii) along focus on results, improvements, for example, in pro- a high-speed and highly trafficked highway, for gram coordination, decentralization and promotion example, Moscow-St. Petersburg, or any other with will often be elusive and unsustainable. Likewise, a high rate of road crashes. Particular attention action plans prepared without a designated agency could be devoted to exploring links and synergies mandated to lead their implementation and a realis- with transport policy options to mitigate the effects tic and sustainable funding base are likely to remain of climate change through reduced greenhouse gas paper plans and make no positive impact on results. emissions, since such attention garners additional support for policies to reduce speeding and a modal C. Staged investment. Countries wishing to shift toward safer, cleaner transport modes. In addi- improve their road safety performance must be well tion, this is an important area for synergy with organized to manage the achievement of improved other health policies and programs, and with other results in a systematic way. Institutional management international agencies and donors. functions must take the highest priority as they are the foundation on which road safety management The objective of the demonstration projects would systems are built: they produce the interventions be to: (i) field-test a road safety improvement strat- that achieve the desired results. In practice, the pro- egy that implements a combination of preventive cess of institutional strengthening must be staged. safety engineering measures and adoption of legal During the formative stages emphasis must be put and regulatory measures to reduce urban speed lim- on improving the focus on results and related inter- its to 50 km/h; and (ii) encourage local authorities agency coordination. As these institutional manage- to impose 30 km/h limits in highly populated areas ment functions become more effective the remaining and to strictly enforce key safety behaviors concern- management functions are in turn strengthened. ing speed, seatbelts, and alcohol, supported by high- 68 intensity public education campaigns and strength- possible at local, regional, and national levels and the ened emergency medical care services. Combined respective responsibilities and related policy options with the development of lead agency capacity to and interventions, particularly since the World Bank operate a continuous, detailed monitoring and evalu- is starting to work at the subnational level. ation system, the demonstration project would gen- erate benchmark performance measures. This would 3. Building blocks allow successful interventions to be extended to the rest of the country within a reasonable time frame, A list of building blocks that could be used for structur- for example, five years. In some countries, this effort ing safe system programs supported by the World Bank would also require a clearer distinction of what is is presented in Table 10. Table 10: Building Blocks for the Implementation of an Effective Road Safety Program Area of intervention Investments and actions 1. Institutional capacity building. Technical assistance and related investments for the establishment, organization and strengthening of management and operational capacity of a lead agency for road safety, resourcing it adequately, and making it pub- licly accountable. Training programs for policymakers, executive managers, road engineers, health practitioners, traffic police officers, and other officials involved in management and design of road safety programs and implementation of road safety programs. 2. National road safety policies, strategies, Technical assistance for developing/updating the legislative framework, plans, and organizational and coordination policies, strategies and plans with targets to halve RTI fatality rates by 2020. arrangements. 3. Road environment: support of interventions Infrastructure investments to improve safety in demonstration road corridors to create a safer road environment. and beyond, such as guardrails, signaling and marking, and reengineering of most critical crossroads in selected urban areas. Technical assistance for undertaking network safety rating surveys and road safety audits and inspections. 4. Road safety enforcement: equipment and Acquisition of radar equipment, speed cameras, and breath analyzers training traffic police to deter risky behavior. combined with roadside checks to control and monitor speed, alcohol, and seatbelt use. 5. Public information and education Technical assistance and funding for the development of public information, campaigns and programs on road safety. education and communication programs to support the enforcement of laws and regulations for speed-control, use of seatbelts, and detering drinking and driving. 6. Support for improvements of health As part of health system reforms and modernization efforts, technical promotion and prevention programs, assistance for strengthening public health programs, national and regional emergency medical services, and road safety strategies and organizational arrangements for first aid emergen- rehabilitation services. cy responses; funding for procurement of ambulances, medical equipment and other inputs; training of medical personnel on basic and advanced life support systems; communication systems investments, including centralized dispatchers and global positioning systems (GPSs); and technical assis- tance and investments for developing/strengthening of trauma centers, safe blood transfusion services, and rehabilitation programs. 7. Monitoring and evaluation. Investments for development of computerized information systems to support data collection, assessment and sharing of information for decision-making and program management across sectors. 69 4. Partnership arrangements with ment of increased capacity to improve emergency trauma services and train health personnel to improve pre-hos- international agencies at the pital and emergency trauma care (WHO 2004b, 2005, country, regional, and global 2009b). levels The World Bank could bring the best international 5. Implementing arrangements approaches to road safety improvement to work alongside Given the multisectoral nature of the road safety effort ECA peers. In particular, partnership arrangements in (Table 11), the proposed support by the World Bank in ECA could be established with the International Road ECA would need to mobilize the involvement of differ- Assessment Program (iRAP) to address engineering ent government agencies, private sector entities, and civil safety issues, and with RoadPOL to offer peer-to-peer society organizations under the overall coordination of a services to traffic police in countries where the World lead agency. Similarly, World Bank teams would need to Bank works. In the case of RoadPOL, a law enforcement include staff from different disciplines and sectors. advisory panel of international police leaders of the high- est rank has been established as its governing body. The World Bank-developed RoadPOL model could be pilot- 6. Choice of Instruments ed as part of World Bank support in a selected major Taking into consideration the medium-long term time- road corridor in ECA. A pilot could engage best practice frame required to improve road-safety, ECA govern- road-policing support, with iRAP providing best practice ments could use an Adaptable Program Lending (APL) safety engineering services. Similar capacity-building instrument. It provides a sequence of well-targeted initiatives in the area of data development, working with investment projects supporting long-term development the International Road Traffic Accident Database Group, programs, such as the ongoing "Traffic Safety Increase could also be supported. 2006­2012." APLs typically involve a series of loans The World Bank could establish partnerships with and that build on lessons learned during previous loans in mobilize the technical cooperation of other special- the series. Loans are phased on the basis of satisfac- ized agencies, such as the World Health Organization tory progress in meeting agreed quantified milestones, (WHO), to contribute to capacity building to comple- benchmarks, or triggers. The APL instrument offers a ment other initiatives to improve road safety. Developing framework for coordinated action by governments and institutional and technical capacity by working with possible co-financing with regional governments in fed- concerned policymakers and practitioners from multiple eral countries and could support a country's agencies in sectors is essential in taking concerted action, and will adapting, according to the country's situation, the provi- achieve synergies with other initiatives. Ample evidence sions of national policies and strategies for road safety demonstrating the cost-effectiveness of interventions improvement. should be disseminated to help create a culture of safety A second instrument ECA authorities could consider is a among key road safety practitioners and policymakers. series of free-standing Specific Investment Loans (SILs) WHO, for example, could provide training to promote that would be designed and implemented in a sequential traffic injury prevention using curriculums already way, either focusing solely on road safety or through available in Russian (WHO's TEACH-VIP (WHO transport projects with road safety components, as is 2007b) and the Road Traffic Injury Prevention: Training currently done in many ECA countries. Manual (WHO 2000). Executive managers, road engi- neers, policymakers, health professionals, and police are A third instrument, Fee-Based Services (FBS), is being among those who could be trained. Information systems used with several regional governments and institu- are essential to monitoring the success of the program. tions in Russia. Under this arrangement, the World WHO may be able to contribute to ensuring the sound Bank would help: (a) design and prepare the techni- development of health information systems for monitor- cal, administrative, and financial aspects of a program, ing, using the WHO guidelines for injury surveillance including the mechanisms for facilitating participation (WHO 2001). Also, WHO could support the develop- of different agencies and local governments; (b) support 70 Table 11: Multisectoral Collaboration for Road Safety Action Areas Scope Main Actors Partnerships Promotion, engagement, coordination, and Governmental agencies addressing transport, harmonization of efforts across many sectors health, education; law enforcement, and civil of society to ensure long term sustainability society organizations; private companies, of the effort. religious entities, and mass media. Policies, legislation, Enactment of laws and regulations. Costing of Governmental agencies, parliaments, civil enforcement strategies and programs, adoption of sustain- society organizations, car insurance compa- able funding mechanisms, and assignment of nies, interior ministries, and police. institutional responsibilities and accountability. Establishment of enforcement mechanisms. Design, building and Assessment and implementation of policies, Transport ministries, finance, economic maintenance of roads plans, and new investment projects. development, private firms, and enterprises. Safe vehicles Improvements in vehicle design to meet Automakers, regulatory agencies, insurance safety and environmental standards. companies, and consumer organizations. Public information, Creation of a road safety culture to support Transport, education and health ministries, education and implementation of road safety strategies. mass media, and insurance companies. communication Inclusion of road safety themes in core curriculum of health education programs, targeting children and adolescents. Injury prevention, Implementation of health system interventions Health ministries and health insurance medical care, along a continuum of service provision: public agencies. rehabilitation health, primary health care, post-impact medical care, including blood transfusion services, and rehabilitation. Data collection, Collection and assessment of detailed and Government agencies and systems (e.g., monitoring, and use accurate data and information on road traffic epidemiological surveillance systems), data for decision-making injuries and fatalities for policymaking and depositories at policy departments, and and management program management across sectors. insurance companies. Source: Bekefi (2006) and Peden and others (2004). national agencies in managing the implementation of 7. "Window of opportunity" for program components, including technical assistance and advancing the road safety agenda administrative tasks (for example, procurement, financial management, and auditing); and (c) support supervision under ECA economic recovery of the implementation of the program at the regional programs and municipal levels, including program monitoring and As seen in ongoing U.S.-supported efforts under the impact evaluation. Recovery and Reinvestment Act, signed by President A fourth instrument, also currently used in several Obama in February 2009 (U.S. Department of Russian regions, is subnational lending as part of a Transportation Federal Highway Administration 2009), newly established World Bank/International Finance programs that are being funded by governments in dif- Corporation (IFC) program. Under this instrument, ferent countries to reactivate economic growth and funding without federal government guarantees could be employment offer a "window of opportunity" to scale-up made available to regional governments to finance the and improve road safety in ECA. In the United States, implementation of "pilot road safety corridors." for example, investment directed to roads and highways 71 incorporates safety features and is coupled with encour- · Provide a common framework for action shared by aging local governments to implement existing strategic countries, bilateral and multilateral donors, NGOs, highway safety plans. The goal is to support the devel- and civil society. opment and promotion of programs and technologies to reduce the number of road traffic injuries (RTIs) on 9. Safety on the roads: Multilateral U.S. roadways, the site of 37,261 deaths in 2008. Development Banks joining forces Looking at economic stimulus packages around the to save lives world, at the 2009 International Transport Forum held in Germany, it was concluded that, while many of these To help achieve the Decade of Action goals, on have significant transport components, projects with November 11, 2009 seven multilateral development short lead times are required in order to create jobs banks (MDBs) issued a joint statement ahead of the rapidly and to resolve chronic maintenance backlogs in Global Ministerial Conference on Road Safety being many countries (ITF, 2009). Maintenance and upgrad- held in Moscow on November 19-20, 2009, outlining a ing of infrastructure is particularly suited to this. broad package of measures that each would implement to reduce an anticipated and alarming rise in the number of road fatalities and casualties in developing countries 8. What could be achieved in a road (World Bank, 2009c). safety decade? The case for action The MDBs--the African Development Bank, Asian Development Bank, European Bank for Reconstruction The Commission for Global Road Safety's "Make Roads and Development, European Investment Bank, Inter- Safe" report (launched in Rome in May 2009) proposed American Development Bank, Islamic Development the following goals for a Decade of Action worldwide Bank, and the World Bank--committed to launching (Ward 2009) that should be adopted to guide ECA coun- joint initiatives as part of growing programs of work they try efforts: will undertake as international development partners. · Demonstrate measurable success in stabilizing and The measures to be carried out fall into four broad then reversing the growth in RTIs by pursuing the categories: goal of achieving a 50 percent reduction in the fore- cast level of fatalities by 2020; · Strengthening road safety management capacity; · Encourage countries to implement the recommen- · Implementing safety approaches in the planning, dations of the World Report on Road Traffic Injury design, construction, operation, and maintenance of Prevention and set interim targets that will contribute road infrastructure projects; to the overall fatality reduction goal; · Improving safety performance measures; and · Raise professional capacity in RTI prevention in low- · Mobilizing more and new resources for road safety. and middle-income countries; · Ensure that road safety management and reducing injury levels become self-sustaining over the long term; and 72 Epilogue "To whom does the ragged condor report after its mission?" ­ Pablo Neruda, Nobel Prize in Literature Laureate, 1971 Epilogue This report makes the case that road traffic safety has ments to raise the political importance of road safety as a tremendous implications for health, social welfare, and development priority, and in designing and implement- economic well-being in the World Bank's ECA countries. ing related programs and projects over the medium term Road traffic injuries are a major cause of death and dis- to achieve road safety targets. This would help to raise ability, and the most vulnerable populations--young the importance of road safety in country and regional people and the elderly--bear the highest burden of assistance agendas of other international agencies and injuries and fatalities, often as pedestrians. The report among the donor community. presents accumulated evidence from country experiences To this end, this report strongly argues that it is critical worldwide that point out a clear path for dealing with that the World Bank mount well-designed and well- the problem: strengthen institutions, laws and regula- funded multisectoral efforts to support ECA countries tions, policies, road design, safety equipment, enforce- in designing and implementing effective and sustain- ment mechanisms, and health service delivery systems able road safety strategies over the medium term. The to reverse increasing road traffic injuries and fatalities in combined participation and contributions of transport, ECA. public health, education, economic, legal, public sector The time to act has arrived. The Ministers and heads management, and private sector specialists operating as of delegations as well as representatives of international, a team could help overcome the limitations of unco- regional and sub-regional governmental and nongovern- ordinated sectoral approaches, harmonize them, and mental organizations and private bodies that gathered sequence the implementation of safe system programs in Moscow, Russian Federation, from 19­20 November over time to address the breadth of factors that drive this 2009 for the First Global Ministerial Conference on silent and neglected epidemic. Road Safety agreed to invite the United Nations General The proposed road safety effort is fully consistent with Assembly to declare the decade 2011­2020 as the and supports the World Bank's transport strategy of "Decade of Action for Road Safety" with a goal to sta- "Safe, Clean and Affordable Transport for Development" bilize and then reduce the forecast level of global road (World Bank 2008a), and the new World Bank guide- deaths by 2020 (see Conference Declaration in Annex lines for implementing the recommendations of the 3). The goal of halving projected deaths by 2020 sets a 2004 World Report (Bliss and Breen 2009c). It also time frame for action. The design and implementation supports the health improvement and poverty allevia- of safe system programs could contribute to revers- tion objectives as outlined in the "Healthy Development" ing premature mortality and disability and supporting strategy for health, nutrition and population results human capital accumulation, a key factor for sustainable (World Bank 2007a), These efforts are also consistent economic growth in ECA countries. with the new strategic directions guiding the World The World Bank, partnering with other international Bank's overall work, particularly those of fostering agencies such as WHO, multilateral development banks, regional and global public goods that transcend national donor agencies, and private and civil society organiza- boundaries and of cooperating with other agencies with tions, could play an important role in supporting govern- specialized expertise (Zoellick 2008). 75 Annexes Annexes: The Response in ECA ­ Selected Indicators by Country ANNEX 1: INSTITUTIONAL FRAMEWORK FOR ROAD SAFETY, ECA COUNTRIES Funded in National National Road Safety Measurable Country Lead Agency Budget Strategy Targets Funded Albania Interministerial Committee of Road Safety No No n.a. n.a. Armenia National Road Safety Council a Yes Yes Yes n.a. Azerbaijan State Road Police Yes Yes Yes Yes Belarus Standing Committee by Council of Ministers of No Yes Yes Yes Republic of Belarus, Ensuring Road Safety Bosnia and Herzegovina Ministry of Communication and Transport Yes Yes Yes Yes Bulgaria State-Public Consultative Commission on the Yes Yes Yes Yes Problems of Road Safety Croatia Ministry of Interior Yes Yes Yes Yes Czech Republic Ministry of Transport Yes Yes Yes No Estonia Government Road Safety Committee Yes Yes Yes Yes Georgia Transport Commission -- Yes Yes Yes Hungary Interministerial Committee for Road Safety Yes Yes Yes Yes Kazakhstan Road Police Department Yes Yes No Yes Kyrgyzstan Kyrgyzstan Commission of Traffic Accident Prevention No Multiple n.a. n.a. Latvia Road Safety Council Yes Yes Yes Yes Lithuania State Traffic Safety Commission No Yes Yes Yes Moldova National Traffic Safety Board No Yes Yes Yes Montenegro None n.a. No n.a. n.a. Poland National Road Safety Council Yes Yes Yes Yes Romania Interministerial Council for Road Safety Yes Yes n.a. n.a. Russian Federation Commission of the Government of the Russian No Yes Yes Yes Federation for Road Safety Slovakia Road Safety Council Yes Yes Yes Yes Slovenia Interministerial Working Group on Road Traffic Safety Yes Yes Yes Yes Serbia None n.a. Multiple n.a. n.a. Tajikistan Department of the State Automobile Inspection Yes Multiple n.a. n.a. (Ministry of Internal Affairs) The Former Yugoslav Republic's Council for Road Traffic Safety Yes Yes Yes n.a. Republic of Macedonia Turkey Board of Road Traffic Safety Yes Multiple n.a. n.a. Turkmenistan None n.a. Multiple n.a. n.a. Ukraine Ministry of Public Health Yes Multiple n.a. n.a. Uzbekistan The State Motor-Vehicle Inspectorate, Ministry of Internal Affairs Yes Yes Yes n.a. n.a. = Not available. a The Strategy approved in August 2009 identifies the National Road Safety Council as the lead agency. The decree on its establishment is under consideration by the government. Source: National sources as reported in WHO (2009a). 77 ANNEX 2: ROAD SAFETY REQUIREMENTS AND COMPLIANCE RATES, BY ECA COUNTRY Maximum BAC Limit, Random Breath Seatbelt Motorcycle Urban Speed General Testing and/or Country Use Helmet Use Limit Population Checkpoints Albania 30% front n.a. 40 km/h 0.05 g/dl Yes Armenia n.a. n.a. 60 km/h 0.08 g/dl Yes Azerbaijan n.a. n.a. 60 km/h 0.0 g/dl Yes Belarus n.a. n.a. 60 km/h 0.05 g/dl Yes Bosnia and Herzegovina n.a. n.a. 60 km/h 0.03 g/dl Yes Bulgaria n.a. n.a. 50 km/h 0.05 g/dl Yes Czech Republic 90% front; 80% rear 97% 50 km/h 0.0 g/dl Yes Bulgaria n.a. n.a. 50 km/h 0.05 g/dl Yes Croatia 45% n.a. 50 km/h 0.05 g/dl Yes Estonia 90% front; 68% rear n.a. 50 km/h 0.02 g/dl Yes Georgia 2% front urban, 41% highways n.a. 60 km/h 0.02 g/dl No Hungary 71% front; 40% rear 95% 50 km/h 0.0 g/dl Yes Kazakhstan n.a. n.a. 60 km/h None Yes Kyrgyzstan n.a. n.a. 60 km/h None Yes Latvia 77% front; 32% rear 93% 50 km/h 0.05 g/dl Yes Lithuania n.a. n.a. 50 km/h 0.04 g/dl Yes Moldova n.a. n.a. 60 km/h 0.05 g/dl Yes Montenegro n.a. n.a. 50 km/h 0.05 g/dl Yes Poland 74% front; 45% rear n.a. 50 km/h 0.02 g/dl Yes Romania 80% front; 20% rear 90% drivers; 65% passengers 50 km/h 0.00 g/dl Yes Russian Federation 33% No consensus 60 km/h 0.03 g/dl Yes Serbia 50-60% front; 4-5% rear n.a. 60 km/h 0.05 g/dl Yes Slovakia n.a. 60 km/h 0.0 g/dl Yes Slovenia 85% front; 50% rear n.a. 50 km/h 0.05 g/dl Yes Tajikistan n.a. n.a. 60 km/h 0.03 g/dl Yes The Former Yugoslav 16% 2% 60 km/h 0.05 g/dl Yes Republic of Macedonia Turkey 70% 12% 50 km/h 0.05 g/dl Turkmenistan n.a. n.a. 60 km/h 0.05 g/dl Yes Ukraine n.a. n.a. 60 km/h 0.00 g/dl Yes Uzbekistan n.a. n.a. 70 km/h None Yes n.a. = Not available. km/h = Kilometers per hour. g/dl = Grams per deciliter. Source: National sources as reported in WHO (2009a). 78 ANNEX 3: CONFERENCE DECLARATION First Global Ministerial Conference on Road Safety: Time for Action Moscow, 19-20 November 2009 Moscow Declaration We, the Ministers and heads of delegations as well as Underlining that the reasons for road traffic deaths and representatives of international, regional and sub-region- injuries and their consequences are known and can be al governmental and nongovernmental organizations and prevented and that these reasons include inappropriate private bodies gathered in Moscow, Russian Federation, and excessive speeding; drinking and driving; failure from 19­20 November 2009 for the First Global to appropriately use seat-belts, child restraints, helmets Ministerial Conference on Road Safety, and other safety equipment; the use of vehicles that are old, poorly maintained or lacking safety features; poorly Acknowledging the leadership of the Government of the designed or insufficiently maintained road infrastructure, Russian Federation in preparing and hosting this First in particular infrastructure which fails to protect pedes- Global Ministerial Conference on Road Safety and the trians; poor or unsafe public transportation systems; lack leadership of the Government of the Sultanate of Oman of or insufficient enforcement of traffic legislation; lack in leading the process for adoption of related United of political awareness and lack of adequate trauma care Nations General Assembly resolutions, and rehabilitation, Aware that as described in the 2004 World Health Recognizing that a large proportion of road traffic deaths Organization/World Bank World report on road traffic and injuries occur in the context of professional activi- injury prevention and subsequent publications, road traf- ties, and that a contribution can be made to road safety fic injuries are a major public health problem and lead- by implementing fleet safety measures, ing cause of death and injury around the world and that road crashes kill more than 1.2 million people and injure Aware that over the last thirty years many high-income or disable as many as 50 million a year, placing road countries have achieved substantial reductions in road traffic crashes as the leading cause of death for children traffic deaths and injuries through sustained commit- and young people aged 5­29 years, ment to well-targeted, evidence-based injury prevention programmes, and that with further effort, fatality free Concerned that more than 90% of road traffic deaths road transport networks are increasingly feasible, and occur in low-income and middle-income countries and that high- income countries should, therefore, continue that in these countries the most vulnerable are pedestri- to establish and achieve ambitious road casualty reduc- ans, cyclists, users of motorised two- and three-wheelers tion targets, and support global exchange of good prac- and passengers on unsafe public transport, tices in road injury prevention, Conscious that in addition to the enormous suffering Recognizing the efforts made by some low- and middle- caused by road traffic deaths and injuries to victims and income countries to implement best practices, set ambi- their families, the annual cost of road traffic injuries in tious targets and monitor road traffic fatalities, low-income and middle-income countries runs to over USD 65 billion exceeding the total amount received Acknowledging the work of the United Nations system, in development assistance and representing 1­1.5% of in particular the long standing work of the United gross national product, thus affecting the sustainable Nations Regional Commissions and the leadership of development of countries, the World Health Organization, to advocate for greater political commitment to road safety, increase road safety Convinced that without appropriate action the prob- activities, promote best practices, and coordinate road lem will only worsen in the future when, according to safety issues within the United Nations system, projections, by the year 2020 road traffic deaths will become one of the leading causes of death particularly Also acknowledging the progress of the United Nations for low-income and middle-income countries, Road Safety Collaboration as a consultative mechanism 79 whose members are committed to road safety and whose Conscious that global results are the effect of national activities include providing governments and civil society and local measures and that effective actions to improve with guidance on good practice to support action to global road safety require strong political will, commit- tackle major road safety risk factors, ment and resources at all levels: national and sub-nation- al, regional and global, Acknowledging the work of other stakeholders, including intergovernmental agencies; regional financial institu- Welcoming the World Health Organization's Global sta- tions, nongovernmental and civil society organizations, tus report on road safety ­ the first country by country and other private bodies, assessment at global level ­ which identifies gaps and sets a baseline to measure future progress, Acknowledging the role of the Global Road Safety Facility established by the World Bank as the first fund- Also welcoming the results of the projects implemented ing mechanism to support capacity building and provide by the United Nations regional commissions to assist technical support for road safety at global, regional and low-income and middle-income countries in setting country levels, their own road traffic casualty reduction targets, as well as regional targets, Acknowledging the report of the Commission for Global Road Safety Make roads safe: a new priority for sustain- Determined to build on existing successes and learn from able development which links road safety with sustain- past experiences, able development and calls for increased resources and a new commitment to road infrastructure safety assess- Hereby resolve to: ment, 1. Encourage the implementation of the recommenda- Acknowledging the findings of the report of the tions of the World report on road traffic injury pre- International Transport Forum and the Organisation vention, for Economic Co-operation and Development Towards 2. Reinforce governmental leadership and guidance in zero: ambitious road safety targets and the safe system road safety, including by designating or strengthen- approach and its recommendation that all countries ing lead agencies and related coordination mecha- regardless of their level of road safety performance move nisms at national or sub-national level; to a safe system approach to achieve ambitious targets, 3. Set ambitious yet feasible national road traffic Acknowledging the findings of the World Health casualty reduction targets that are clearly linked Organization/UNICEF World report on child injury pre- to planned investments and policy initiatives and vention which identifies road traffic injuries as the lead- mobilize the necessary resources to enable effective ing cause of all unintentional injuries to children and and sustainable implementation to achieve targets in describes the physical and developmental characteristics the framework of a safe systems approach; which place children at particular risk, 4. Make particular efforts to develop and implement Recognizing that the solution to the global road safety policies and infrastructure solutions to protect all crisis can only be implemented through multi-sectoral road users in particular those who are most vulner- collaboration and partnerships among all concerned in able such as pedestrians, cyclists, motorcyclists and both public and private sectors, with the involvement of users of unsafe public transport, as well as children, civil society, the elderly and people living with disabilities; Recognizing that road safety is a `cross cutting' issue 5. Begin to implement safer and more sustainable which can contribute significantly to the achievement of transportation, including through land-use planning the Millennium Development Goals and that capacity initiatives and by encouraging alternative forms of building in road traffic injury prevention should be fully transportation; integrated into national development strategies for trans- port, environment and health, and supported by multi- 6. Promote harmonization of road safety and vehicle lateral and bilateral institutions through a better aligned, safety regulations and good practices through effective, and harmonized aid effort, the implementation of relevant United Nations 80 resolutions and instruments and the series of 11. Strengthen the provision of prehospital and hospital manuals issued by the United Nations Road Safety trauma care, rehabilitation services and social reinte- Collaboration; gration through the implementation of appropriate legislation, development of human capacity and 7. Strengthen or maintain enforcement and awareness improvement of access to health care so as to ensure of existing legislation and where needed improve the timely and effective delivery to those in need; legislation and vehicle and driver registration sys- tems using appropriate international standards; Invite the United Nations General Assembly to declare the decade 2011­2020 as the "Decade of Action for 8. Encourage organizations to contribute actively to Road Safety" with a goal to stabilize and then reduce the improving work-related road safety through adopt- forecast level of global road deaths by 2020; ing the use of best practices in fleet management; Decide to evaluate progress five years following the First 9. Encourage collaborative action by fostering coopera- Global Ministerial Conference on Road Safety; tion between relevant entities of public administra- tions, organizations of the United Nations system, Invite the international donor community to provide private and public sectors, and with civil society; additional funding in support of global, regional and country road safety, especially in low- and middle- 10. 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