83726 December 2013 – Number 111 ROAD TRAFFIC INJURIES: A PUBLIC HEALTH CRISIS IN MENA Said Dahdah, Dipan Bose1 Introduction: Over the last 20 years, the Middle East and North Africa (MENA) has made dramatic progress in lowering premature death and disability from most communicable, newborn, nutritional, and maternity causes. The Global Burden of Disease study (GBD, 2010) confirms that the number of deaths and years of healthy life years lost are decreasing for the above causes. However, the numbers for non- communicable diseases (NCD) are at 73% and while deaths due to injuries (9%) is a small proportion of the overall total, there has been a dramatic increase in its magnitude and relative proportion over the last 20 years. To Road Conditions in Yemen contextualize, communicable diseases such as lower respiratory infection are currently the Source: International Relief and Development and third leading cause of death in MENA (across all Engicon - Yemen ages and gender), and this has been steadily decreasing - by 30% since 1990. Compared to other developing countries, the composition of road injury deaths in the MENA Road traffic injuries, on the other hand, are the region stands out even more. MENA traffic fourth leading cause of death in MENA killing injury victims are mostly vehicle occupants 82,000 people in 20102 and increasing by 53% (63%), pedestrians (22%) and motorcyclists (8%). since 1990. This is the highest percentage In other developing countries, around 50% of among all regions. The road traffic annual road traffic deaths are pedestrians. mortality rate in the region is 22 deaths per 100,000 population (compared to less than 5 Figure 1: Road traffic fatality rates for the ten worst performing countries including four (red) from deaths per 100,000 population in the best MENA region. Number over the bar shows the rank of performing countries worldwide). road traffic injuries as cause of death among all causes in that country. (Source: GBD study 2010) 1 Said Dahdah, Transport Specialist, Middle East and North Africa (MENA) region, the World Bank (sdahdah@worldbank.org). Dipan Bose, Transport Specialist, Global Road Safety Facility (dbose@worldbank.org). This Quick Note is based on the World Bank’s Transport Notes (TRN-45) and was cleared by Patricia Veevers-Carter, Sector Manager, Sustainable Development Department, MENA, the World Bank. 2 WHO Global Status Report on Road Safety, 2013). The poor road safety performance of Oman, Without strong social safety nets in these Saudi Arabia, Iran, Libya (Figure 1) and others countries, the disabled – often the chief in MENA is largely due to excessive speeding breadwinners – can face a lifetime of physical and lack of police enforcement, with ineffective pain, as well as loss of wage earnings, mobility, penalty systems; and rapid motorization growth and capacity to provide for their families. and road building combined with poor road design and vehicle regulations. In Iran, the Figure 2: Age distribution of road deaths in MENA situation is worsened by motorcycles whose region by sex. Numeral over the bar indicates the rank of riders constitute 23% of road traffic fatalities. road traffic injuries among all causes of death in that age group. (Source: GBD study 2010) Iranian traffic police says that helmet usage is 30% and 10% for drivers and passengers, respectively. The Social and Economic Costs of Road Crashes in MENA: International comparisons provide insights into the differences in the economic burden of road crashes across countries. Based on international comparisons, the costs of road crashes have been estimated between 1% of Gross Domestic Product (GDP) in low income countries to 2-3% in high income countries. The current figures for MENA are grim. On average, MENA high income countries lose around 3.9% of GDP to road crashes (Oman ranks worst with a loss 7.4% of GDP, Malta fares best losing 0.9% of GDP to road traffic injuries). The economic loss is even worse for some of the While considering the cost of road traffic lower and upper middle income countries in injuries, one must also take into account that in MENA. On average, these MENA countries lose middle-income countries, government spending around 5.4% of GDP, with Iran losing a on health care is relatively low. MENA significant 8.4% of GDP to road traffic injuries, governments commit on average only 8% of which is among the highest in the world. The their national budgets to healthcare (World total cost of road traffic injuries in the MENA Bank, 2013). This compares with an average of region has been estimated at USD 120 billion for 17% in OECD countries. One major consequence 2010 (iRAP analysis of road crashes - WHO of this low spending is that individuals are (2013), McMahon and Dahdah (2008). responsible for the majority of their healthcare costs, which for poor families often is Road injuries take a lasting toll as they mainly unaffordable. Thus low public financing for affect young populations (Figure 2). Globally, health compromises access and quality of care. road traffic injuries are the number one killer for ages 10 to 24 years. For MENA, the problem is Data suggests that low and middle income more acute as road traffic injuries are the countries are the worst performers in road safety leading cause of death for a wider age group - 10 - 90% of the road deaths occur in these countries. to 35 year olds. This has serious social This implies that wealthier nations have better repercussions, especially in developing road safety, with more resources to manage economies, given that traffic injuries weaken infrastructure, safety systems and institutional economic growth and the resulting costs are capacity. While this is true for most high-income borne disproportionately by the poor, who make countries in Europe, North America and South up the majority of road traffic injury victims. West Pacific, it does not hold for high income The combined effects of health costs and loss of MENA countries. In Oman and Saudi Arabia, livelihood can put poor and vulnerable families for example, road traffic injuries are the second into the vicious cycle of debt and poverty. and third leading causes of death respectively. December 2013 · Number 111·2 Iran, a middle-income country, has a road traffic Figure 3: Road fatalities (Global Status Report-WHO mortality rate of 44 per 100,000 among the 2013) as a function of GDP per capita income (in 2010 highest in the world. USD) compared with adjusted time trend results from Kopits and Cropper (2003). Policy research such as by Kopits and Cropper (2003), predicted the impact of income growth on road deaths across 88 countries using historic time trend data (1963-1999). The results from the fixed effect regression model estimated that road traffic deaths per population rises at lower values with increasing GDP per capita. The trend is reversed at a threshold income, after which increases in income levels led to steady improvement in road safety. The study shows that the GDP per capita income at which road traffic fatality rates begin to decline is approximately USD 12,383 when a common time trend is assumed across all countries and USD 17,458 when region specific time trends are used. This note compares the relative performance of MENA countries in their current situation and implications of observed differences from the generalized historic trend. Figure 3 plots the annual road traffic fatality rate In developed countries across the world, , high per 100,000 people as a function of GDP per levels of motorization correlate with better road capita income for all countries, with MENA safety performance – except for developed countries in red. The distribution for all MENA countries. Clearly then in MENA countries clearly demonstrates that those with motorization alone does not reduce road lower income levels have significantly poorer injuries. World Bank data shows that high road safety performance. The quadratic income OECD countries have a motorization regression model with linearized regional time rate of 630 motor vehicles per 1,000 people trend developed by Kopits and Cropper is (excluding two-wheelers). This is comparable to superimposed on the 2010 fatality rates. The rates in Kuwait (527), Qatar (532), and the UAE comparison shows that most MENA countries, (313). Yet, road fatality rates for all three are in any income category, have poor road traffic much higher than in the OECD. Indeed, in most fatality rates compared to other countries with MENA countries, fatality rates are increasing similar incomes. Saudi Arabia and Slovakia despite increased motorization and incomes. It have similar income levels but the road traffic should be underscored that countries that have fatality rate in Saudi Arabia is 25 per 100,000 reduced the level of trafic fatalities have people, but 9.5 for Slovakia. Road traffic fatality invested heavily in effective programs tackling data (from GBD 2010) shows no appreciable laws, institutions and behaviors. decline in fatality rates in high income MENA countries in the past 20 years. As to low and Improving Road Safety in MENA: In March middle income MENA countries, their high road 2010, the UN General Assembly adopted fatality rates will continue to go up (GBD 1010). Resolution 64/255, proclaiming 2011-2020 the Thus, it is imperative that as the income and Decade of Action for Road Safety, to stabilize motorization levels continue to rise for MENA and reduce global road fatalities 50% by 2020. If developing economies, strong measures for MENA countries are successful, estimates are improving road safety management are that 380,000 lives will be saved and 3.8 million immediately put in place to avoid the increasing serious injuries avoided. This is equivalent to a burden of road traffic injuries. December 2013 · Number 111·3 saving of USD 200-300 billion, i.e. the largest World Bank Resources for Road Safety lifesaving public health program in MENA. Engagements: World Bank resources include: A Global Plan for the Decade of Action : This í¯€Global Road Safety Facility (GRSF), a global was launched in May 2011 to guide countries partnership established in 2006 to address the and facilitate coordinated actions to achieve its crisis of road traffic deaths and injuries in low goals and objectives. The Plan engages at local, and middle income countries. It provides national, regional and global levels, with a focus funding, knowledge and technical assistance to on the national and local-level. Countries are achieve sustainable results and leverage encouraged to adopt a five-pillared multi- investments in member countries. sectorial approach: Road Safety Management, Safer Roads and Mobility, Safer Vehicles, Safer í¯€Institutional Development Fund (IDF): The IDF’s Road Users, and Post-Crash Response. strategic focus is to strengthen the capability of client institutions, but with a new orientation to Global Plan Activities: The first step for MENA address specific delivery challenges. Road Safety countries is to establish a national lead road projects aligned with the Bank’s strategy may safety agency accountable for the Decade of call on IDF support. Action Goals. Without accountability mechanisms, the goals are unlikely to be í¯€The World Bank’s own budget provides technical achieved even if countries start on the Global assistance to client countries as in Iran’s 2009- Plan. Next should be the adoption of a national 2011 Road Safety Project. There are also road safety strategy which sets realistic short, partnerships with the private sector, per medium and long term targets with well-funded example GRSF and the oil company TOTAL evidence-based activities. The second step is to launched an initiative along the main transport pass appropriate legislation and enforce these corridors of Northern and Central Africa. through evidence-based, sustained activities promoting positive changes in behaviors and í¯€Multilateral-Development Banks Road Safety improved vehicle standards. This should be Initiative was launched in 2009 to leverage done in conjunction with capacity building country and regional road safety programs, social marketing programs in areas of risk accelerate knowledge transfer, strengthen factors, i.e. speed limits, drinking and driving, institutional capacity, and scale up road safety seat belt and helmet usage, etc. investment. Under this Initiative, the World Bank is partnering with the European The third step is a large road improvement Investment Bank to address road safety in program based on retrofitting high risk sections Morocco and possibly Egypt and Jordan. of the road network with protective features for all road users. Low-cost and sporadic black-spot treatments have not achieved a sustained reduction in road traffic crashes. Contact MNA K&L: Gerard A. Byam, Director, Strategy and Operations. MENA Region, The World Bank A 2008 expenditure review conducted by the Preeti S. Ahuja, Manager, MNADE World Bank-administered Global Road Safety Regional Quick Notes Team: Facility noted that MENA should invest USD 4 Omer Karasapan and Roby Fields billion in 2010 and up to a USD 9 billion in 2020 Tel #: (202) 473 8177 to achieve the goal of a 50 % reduction in road The MNA Quick Notes are to summarize traffic fatalities by 2020, i.e. decreasing from a lessons learned from MNA and other Bank forecast of 125,000 to 65,000 which is equivalent Knowledge and Learning activities. The Notes to a 20% reduction over 2010. Investment needs do not necessarily reflect the views of the World are a fraction of the annual cost from road Bank, its board or its member countries. crashes estimated at USD 120 billion for 2010. December 2013 · Number 111·4