Measurement is not enough for global road safety: implementation is key
Authors: Adnan A Hyder
Journal: The Lancet Public Health (2018)

On Dec 7, WHO releases the latest 2018 Global Status Report on Road Safety.1WHOGlobal Status Report on Road Safety 2018. World Health Organization, Geneva2018Google Scholar The report serves as an important tool for monitoring the risks, outcomes, and progress related to road safety and transport across WHO members states. Fourth in the Global Status Report on Road Safety series, it aims to provide a systematic and consistent approach to measuring the burden of road injuries in terms of crashes, disability, and mortality. According to the report, more than 1·3 million people die on the world's roads each year, with millions more injured and disabled, and these numbers appear mostly unchanged since the first report in 2009.2WHOGlobal Status Report on Road Safety 2009. World Health Organization, Geneva2009http://www.who.int/violence_injury_prevention/road_safety_status/2009/en/Date accessed: November 26, 2018Google Scholar These reports are important and have changed the discourse on global road safety in many ways since their initial publication. First, they have brought technical and political attention to a condition that previously had not been on the global stage; injuries in general, and road injuries in particular, were neglected by the global health community. Second, they have highlighted the inconsistencies between data reported by member states and the expected numbers of deaths predicted by good modelled data, thus providing a stimulus for countries to review their own data systems. Although these inconsistencies raised much political concern, WHO is to be commended for defending their methods. Third, the public availability of such road injury data has allowed institutions and individuals to use and analyse it for their national or programmatic use and dissemination.3Evaniew N Godin K Schemitsch EH Bhandari M Evidence gaps in the global decade of road traffic safety.J Orthop Trauma. 2014; 28: S15-S17Crossref PubMed Scopus (8) Google Scholar Fourth, the fact that these reports have been published over time allows the global community to track the progress of road safety efforts over the past decade.4Hyder AA Paichadze N Toroyan T Peden MM Monitoring the decade of action for global road safety 2011–2020: an update.Glob Public Health. 2017; 12: 1492-1505Crossref PubMed Scopus (37) Google Scholar The current report shows that numbers of deaths from road injuries have not been majorly reduced since the first report, and that increasing numbers of people, especially young people, have continued to die across low-income and middle-income countries since the year 2000.1WHOGlobal Status Report on Road Safety 2018. World Health Organization, Geneva2018Google Scholar, 2WHOGlobal Status Report on Road Safety 2009. World Health Organization, Geneva2009http://www.who.int/violence_injury_prevention/road_safety_status/2009/en/Date accessed: November 26, 2018Google Scholar Although there are specific locations where road injuries have been reduced and successful case studies are quoted, the widespread change needed has not happened. Furthermore, although measurement is necessary for change, it is clearly not sufficient, and that is of concern, especially as the Decade of Action for Global Road Safety 2011–2020 comes to an end.5Krug E Decade of action for road safety 2011–2020.Injury. 2012; 43: 6-7Summary Full Text Full Text PDF PubMed Scopus (21) Google Scholar It is important to ask tough questions and to understand what was declared, what was actually implemented, and how—despite a decade of effort—the numbers have not changed. Key to reducing numbers of deaths is implementation of effective interventions on the ground. That goal, in turn, requires not just providing a menu of actions, but also a consideration of five key issues: political commitment, an enabling environment, implementation support, public engagement, and confronting threats. First, it is credit-worthy that the number of UN General Assembly and World Health Assembly resolutions on road safety and injury prevention have increased since 2003. However, these declarations appear not to have been followed up with support for national actions or major financial allocations for programmes at the country level. Thus, a sense of achievement at declarations alone is short sighted: governments must be held responsible for their commitment to convert declarations into actions and delegation of both authority and finances for road safety. Second, road safety programmes cannot be implemented in a vacuum and without a supportive environment across a nation or state. Attempting to create one more vertical programme for ministries of health might not be the optimal direction for success. Developing the human, technical, and financial capacity for successful programmes is crucial in an area of health that has been traditionally neglected. WHO and partners need to support a multisectoral approach to road safety and ensure that it is a high priority, not only for the health sector, but also for transport, environment, justice, education, and the economy. Third, and most concerning, is the apparent assumption that providing lists of interventions will somehow lead to their adoption on the ground.6Peden MM Khayesi M Save LIVES technical package: 22 interventions that could make a difference.Inj Prev. 2018; 24: 381-383Crossref PubMed Scopus (7) Google Scholar Implementation of effective interventions at scale is the only way to decrease death and disability across the globe. Such implementation requires an orientation to context—how specific features of each country can affect the rollout and sustainability of road safety programmes—and defining packages alone is not enough. Operational guidance, contextual analysis, implementation research, and systems science are all needed. WHO must provide support for this implementation, and understand that normative guidance alone does not guarantee real-world change. Fourth, one of the crucial gaps for global road safety, compared with even other health issues, is a relatively weak non-governmental sector and poor civil society engagement, especially in low-income and middle-income countries. The presence of a global alliance for non-governmental organisations or a victims organisation in a country, though encouraging, is not enough, nor are these organisations sufficiently scaled, to ensure a public movement for safety in the countries that need it most. The public outrage briefly seen among youth in Bangladesh in 20187The LancetThe wrong kind of enforcement in Bangladesh.Lancet. 2018; 392: 531Summary Full Text Full Text PDF PubMed Scopus (4) Google Scholar captures the fundamental motivation for road safety that should be seen in all countries of the world: that these injuries and deaths are preventable. It is time for WHO and partners to make road safety a high priority, framed as a fight for reducing vulnerability, supporting social justice, and ensuring that the poorest do not bear a disproportionately high burden of death and disability. It is time to give voice to this outrage, expressed by those who have lost loved ones on the world's roads, and encourage societies to hold their policy makers accountable. Finally, it is also important for WHO and partners to acknowledge the threats to global road safety, especially from industry. For example, the alcohol industry openly engages in and promotes actions that, at best, have little or no evidence for success.8Esser MB Bao J Jernigan DH Hyder AA Evaluation of the evidence base for the alcohol industry's actions to reduce drink driving globally.Am J Public Health. 2016; 106: 707-713Crossref PubMed Scopus (22) Google Scholar Their actions to engage as a partner in road safety should be viewed with concern—their probable motivation being to prevent actors from affecting their market. It is unfortunate that UN agencies have accepted funds from the alcohol industry, purportedly to be used for road safety, knowing that such engagement raises concerns over conflicts of interest and transparency.9United Nations Institute for Training and ResearchUNITAR and Diageo sign strategic partnership agreement on road safety.https://www.unitar.org/fr/unitar-and-diageo-sign-strategic-partnership-agreement-road-safetyDate: June 2, 2016Date accessed: November 23, 2018Google Scholar Although WHO has, thus far, not accepted funds from this industry, unfortunately, it does not appear to have a strict policy of non-engagement as with the tobacco industry. It might be time to develop a UN-wide policy for this type of industry engagement to set an example for the rest of the world. Global road safety is crucial in the path towards the UN Sustainable Development Goals. Although the monitoring approach of WHO through the Global Status Report on Road Safety is commendable, the time and effort need to be balanced with proactive support for implementation of known and effective interventions on the ground. Measurement alone is not enough, and recognising the lack of progress is the first step towards the development of a strong and sustainable set of actions for changing the current status quo on global road safety. For the Global Alliance of NGOs for Road Safety see http://roadsafetyngos.org For the Global Alliance of NGOs for Road Safety see http://roadsafetyngos.org This online publication has been corrected. The corrected version first appeared at thelancet.com/public-health on December 10, 2018 This online publication has been corrected. The corrected version first appeared at thelancet.com/public-health on December 10, 2018 I was a member of the WHO advisory committee for this report on road safety. I declare no competing interests. Correction to Lancet Public Health 2019; 4: e12–13Hyder AA. Measurement is not enough for global road safety: implementation is key. Lancet Public Health 2018; 4: e12–13—The declaration of interest statement should have read "I was a member of the WHO advisory committee for this report on road safety. I declare no competing interests." This has been corrected as of Dec 10, 2018. Full-Text PDF Open AccessSpeaking up for global road safetyThis week marks the fifth UN Global Road Safety Week. This year's biennial events and activities aim to galvanise public demand for stronger leadership for road safety worldwide. Every day some 3700 people die on the world's roads, equating to 1·35 million lives lost every year, according to WHO. Furthermore, up to 50 million people are left injured or disabled after a crash. Poorer countries bear the brunt of the burden, with 93% of deaths taking place in low-income or middle-income countries. Regionally, Africa and southeast Asia experience the highest number of fatalities. Full-Text PDF Open Access