Filling know-do gaps in road safety policy in developing countries: a ...

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Filling know-do gaps in road safety policy in developing countries: a case study of Thailand

Authors: Paibul Suriyawongpaisal MD, MMSc∗ Community Medicine Center, Faculty of Medicine, Ramathibodi Hospital, Rama 6, Rajathewee, Bangkok 10400, Thailand. Email: [email protected]

Adnan A. Hyder MD, MPH, PhD Assistant Professor, Department of International Health & Center for Injury Research and Policy, Johns Hopkins Bloomberg School of Public Health, Baltimore MD 21205 USA. Email: [email protected]

Nicholas H Juul Research Assistant, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore MD 21205 USA. Email: [email protected]

Keywords: Developing countries, know-do gaps, road safety, policy, Haddon’s Matrix



Corresponding author

Title: Filling know-do gaps in road safety policy in developing countries: a case study of Thailand

Authors: Paibul Suriyawongpaisal MD, MMSc



Community Medicine Center, Faculty of Medicine, Ramathibodi Hospital, Rama 6, Rajathewee, Bangkok 10400, Thailand. Email: [email protected]

Adnan A. Hyder MD, MPH, PhD Assistant Professor, Department of International Health & Center for Injury Research and Policy, Johns Hopkins Bloomberg School of Public Health, Baltimore MD 21205 USA. Email: [email protected]

Nicholas H Juul Research Assistant, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore MD 21205 USA. Email: [email protected]

Keywords: Developing countries, know-do gaps, road safety, policy, Haddon’s Matrix

Word count: 4990 ∗

Corresponding author

Abstract Mortality differentials in road traffic injuries (RTIs) in developed and developing countries over the past two decades indicate differences in the application of scientific knowledge for injury prevention. The majority of global RTIs occur in developing countries, and over time RTIs will become the third leading cause of global health burden by 2020. Given these alarming trends, there is a clear need to build capacity in the application of injury prevention knowledge in developing countries. Such application of knowledge requires both technical capacity and contextual awareness for locally relevant processes of knowledge translation. Using local evidence and international expertise, this paper endeavors to illustrate an example of translating knowledge into road-safety policies and practices in Thailand, a developing country with rapid motorization and high mortality from RTIs. It also offers a systematic approach for identifying key factors for knowledge translation in road safety systems; an approach which has potential relevance in other developing countries.

Introduction Over several decades, the application of specific interventions and road safety policies has resulted in continuing reduction of road traffic injuries (RTIs) in many developed countries(Nantulya and Reich 2002).1 On the other hand, an increasing trend of RTIs is observed in developing countries, and by the year 2020, RTIs will be the third leading cause of disease burden in terms of Disability Adjusted Life Years (DALYs)( Murray and Lopez 1996).2 Despite being less motorized than developed countries, developing countries suffer the majority of the global RTI burden. These opposite trends in RTIs between developed and developing countries indicates differences in context, which in turn influence the feasibility and effectiveness of applying safety interventions.

There has recently been a growing concern about contextual factors in the application of knowledge in road traffic injury prevention(Nantulya VM and Reich MR 2002, Runyan 1998).1,3 Following from this concern, it was proposed that another dimension be added into the Haddon matrix (a conceptual framework for injury interventions) to better assist policy analysis for injury prevention(Runyan 1998).3 The proposed dimension adds a set of criteria for decision making including equity, cost, preferences of an affected community or individual, and the effectiveness of an intervention. In 2004, the World Health Organization (WHO) and the World Bank published The World Report on Road Traffic Injury Prevention to guide road safety policy and program formulation, especially for developing countries(Peden et al. 2004).4

The report provides both conceptual frameworks and content knowledge about risk factors, as well as proven interventions for practical implementation in a developing country setting(Peden et al. 2004).4

In practice, action in a specific country requires an in-depth understanding of the context that influences traffic safety policy processes. For instance, Breen defined three major barriers to improved road safety: attempts by proponents of particular political philosophies to undermine health at the expense of economic considerations; interference of major injury prevention policies by vociferous minorities fearing state interference with civil liberties; and commercial groups opposing road safety policies deemed jeopardizing to their vested interests(Jeanne 2004).5

This paper presents a case study from Thailand. It aims to demonstrate how existing knowledge has been translated, within a dynamic and complex socio-political context, into policies and actions. It offers a road-safety system analysis and identification of potential success factors in reforming these systems. The paper is organized into four sections under key questions: 1) Why should road safety be a public policy concern in Thailand? 2) What are the know-do gaps in road safety in Thailand? 3) How were the gaps filled and what was achieved in the pre 2003 era (1992-2003)? and 4) How were the gaps filled and what was achieved in the post 2003 era? The paper ends with a discussion of lessons learned from Thailand that have the potential for application in other low and middle income countries.

Why should road safety be a public policy concern in Thailand? Over two decades of rapid motorization has caused Thailand to pay a price in terms of deaths and injuries. Annual death tolls have amounted to over 14,000 cases or approximately one death every 40 minutes.6 In contrast to statistics in developed countries, motorcyclists make up the largest portion of deaths, with 77% of such deaths due to head injuries(Suriyawongpaisal and Kanchanasut 2003).6 RTIs pose a big threat to families as well, since compared to other injuries, RTIs affect household bread-winners more than any other type of injury(Sitthi-amorn 2004).7 In terms of economic loss, RTIs cost the country 3% of its GDP in 2002(Suwanrada 2005).8 In comparison to other health burdens, RTIs ranked second only to HIV/AIDS, in term of disease burden as measured by DALYs(The Thai Working Group on Burden of Disease and Injuries 2006).9

Studies in Thailand have provided knowledge about time-place-person distribution and well-established risk factors for RTI. For instance, 69% of road victims visiting emergency rooms came at night time(Siwiroj 2003).10 The reported crash severity in the capital city of Bangkok is much lower than that in the rest of the country probably due to lower speeds as a result of traffic jams, and a smaller proportion of motorcycles, as compared to the rest of the country(Suriyawongpaisal and Kanchanasut 2003).6 Similar to other developing countries, the majority of road crashes in Thailand involve multiple vehicles(Tanaboriboon 2004, Litman and Fitzroy 2005).11,12 Over two decades, police reports have consistently claimed that speeding is the most common cause of RTIs(Siwiroj 2003).10 Alcohol plays a major role in RTIs with 44% of road victims presenting to the emergency room with illegal Blood Alcohol

Content(Suriyawongpaisal et al. 2002).13 Hazardous locations, where severe or fatal crashes have repeatedly occurred, have also been monitored during 1992-96, and 1,211 hazardous road intersections were identified using a black spot surveillance system(Suriyawongpaisal and Kanchanasut 2003).6 these studies establish both the impact of road traffic injuries and the some of the causative mechanisms at play.

What are the know-do gaps in road safety in Thailand? Over the last three decades, several attempts have been made to address the problem of road traffic injuries in Thailand, including the establishment of groups to coordinate policies and plans across ministries, and the formulation and approval in the Cabinet of national road safety policies and plans(Suriyawongpaisal and Kanchanasut 2003).6 Since 1987, engineering measures to improve road conditions, such as the treatment of hazardous locations, have been a part of every five-year National Social and Economic Development Plan(Charoenkolakit 2002).14 Millions of dollars have flowed through the Department of Highways for the installation of traffic signaling and lighting systems, guard rails, road markings and other such improvements(Department of Highways 1994-2006).15 From 1994 to 2003, the crash rate per 100 million vehiclekilometers declined from 26 to 10 and the RTI death rate per 100 million vehiclekilometers also decreased from 9 to 1(Bureau of Traffic Safety 2003).16 However, implementation of engineering measures and the statistics describing their effect included only one-fifth of the countrywide road network, a portion associated with only 17.7% of traffic related injuries and 14.2% of traffic related deaths countrywide(Bureau of Traffic Safety 2003).16

The scope and intensity of the implementation of law enforcement measures had been more limited than that of engineering measures. It was documented that a few adhoc law enforcement activities had been undertaken to encourage the use of helmets and seat belts and to discourage drunken driving, but they were limited to Bangkok and Khon Kaen(Suriyawongpaisal and Kanchanasut 2003).6 In spite of progress made in policy formulation, resource allocation, and the implementation of engineering and law enforcement measures, a large gap remains in terms of expanding and sustaining the scope and intensity of implementing proven, cost-effective, and locally relevant measures.

To fill this gap with an effective policy framework for RTI prevention, additional ‘decision determinants’ such as policy and planning, resource allocation, governance, and the functioning of implementing agencies need to be addressed. Safety measures traditionally tried in Thailand often lacked opportunities for community participation, had limited outreach, and were limited to road safety awareness and attempts to affect road user behavior. It was not clear if decisions were based on best evidence and their degree of transparency was varied. Implementing agencies responsible for road safety were large and difficult to manage, too numerous, and had overlapping responsibilities, thereby creating very inefficient structures. Finally, implementing agencies suffered from reported corruption and a lack of knowledgeable personnel(Anandapibutra 2002).17 These systemic challenges required effective responses, and by the end of the nineteen nineties, Thailand was ready to respond.

How was the gap filled and what was achieved in the pre 2003 era (1992-2003)? Attempts to respond to the know-do gap in Thailand can be divided into two periods characterized by different political and economic contexts. The first periods runs from 1992, when the gap began to be tackled in a truly effective way, until 2003; and then the period after 2003. Table 1 compares the context and road safety profiles between these two time periods(James 1998, Barbara 2003, Pasuk and Chris 2002).18,19,20 The 1992-2002 (pre-2003) period was a time of short-lived coalition governments ruling the country. Political leadership was weak, and road safety received little political attention. Hence, the government’s commitment in terms of resources and actions was limited. There are, however, three important initiatives from this period worth discussing, as they were an impetus for efforts in the later (2003) period.

The first innovative initiative began in 1992 against drunk driving. A coalition of physicians, mass media people, celebrities, and private sector entities developed around a growing knowledge and concern regarding the threat of drunk driving. Initially, this effort took the form of dialogue between proponents against drunk driving and the police, to establish an operational definition of drunk driving and clear penalties for the violators of drunk driving ordinances. This was necessary to pave the way for actual law enforcement which required clear and objective evidence to prosecute drunk drivers. Arguments to amend the law were supported by evidence of a high Blood Alcohol Content (BAC) among a large proportion of injured drivers arriving at emergency rooms(Suriyawongpaisal et al. 2002).13 In 1994, 15 years after the enactment of the 1979

law against drunk driving, a provision for the operational definition of and penalty for drunk driving was added to Thailand’s laws. Soon after, an official mechanism to approve the quality of imported breathalyzers was established in order to protect the credibility of the police using the instruments. In 1997, following a study revealing that a publicity campaign might succeed in raising public support against drunk driving a nationwide publicity campaign was initiated. The campaign was credited as being successful in winning public support to enable proponents to lobby for sobriety check points. However, the campaign was too narrow in scope and failed to change injury outcomes related to drunk driving in a sustained way. The second initiative mobilized political concern for road safety through injury surveillance. For decades, RTIs had consistently peaked during New Year and Song Kran, two national one-week holidays when millions of people throughout Thailand take trips for recreation. These surges of RTIs had concerned the public and health personnel in particular but nothing had been done to address the problem. The then Permanent Secretary of the Ministry of Public Health (MOPH) at that time instructed an ad-hoc RTI daily reporting system during the two festivals, which succeeded in drawing the attention of the media. Many popular newspapers put the figures of RTIs in the headlines every day, and all TV channels highlighted the problem during prime viewing time. As a consequence, concerned public agencies were pressured to respond. On the other hand, the MOPH was also under pressure from the central government to tone down the initiative to save face. This series of events showed that appropriate use of news media could influence policy initiatives in Thailand(Holder and Treno 1997).21

Finally, a best practice model in promoting helmet use through law enforcement and publicity campaigns in the northeastern urban center of Khon Kaen was put into place. The model consisted of establishing a trauma registry and then using evidence from analysis of the registry data to communicate with the public and with the Provincial Safety Council. Using the evidence, a local surgeon was able to convince the provincial Council that enforcement for helmet use was the most effective and feasible choice to cut death tolls from head injuries, the most common types of injuries among all fatal RTIs(Ichikawa et al. 2003).22 The Council acted on the suggestion, and with a long term commitment in law enforcement, day-time helmet use increased to almost a 100% within 2 years(Ichikawa et al. 2003).22 The provincial RTI mortality rate gradually declined from a level higher than the national average for RTIs to a level below that figure(Chadbanchachai et al. B.E.2540).23

The pre-2003 period set the stage for a more coordinated RTI prevention movement in four main ways. Road safety was raised to a higher level on the political agenda. A small network of researchers, bureaucrats and civil society with a long term commitment in road safety was established, preparing a team of minds capable of making use of any windows of opportunity that would emerge in the future. Champions in road safety promotion, important catalysts in the process of changing policy, were born. And, importantly, the public perception that RTIs were an unpreventable act was successfully addressed. This set the stage for developments in the last few years as described below.

How were the gaps filled and what was achieved post 2003 era?

The next period of RTI prevention reform occurred in the context of a singleparty government since 2003 (Table 1). A more corporate style of management was introduced in public administration, and provincial governors were required to report directly to the Prime Minister, in addition to their usual reporting to the Minister of Interior. In addition, more emphasis was given to an integrated approach in policy and planning for road safety. In response to the challenges of road safety, the Road Safety Operations Center (dubbed “The War Room for Road Safety”) was set up to develop an integrated national road safety action plan across all relevant public agencies and to mobilize integrated budgetary support for those plans. To ensure integration across ministries, a Deputy Prime Minister chaired the War Room. Some of the individual champions and colleagues from the private sector were also invited to sit in the War Room. A window of opportunity had presented itself to those concerned with developing a national road safety policy.

The War Room acted as an official forum in which knowledge translation took place via stakeholders’ interactions with policy processes. The knowledge translation process was not straightforward; the interpretation of knowledge placed before the council depended to a large extent on value preferences and vested interests of those in the room. Policies developed in the War Room faced further challenges by being subject to approval by the Cabinet, where road safety had to compete with other priority issues and was subjected to further sets of value preferences and vested interests. To enhance evidence-based policy decisions under these complex circumstances, a single strategy for knowledge translation was not sufficient.

Considering the amount of evidence used and the nature of the interaction among stakeholders, Start and Hovland have classified four major strategy levels in the knowledge translation process: advising, advocating, lobbying, and activism(Start and Hovland 2004).24 Advising refers to the use of evidence to influence policy in a cooperative manner. Advocating is similarly informed by evidence but uses it in a confrontational manner. Apart from evidence, a group interests and value system is integral in policy decisions. Lobbying is a means to influence policy through use of interests and values, rather than evidence, in cooperative manner; while activism is a confrontational approach similarly based on group interests and values.

In the case of RTI prevention, all strategies except activism were adopted and employed in both the War Room and the Parliament in Thailand. For example, in a presentation given to the Cabinet in the early days of the War Room operation, local and international evidence was used to show that by increasing the percentage of helmet use from 42% to 95%, the annual number of head injuries in Thailand could be reduced from 112,000 to between 89,600 and 36,960. The Cabinet approved an overall road safety plan in March 2003.

In June of 2003, three months after the acceptance by the Cabinet of the strategic plan, the War Room developed a detailed plan of action. The action plan encompassed the three “E” components of injury prevention - enforcement, education, engineering based on the Haddon Matrix with an evaluation and an emergency care component

included(Road Safety Operations Center 2003).25 A position paper synthesizing state-ofthe art evidence for policy recommendations was the key technical input for the plan(Knowledge Management Unit for Road Safety 2003).26 This plan led to media sponsorship, and to the procurement and distribution of a large number of speed radar guns, and breathalyzers. To aid Parliament in its role of monitoring government policy development, the Transport Commission of the House of Representatives was advised using the same position paper as a key input(Transport Commission 2003).27 In contrast to the pre-2003 era when Cabinet approval of a plan frequently failed to get money from the government budget, the approval of the War Room action plan led to allocation of between two and three million dollars for interventions targeted at the two national weeklong holiday festivals in 2003 and 2004(Road Safety Operations Center 2006).28 In 2005, for the first time in Thai history and starting with an annual budget of 112 million USD, year-round road safety interventions were funded(Budget Bureau 2005).29

Clearly, under the advising approach much ground was covered, but the barriers pointed out by Breen were still present and potent. To enhance rational policy decisions, the more aggressive tactic of policy advocacy was also adopted. The public was kept informed and involved in policy debates on specific issues about road safety through the media. Policy-linked messages were regularly delivered through multiple channels such as newspaper articles (more than four pieces per month) and talk shows on television.

One of the key messages in advocacy was a total ban of alcoholic beverage advertising on electronic media. Evidence from analyzing advertising spending by

alcohol industry and its potential impacts on road safety was used to initiate a policy debate. Industry spending on advertising had more than tripled from 1994 to 2000; in 2000 alone, the alcoholic beverage industry spent US$ 66 million on advertising. This was more than twice the US$ 30 million annual budget of the Thai Health Promotion Fund - a major source of funds for health promotion in the country. The two beer brands with the highest spending on advertising in 2000 held the biggest market share among injured drivers seeking care at emergency rooms and reporting alcohol use prior to their crash events(Suriyawongpaisal et al. 2002).13 After a few months of intensive policy debates in public with strong support from print-media columnists, civil society, health professionals and a big alcohol beverage producer, the Government finally issued a Cabinet resolution banning alcohol-drink advertising on electronic media during the hours of 5:00 am to 10:00 pm, effective October, 2004(Working Group on Evaluation Research of Drink Driving Campaign 2006).31

Lobbying also became part of the knowledge translation process in the organization of social events to engage senior policy makers. This used a tactic referred to in Thailand as “putting people on the back of a tiger.” For example, an event was organized to get provincial governors to sign a memorandum of understanding with the Chair of the War Room. The memorandum aimed to make governors commit to taking substantive actions for road safety with support from the War Room. In collaboration with the motorcycle industry, the chair and a co-chair of the War Room were involved in an opening ceremony to endorse a safe motorcycle rider training program. In the context

of many competing factors in policy decision making, lobbying such as this was effective in keeping decision makers’ attention on road safety (Start and Hovland 2004).

The advising, advocating, and lobbying described above had the result of bringing about policies that intensified law enforcement, campaigns targeting and promoting helmet use, seat belt use, day-time use of motorcycles headlights, the prevention of drunk driving, and speeding control during the New Year and Song Kran festival weeks (Figure 1)( Chongsuvivatwong 2003, Siviroj et al. 2003, Siviroj et al. January 2004, Siviroj et al. April 2004, Department of Disaster Prevention and Mitigation 2005).10,32-36 Evaluation during the festival showed impressive improvements of certain target behaviours like helmet use, seat belt use, and day-time use of motorcycle headlights; on the other hand, drunk driving and speeding did not show any improvement. It should be noted here that these figures only depict changes that occurred during the New Year and Song Kran Festivals, and evaluation beyond these short periods was not conducted. Using police data, Tanaboriboon reported declining trends of road traffic injuries and deaths during the New Year and Song Kran Festivals from 2000 to 2005 (Figure 2)(Tanaboriboon 2005).37 It is difficult to attribute the decline of RTIs after 2003 to the policies discussed above, however, they represent positive developments in the field of road safety. Longer-term data is needed to gain an accurate assessment of festival-related interventions.

Judging Thai road safety policy progress by the 2004 World Health Assembly “Road Safety and Health” resolution, it can be seen that Thailand has made improvements in road safety, particularly in the areas of planning, resource mobilization,

and public awareness of risk factors. However, it is also evident that there are several areas needing improvement. For example, Tanaboriboon’s report demonstrated a mismatch in the distribution of the number of road traffic fatalities and frequency of police surveillance activities during Festivals(Tanaboriboon 2005).37 This finding indicated a need for institutional capacity development in terms of action plan deployment. The report also documented the key weakness of under-reporting in the information system, highlighting the need for better data gathering.

Discussion In any movement for social change, a myriad of known and unknown factors interact dynamically, so it is challenging to establish clear causal relationships. However, it is important to describe potential success factors, and five such factors can be highlighted in the case of road safety in Thailand. First, individual champions who knew enough to connect and mobilize all relevant resources and knowledge for change were ready and waiting for a window of opportunity, such that they could move quickly and effectively. Second the network of stakeholders with the potential to influence change were ready; often the complexity of the issue reflects the complexity of the network. Third the funding support for research and knowledge translation activities was forthcoming. Fourth a core group of change agents relentlessly committed to take a move in influencing change. And, finally, relevant and appropriate knowledge was available to guide the movement for change including collation of local evidence and reviews of international evidence.

This case study provides an example of the key issues in designing road safety policy with emphasis on contextual determinants and local interventions. Translating knowledge into relevant and effective policies and actions for road safety requires additional knowledge about the political, social, and economic context of the specific country in which policy is to be developed. Contextual knowledge is important in designing strategies to advise, advocate, and lobby stakeholders to better address determinants of road safety. Given the complexity of policymaking processes, constant effort is needed to stimulate evidence-based policy decisions and implementation oriented towards public interest. Experience from Thailand shows that champions and core groups can provide such constant forces and they deal with knowledge brokering i.e., linking knowledge-generating mechanisms with users of the knowledge. Indeed, governments, international agencies, and civil society should sponsor such forces. Lessons learned in Thailand point to the necessity for more emphasis on addressing the process of developing a road-safety system using local evidence integrated with international expertise and knowledge translation within the specific country’s context.

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6

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11

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Table 1 A comparison of the context and road-safety policy between pre-2003 (1992-2002) and 2003 time periods in Thailand Pre 2003 era (1992-2002) - Short-term coalition governments

2003 to present era - Full-term single party governments

- Less weakened check-balanced mechanisms

- Weakened check-balanced mechanisms

- Centralized bureaucratic system

- Centralized bureaucratic system

Economic

Bubble economy followed by an economic crisis

Recovery from economic crisis

Social

Emerging of

Consolidation of the pre-2003 entities

Context Political

-

autonomous public research funding agencies

-

road safety focused champions

-

road safety focused NGOs

-

Network of individuals and organizations with more focus on road safety

Road safety policy arena

- Less opened to public participation with a

- More opened to public participation with a

predominance of bureaucracy and politicians

predominance of bureaucracy and

- fragmented, weak leadership

politicians

- International agencies involvements were technical

- more unified, stronger leadership

consultancy and research funding at country or regional

- International agencies involvements were

level

less in technical consultancy and research funding but more in guidance of policy framework at global level

Road safety policy process

- Interrupted

- Less interrupted

- Top-down

- Top-down

Figure 1. Trends of target behaviors during the New Year and Song Kran festivals of 2003 through 2005 Figure 2. Injuries and deaths in Thailand during New Year's and Song Kran festivals, 2000 to 2005

Figure 1. Trends of target behaviors during the New Year and Song Kran festivals of 2003 through 2005 90

9

80 Percentage of helmet and seat belt use

8

70

7

60

6 Percentage of drunk driving

50

5

40

4

30

3

20

2

10

1

0

0 New Year 03

Song Kran 03 Seat belt use

New Year 04

Song Kran 04 Helmet use

New Year 05

Song Kran 05

Drunk driving

Figure 2. Injuries and deaths in Thailand during New Year's and Song Kran festivals, 2000 to 2005 45,000

800

40,000

700

35,000

600

30,000 Injuries 25,000

500 Deaths 400

20,000

300

15,000 10,000

200

5,000

100

0

0 2000

2001

2002

2003

2004

2005

New Years Injuries

Song Kran Injuries

New Years Deaths

Song Kran Deaths