Two innovative Brazilian programs relating to road safety prevention. A case study

ABSTRACT BACKGROUND: The World Health Organization (WHO) 2017 Global Conference in Montevideo, Uruguay, was dedicated to promoting successful cases and best practices in fighting and preventing noncommunicable disease (NCDs). The global effort undertaken by WHO aims to reduce road traffic deaths in order to meet goal number 3.4 of the sustainable development goals. OBJECTIVES: To describe two Brazilian road safety prevention programs, presented at the WHO 2017 Global Conference: São Paulo Traffic Safety Movement (Movimento Paulista de Segurança no Trânsito) and Safe Life Program of Brasília (Programa Brasília Vida Segura), along with their governance structures, models and results. DESIGN AND SETTING: This was a descriptive case study conducted in São Paulo and Brasilia from 2015 to 2018. These programs aimed to reduce the number of deaths caused by road accidents to 8.3 deaths per 100,000 inhabitants in São Paulo by 2020 and in Brasília by 2016; and to reduce harmful use of alcohol by 10% by 2020. METHODS: These two initiatives were designed, managed and operated to bring together government and civil society, i.e. industry, academia, non-governmental organizations (NGOs), etc., around the common goal of saving lives. They were collaborative and guided by sharing of best practices, learning and information, thereby making it possible to attain more and better results. Their format enables reproduction in cities across all Brazilian regions. RESULTS: The results attest to the efficacy of the programs implemented in these two cities. In Brasília, the initiative helped reduce the number of traffic-related deaths by 35% (2017). In the same year in the state of São Paulo, 7,600 deaths were avoided. CONCLUSION: Both programs are innovative public policies that deal with health issues caused by the external agents that ultimately account for the rapid increase in days lost to disability. Prevention of external causes of deaths and injuries, such as traffic violence, strongly correlates with changes in habits and actions, especially excessive consumption of alcohol, and with NCDs in Brazil.


INTRODUCTION
Noncommunicable diseases (NCDs) are currently one of the greatest challenges faced within public health. Their impact is so severe that the World Health Organization (WHO) has come to classify them as an epidemic. According to the organization, around 36 million people die prematurely due to cardiovascular and respiratory diseases, cancer and diabetes worldwide every year. 1 Around 85% of the deaths caused by NCDs occur either in poor or in developing countries, which contributes towards further aggravation of the situation 1 . The main risk factors are excessive alcohol consumption, smoking, unbalanced diets and lack of exercise. 1 Just as drinking too much alcohol is a risk factor for NCDs, the association of drinking and driving is one of the main causes of traffic accidents. 1 According to a study conducted by the World Health Organization, approximately 1.25 million people die in road accidents around the world every year, and another 50 million get injured. 1 Aside from natural causes of death, traffic accidents are one of the leading causes of death among young people between 15 and 29 years of age, at the global level. 1 If this upward trend is not reversed, deaths due to traffic accidents may become the seventh biggest reason for loss of life worldwide by 2030. 2 This would represent a mortality rate 30% higher than the 10% rate recorded in 2015. 2   These two initiatives were designed, managed and operated to bring together government and civil society, i.e. industry, academia, non-governmental organizations (NGOs), etc., around the common goal of saving lives. They were collaborative and guided by sharing of best practices, learning and information, thereby making it possible to attain more and better results. Their format enables reproduction in cities across all Brazilian regions.

Internal review board
The data collection conducted in Brazil (the Federal District) is part of a research initiative carried out in partnership with the Pacific Institute for Research and Evaluation (PIRE). The study protocol was duly evaluated and approved by an Internal Review Board from the North American institution (IRBNET ID: 1116187-18; approval date: August 28, 2018).

RESULTS
The application of the model yielded surprising results that went beyond reduction of deaths and injuries in traffic accidents. Educational actions that were developed in schools and public spaces made the programs more sustainable. These interventions being developed separately or that were scattered among various state departments, to start to be analyzed as a group, in a way that was result-driven. This meant efforts were synchronized so that everyone could work towards the same goal: to reach the objective established by WHO.
The São Paulo Traffic Safety Movement has taken "make way for life" (vida, dê preferencia) as its motto and its aim is to reduce the number of deaths caused by road accidents to 8.3 deaths per 100,000 inhabitants in São Paulo by 2020.
In implementing this movement, 15 cities were initially prioritized. The state capital (city of São Paulo) was one of them. In total, 122 actions were identified, and these were divided into three types: engineering, education and communication plus control. Each of the municipalities thus selected received a customized action plan, so that the program could be implemented quickly and effectively.
The implementation of the program evolved rapidly, and all 645 municipalities in São Paulo are now part of the movement. Table 1 shows details regarding the items corresponding to each of the three types of action.
The first results from the movement have shown that the design and dynamics of the program are on track to achieve the stated goal.
In 2016, 460 lives were saved, in the 15 municipalities that were initially chosen to receive the program. This number represented 6.5% fewer deaths than in 2015. In the following year (2017), an astounding 7,600 casualties were avoided. The aim of the movement now is to get to 2020 with a maximum of 3,880 accidents involving victims. If nothing were to be done, this number would double, reaching 7,760 accidents. Through communication and engagement actions, civil society agents contributed towards dissemination of information and guidance to the population, thereby multiplying the impact of the project. This whole process used a method developed by Falconi, the consulting firm that was in partnership with the project. 4 Defining a working method makes it possible to implement the project in any municipality. The flexibility of the model thus developed allowed it to be adapted to the characteristics of each location, thereby maintaining its principles of seeking consistent results that met the goals that had been established. Figure 2 shows how the governance of the movement was designed and the actors involved in it.
The traffic accident management information system of the state of São Paulo (Infosiga SP) can be considered to be a legacy created by the movement for society. The system is a database that collects information from traffic accidents throughout the state. The information is updated monthly, which constitutes a major advance, and it provides fundamental support for the safety and agility of public policies that are aimed towards preventing and combating accidents, since other databases are only updated once a year.
By cross-referencing the information available in Infosiga SP, it is possible to obtain data on the locations of accidents, their causes and category, the victims' age group and sex, vehicle specifications,   shown results that indicate that the model adopted is appropriate.
The education factor was designed as a school and communitybased preventive program to be implemented in 2019.

Road safety: increasing life in traffic
The   The data obtained will help define specific actions aimed at reducing alcohol use among school students. Interventions will take place in public schools, but before they are disseminated in all the places benefited by the project, they will be tested in pilot areas.
The results from the survey will provide a baseline for monitoring and managing the project. With these data, it will be possible to create a database, evaluate the effectiveness of the measures adopted and identify places or groups of people that need to be prioritized.

Governance
The governance of the Safe Life Program of Brasília was based on a public-private partnership model, which allows for agile management and speedy results. The program is coordinated by a nationally based non-governmental organization (NGO) that focuses on developing leadership, activities and knowledge regarding public policies.
This NGO is at the heart of the organizational chart and its role is to integrate the other actors. Both the format and the governance of the Safe Life Program of Brasília make it possible to state that the project constitutes an innovative public-private partnership for preventing NCDs. Involvement of the road safety agencies, which work to combat traffic accidents in their various areas of activity, and the synergy achieved through formation and implementation of management committees, have been fundamental for the success of the project.

DISCUSSION
It is also important to highlight that one of the greatest defining features of the models presented here is that they both use and cross-reference information. Data that previously were scattered across various departments and sectors of government dealing with traffic, healthcare and surveillance have been analyzed in an integrated manner. The system enables anticipation of trends, for action in critical locations, for support of education and training campaigns, for structuring of emergency room care systems and for rehabilitation services and their care teams. Adoption of public policies based on the knowledge and results obtained from the two programs provides solid support for enabling Brazil to meet the sustainable development goals, i.e. to ensure healthy lives and promote wellbeing at all ages.

CONCLUSIONS
Both programs are innovative public policies that deal with health issues caused by external agents that ultimately account for rapid increases in days lost due to disability. Prevention of external causes of deaths and injuries, such as traffic-related violence, strongly correlates with changes in habits and actions, especially excessive consumption of alcohol, and with NCDs in Brazil.