Global, regional, and national disability-adjusted life years (DALYs) for 306 diseases and injuries and healthy life expectancy (HALE) for 188 countries, 1990–2013: Quantifying the epidemiological transition

Background The Global Burden of Disease Study 2013 (GBD 2013) aims to bring together all available epidemiological data using a coherent measurement framework, standardised estimation methods, and transparent data sources to enable comparisons of health loss over time and across causes, age–sex groups, and countries. The GBD can be used to generate summary measures such as disability-adjusted life-years (DALYs) and healthy life expectancy (HALE) that make possible comparative assessments of broad epidemiological patterns across countries and time. These summary measures can also be used to quantify the component of variation in epidemiology that is related to sociodemographic development. Methods We used the published GBD 2013 data for age-specific mortality, years of life lost due to premature mortality (YLLs), and years lived with disability (YLDs) to calculate DALYs and HALE for 1990, 1995, 2000, 2005, 2010, and 2013 for 188 countries. We calculated HALE using the Sullivan method; 95% uncertainty intervals (UIs) represent uncertainty in age-specific death rates and YLDs per person for each country, age, sex, and year. We estimated DALYs for 306 causes for each country as the sum of YLLs and YLDs; 95% UIs represent uncertainty in YLL and YLD rates. We quantified patterns of the epidemiological transition with a composite indicator of sociodemographic status, which we constructed from income per person, average years of schooling after age 15 years, and the total fertility rate and mean age of the population. We applied hierarchical regression to DALY rates by cause across countries to decompose variance related to the sociodemographic status variable, country, and time. Findings Worldwide, from 1990 to 2013, life expectancy at birth rose by 6·2 years (95% UI 5·6–6·6), from 65·3 years (65·0–65·6) in 1990 to 71·5 years (71·0–71·9) in 2013, HALE at birth rose by 5·4 years (4·9–5·8), from 56·9 years (54·5–59·1) to 62·3 years (59·7–64·8), total DALYs fell by 3·6% (0·3–7·4), and age-standardised DALY rates per 100 000 people fell by 26·7% (24·6–29·1). For communicable, maternal, neonatal, and nutritional disorders, global DALY numbers, crude rates, and age-standardised rates have all declined between 1990 and 2013, whereas for non–communicable diseases, global DALYs have been increasing, DALY rates have remained nearly constant, and age-standardised DALY rates declined during the same period. From 2005 to 2013, the number of DALYs increased for most specific non-communicable diseases, including cardiovascular diseases and neoplasms, in addition to dengue, food-borne trematodes, and leishmaniasis; DALYs decreased for nearly all other causes. By 2013, the five leading causes of DALYs were ischaemic heart disease, lower respiratory infections, cerebrovascular disease, low back and neck pain, and road injuries. Sociodemographic status explained more than 50% of the variance between countries and over time for diarrhoea, lower respiratory infections, and other common infectious diseases; maternal disorders; neonatal disorders; nutritional deficiencies; other communicable, maternal, neonatal, and nutritional diseases; musculoskeletal disorders; and other non-communicable diseases. However, sociodemographic status explained less than 10% of the variance in DALY rates for cardiovascular diseases; chronic respiratory diseases; cirrhosis; diabetes, urogenital, blood, and endocrine diseases; unintentional injuries; and self-harm and interpersonal violence. Predictably, increased sociodemographic status was associated with a shift in burden from YLLs to YLDs, driven by declines in YLLs and increases in YLDs from musculoskeletal disorders, neurological disorders, and mental and substance use disorders. In most country-specific estimates, the increase in life expectancy was greater than that in HALE. Leading causes of DALYs are highly variable across countries. Interpretation Global health is improving. Population growth and ageing have driven up numbers of DALYs, but crude rates have remained relatively constant, showing that progress in health does not mean fewer demands on health systems. The notion of an epidemiological transition—in which increasing sociodemographic status brings structured change in disease burden—is useful, but there is tremendous variation in burden of disease that is not associated with sociodemographic status. This further underscores the need for country-specific assessments of DALYs and HALE to appropriately inform health policy decisions and attendant actions.

Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013

Background The Global Burden of Disease, Injuries, and Risk Factor study 2013 (GBD 2013) is the first of a series of annual updates of the GBD. Risk factor quantification, particularly of modifiable risk factors, can help to identify emerging threats to population health and opportunities for prevention. The GBD 2013 provides a timely opportunity to update the comparative risk assessment with new data for exposure, relative risks, and evidence on the appropriate counterfactual risk distribution. Methods Attributable deaths, years of life lost, years lived with disability, and disability-adjusted life-years (DALYs) have been estimated for 79 risks or clusters of risks using the GBD 2010 methods. Risk–outcome pairs meeting explicit evidence criteria were assessed for 188 countries for the period 1990–2013 by age and sex using three inputs: risk exposure, relative risks, and the theoretical minimum risk exposure level (TMREL). Risks are organised into a hierarchy with blocks of behavioural, environmental and occupational, and metabolic risks at the first level of the hierarchy. The next level in the hierarchy includes nine clusters of related risks and two individual risks, with more detail provided at levels 3 and 4 of the hierarchy. Compared with GBD 2010, six new risk factors have been added: handwashing practices, occupational exposure to trichloroethylene, childhood wasting, childhood stunting, unsafe sex, and low glomerular filtration rate. For most risks, data for exposure were synthesised with a Bayesian meta-regression method, DisMod-MR 2.0, or spatial-temporal Gaussian process regression. Relative risks were based on meta-regressions of published cohort and intervention studies. Attributable burden for clusters of risks and all risks combined took into account evidence on the mediation of some risks such as high body-mass index (BMI) through other risks such as high systolic blood pressure and high cholesterol. Findings All risks combined account for 57·2% (95% uncertainty interval [UI] 55·8–58·5) of deaths and 41·6% (40·1–43·0) of DALYs. Risks quantified account for 87·9% (86·5–89·3) of cardiovascular disease DALYs, ranging to a low of 0% for neonatal disorders and neglected tropical diseases and malaria. In terms of global DALYs in 2013, six risks or clusters of risks each caused more than 5% of DALYs: dietary risks accounting for 11·3 million deaths and 241·4 million DALYs, high systolic blood pressure for 10·4 million deaths and 208·1 million DALYs, child and maternal malnutrition for 1·7 million deaths and 176·9 million DALYs, tobacco smoke for 6·1 million deaths and 143·5 million DALYs, air pollution for 5·5 million deaths and 141·5 million DALYs, and high BMI for 4·4 million deaths and 134·0 million DALYs. Risk factor patterns vary across regions and countries and with time. In sub-Saharan Africa, the leading risk factors are child and maternal malnutrition, unsafe sex, and unsafe water, sanitation, and handwashing. In women, in nearly all countries in the Americas, north Africa, and the Middle East, and in many other high-income countries, high BMI is the leading risk factor, with high systolic blood pressure as the leading risk in most of Central and Eastern Europe and south and east Asia. For men, high systolic blood pressure or tobacco use are the leading risks in nearly all high-income countries, in north Africa and the Middle East, Europe, and Asia. For men and women, unsafe sex is the leading risk in a corridor from Kenya to South Africa. Interpretation Behavioural, environmental and occupational, and metabolic risks can explain half of global mortality and more than one-third of global DALYs providing many opportunities for prevention. Of the larger risks, the attributable burden of high BMI has increased in the past 23 years. In view of the prominence of behavioural risk factors, behavioural and social science research on interventions for these risks should be strengthened. Many prevention and primary care policy options are available now to act on key risks.

Materials and technologies for energy conversion, saving and storage: A global network enabling capacity-building for sustainable energy in developing countries

Access to energy is a fundamental component of poverty abatement. People who live in homes without electricity are often dependent on dirty, time-consuming and disproportionately expensive solid fuel sources for heating and cooking. [1] In developing countries, the Human Development Index (HDI), which comprises measures of standard of living, longevity and educational attainment, increases rapidly with per capita electricity use. [2] For these reasons the United Nations has been making a concerted effort to promote global access to energy, first by naming 2012 the Year of Sustainable Energy for All, [3] and now by declaring 2014-2024 the Decade of Sustainable Energy for All. [4]

Traffic behaviour and compliance with the law in low and middle income countries: are we observing "pragmatic driving"?

A common theme in many accounts of road safety and road use in low and middle income countries is a widespread lack of compliance with traffic laws and related legislation. A key element of the success of road crash prevention strategies in high income countries has been the achievement of safer road user behaviour through compliance with traffic laws. Deterrence-based approaches such as speed cameras and random breath testing, which rely on drivers making an assessment that they are likely to be caught if they offend, have been very effective in this regard. However, the long term success of (for example) drink driving legislation has been supported by drivers adopting a moral approach to compliance rather than relying solely on the intensity of police operations. For low and middle income countries such morally based compliance is important, since levels of police resourcing are typically much lower than in Western countries. In the absence of morally based compliance, it is arguable that the patterns of behaviours observed in low and middle income countries can be described as "pragmatic driving": compliance only when there is a high chance of being detected and fined, or where a crash might occur. The potential characteristics of pragmatic driving in the macro-, meso- and micro-context of driving and the enforcement approach that could address it are outlined, with reference to the limited existing information available.

Alkaloid production by isolates of the sorghum ergot pathogen (Claviceps africana) from Australia and other countries

Isolates of Claviceps africana from Australia, Africa, Asia, and America were tested for the production of dihydroergosine (DHES), and its biogenic precursors dihydroelymoclavine (DHEL) and festuclavine (FEST), in culture. Several growth media were evaluated to optimise alkaloid production with little success. The best of these involved 2-stage culturing on high-sucrose substrate. Australian C. africana isolates varied widely and inconsistently in alkaloid production, with DHES concentrations in mycelium ranging from: <0.1 to 9 mg DHES/kg; <0.1 to 1.6 mg DHEL/kg; and <0.1 to 0.4 mg FEST/kg. In a separate experiment using similar culturing techniques, DHES was produced by 2 of 3 Australian isolates, 1 of 3 USA isolates, 1 of 4 Indian isolates, the sole Puerto Rican isolate, the sole Japanese isolate, but not the sole South African isolate. In this experiment, DHES concentrations detected in mycelium of Australian isolates (0.1-1.0 mg DHES/kg) were of similar magnitude to isolates from other countries (0.2-1.8 mg DHES/kg). Three C. africana isolates, including one that produced only traces of alkaloid in culture after 8 weeks, were inoculated onto panicles of sterile male sorghum plants. After 8 weeks, all 3 isolates produced 10-19 mg DHES/kg in the panicles, demonstrating that the growing plant favoured more consistent alkaloid production than culture medium.

More cercosporoid hyphomycetes from some South Pacific island countries

Two new cercosporoid hyphomycetes from Vanuatu, Cercospora sphathulata and Pseudocercospora pometiae, are described and illustrated. Six new records of cercosporoid hyphomycetes that cause plant diseases from New Caledonia, Samoa and Vanuatu are given. Four new hosts of Cercospora apii s. lat. from the region are reported.

The regional differences between countries in traffic safety: A cross-cultural study and Turkish Case

Road traffic accidents are a large problem everywhere in the world. However, regional differences in traffic safety between countries are considerable. For example, traffic safety records are much worse in Southern Europe and the Middle East than in Northern and Western Europe. Despite the large regional differences in traffic safety, factors contributing to different accident risk figures in different countries and regions have remained largely unstudied. The general aim of this study was to investigate regional differences in traffic safety between Southern European/Middle Eastern (i.e., Greece, Iran, Turkey) and Northern/Western European (i.e., Finland, Great Britain, The Netherlands) countries and to identify factors related to these differences. We conducted seven sub-studies in which I applied a traffic culture framework, including a multi-level approach, to traffic safety. We used aggregated level data (national statistics), surveys among drivers, and data on traffic accidents and fatalities in the analyses. In the first study, we investigated the influence of macro level factors (i.e., economic, societal, and cultural) on traffic safety across countries. The results showed that a high GNP per capita and conservatism correlated with a low number of traffic fatalities, whereas a high degree of uncertainty avoidance, neuroticism, and egalitarianism correlated with a high number of traffic fatalities. In the second, third, and fourth studies, we examined whether the conceptualisation of road user characteristics (i.e., driver behaviour and performance) varied across traffic cultures and how these factors determined overall safety, and the differences between countries in traffic safety. The results showed that the factorial agreement for driver behaviour (i.e., aggressive driving) and performance (i.e., safety skills) was unsatisfactory in Greece, Iran, and Turkey, where the lack of social tolerance and interpersonal aggressive violations seem to be important characteristics of driving. In addition, we found that driver behaviour (i.e., aggressive violations and errors) mediated the relationship between culture/country and accidents. Besides, drivers from "dangerous" Southern European countries and Iran scored higher on aggressive violations and errors than did drivers from "safe" Northern European countries. However, "speeding" appeared to be a "pan-cultural" problem in traffic. Similarly, aggressive driving seems largely depend on road users' interactions and drivers' interpretation (i.e., cognitive biases) of the behaviour of others in every country involved in the study. Moreover, in all countries, a risky general driving style was mostly related to being young and male. The results of the fifth and sixth studies showed that among young Turkish drivers, gender stereotypes (i.e., masculinity and femininity) greatly influence driver behaviour and performance. Feminine drivers were safety-oriented whereas masculine drivers were skill-oriented and risky drivers. Since everyday driving tasks involve not only erroneous (i.e., risky or dangerous driving) or correct performance (i.e., normal habitual driving), but also "positive" driver behaviours, we developed a reliable scale for measuring "positive" driver behaviours among Turkish drivers in the seventh study. Consequently, I revised Reason's model [Reason, J. T., 1990. Human error. Cambridge University Press: New York] of aberrant driver behaviour to represent a general driving style, including all possible intentional behaviours in traffic while evaluating the differences between countries in traffic safety. The results emphasise the importance of economic, societal and cultural factors, general driving style and skills, which are related to exposure, cognitive biases as well as age, sex, and gender, in differences between countries in traffic safety.

Labor Regulations and Unionization Trends: Comparative Analysis of Latin American Countries

This paper discusses the influences of labor regulations on unionization rates through the comparative analysis of Argentina, Chile and Mexico, expecting to contribute to the understanding of the determinants of unionization in Latin America. These regulations, though only one of the factors determining unionization levels, have a crucial role, their influence being at least threefold: they define entitlements to and exclusions from the right to unionize, affect union recruitment strategies and, by generating incentives and disincentives, contribute to shape individual membership decisions. After discussing historical aspects of unionization in the three countries, the analysis centers successively in two periods in which the countries compared showed both similarities and contrasts relevant to the analysis of unionization trends. In the first, the comparison is between Argentina (1976-83) and Chile (1973-89), both under military regimes that had much in common, but with contrasting unionization trends. In the second, the focus is in Argentina (1991-2001) and Mexico (1984-2000), where the reforms implemented to liberalize the economy and ensuing social-economic and labor market transformations were similar, but unionization trends differed. It is argued that, in each case, the divergent behavior of unionization, in spite of the similar economic and sociopolitical contexts, may at least partly be attributed to differences in key labor institutions.

Transitions to K–12 Education Systems: Experiences from Five Case Countries

Currently more than 140 countries offer, or are in transition to, what has become the international norm for pre-tertiary education, namely a kindergarten through grade 12 (K–12) school education system—kindergarten because of the preponderance of research asserting the long-term learning and social benefits of school readiness programs; and 12 years of primary and secondary schooling due to the time needed to acquire the knowledge and skills sets necessary for 21st century university education, postsecondary training, or decent1 work. This desk study2 conveys the experiences of four countries and one province in preparing and implementing a transition to a K–12 school education system: Mongolia, Ontario (Canada), the Philippines, Poland, and Turkey. Looking at K–12 transition in countries and systems that vary as broadly as this set enables common threads to stand out and divergent options to be noted.

Technical efficiency of blood component preparation in blood centres of 10 European countries

Various reasons, such as ethical issues in maintaining blood resources, growing costs, and strict requirements for safe blood, have increased the pressure for efficient use of resources in blood banking. The competence of blood establishments can be characterized by their ability to predict the volume of blood collection to be able to provide cellular blood components in a timely manner as dictated by hospital demand. The stochastically varying clinical need for platelets (PLTs) sets a specific challenge for balancing supply with requests. Labour has been proven a primary cost-driver and should be managed efficiently. International comparisons of blood banking could recognize inefficiencies and allow reallocation of resources. Seventeen blood centres from 10 countries in continental Europe, Great Britain, and Scandinavia participated in this study. The centres were national institutes (5), parts of the local Red Cross organisation (5), or integrated into university hospitals (7). This study focused on the departments of blood component preparation of the centres. The data were obtained retrospectively by computerized questionnaires completed via Internet for the years 2000-2002. The data were used in four original articles (numbered I through IV) that form the basis of this thesis. Non-parametric data envelopment analysis (DEA, II-IV) was applied to evaluate and compare the relative efficiency of blood component preparation. Several models were created using different input and output combinations. The focus of comparisons was on the technical efficiency (II-III) and the labour efficiency (I, IV). An empirical cost model was tested to evaluate the cost efficiency (IV). Purchasing power parities (PPP, IV) were used to adjust the costs of the working hours and to make the costs comparable among countries. The total annual number of whole blood (WB) collections varied from 8,880 to 290,352 in the centres (I). Significant variation was also observed in the annual volume of produced red blood cells (RBCs) and PLTs. The annual number of PLTs produced by any method varied from 2,788 to 104,622 units. In 2002, 73% of all PLTs were produced by the buffy coat (BC) method, 23% by aphaeresis and 4% by the platelet-rich plasma (PRP) method. The annual discard rate of PLTs varied from 3.9% to 31%. The mean discard rate (13%) remained in the same range throughout the study period and demonstrated similar levels and variation in 2003-2004 according to a specific follow-up question (14%, range 3.8%-24%). The annual PLT discard rates were, to some extent, associated with production volumes. The mean RBC discard rate was 4.5% (range 0.2%-7.7%). Technical efficiency showed marked variation (median 60%, range 41%-100%) among the centres (II). Compared to the efficient departments, the inefficient departments used excess labour resources (and probably) production equipment to produce RBCs and PLTs. Technical efficiency tended to be higher when the (theoretical) proportion of lost WB collections (total RBC+PLT loss) from all collections was low (III). The labour efficiency varied remarkably, from 25% to 100% (median 47%) when working hours were the only input (IV). Using the estimated total costs as the input (cost efficiency) revealed an even greater variation (13%-100%) and overall lower efficiency level compared to labour only as the input. In cost efficiency only, the savings potential (observed inefficiency) was more than 50% in 10 departments, whereas labour and cost savings potentials were both more than 50% in six departments. The association between department size and efficiency (scale efficiency) could not be verified statistically in the small sample. In conclusion, international evaluation of the technical efficiency in component preparation departments revealed remarkable variation. A suboptimal combination of manpower and production output levels was the major cause of inefficiency, and the efficiency did not directly relate to production volume. Evaluation of the reasons for discarding components may offer a novel approach to study efficiency. DEA was proven applicable in analyses including various factors as inputs and outputs. This study suggests that analytical models can be developed to serve as indicators of technical efficiency and promote improvements in the management of limited resources. The work also demonstrates the importance of integrating efficiency analysis into international comparisons of blood banking.

Devolution of forest-related rights: Comparative analyses of six developing countries

The study focused on the different ways that forest-related rights can be devolved to the local level according to the current legal frameworks in Laos, Nepal, Vietnam, Kenya, Mozambique and Tanzania. The eleven case studies represented the main ways in which forest-related rights can be devolved to communities or households in these countries. The objectives of this study were to 1) analyse the contents and extent of forest-related rights that can be devolved to the local level, 2) develop an empirical typology that represents the main types of devolution, and 3) compare the cases against a theoretical ideal type to assess in what way and to what extent the cases are similar to or differ from the theoretical construct. Fuzzy set theory, Qualitative Comparative Analysis and ideal type analysis were used in analysing the case studies and in developing an empirical typology. The theoretical framework, which guided data collection and analyses, was based on institutional economics and theories on property rights, common pool resources and collective action. On the basis of the theoretical and empirical knowledge, the most important attributes of rights were defined as use rights, management rights, exclusion rights, transfer rights and the duration and security of the rights. The ideal type was defined as one where local actors have been devolved comprehensive use rights, extensive management rights, rights to exclude others from the resource and rights to transfer these rights. In addition, the rights are to be secure and held perpetually. The ideal type was used to structure the analysis and as a tool against which the cases were analysed. The contents, extent and duration of the devolved rights varied greatly. In general, the results show that devolution has mainly meant the transfer of use rights to the local level, and has not really changed the overall state control over forest resources. In most cases the right holders participate, or have a limited role in the decision making regarding the harvesting and management of the resource. There was a clear tendency to devolve the rights to enforce rules and to monitor resource use and condition more extensively than the powers to decide on the management and development of the resource. The empirical typology of the cases differentiated between five different types of devolution. The types can be characterised by the devolution of 1) restricted use and control rights, 2) extensive use rights but restricted control rights, 3) extensive rights, 4) insecure, short term use and restricted control rights, and 5) insecure extensive rights. Overall, the case studies conformity to the ideal type was very low: only two cases were similar to the ideal type, all other cases differed considerably from the ideal type. The restricted management rights were the most common reason for the low conformity to the ideal type (eight cases). In three cases, the short term of the rights, restricted transfer rights, restricted use rights or restricted exclusion rights were the reason or one of the reasons for the low conformity to the ideal type. In two cases the rights were not secure.

Genetic and environmental influences on migraine: a twin study across six countries

Migraine is a common neurovascular brain disorder that is manifested in recurrent episodes of disabling headache. The aim of the present study was to compare the prevalence and heritability of migraine across six of the countries that participate in GenomEUtwin project including a total number of 29,717 twin pairs. Migraine was assessed by questionnaires that differed between most countries. It was most prevalent in Danish and Dutch females (32% and 34%, respectively), whereas the lowest prevalence was found in the younger and older Finnish cohorts (13% and 10%, respectively). The estimated genetic variance (heritability) was significant and the same between sexes in all countries. Heritability ranged from 34% to 57%, with lowest estimates in Australia, and highest estimates in the older cohort of Finland, the Netherlands, and Denmark. There was some indication that part of the genetic variance was non-additive, but this was significant in Sweden only. In addition to genetic factors, environmental effects that are non-shared between members of a twin pair contributed to the liability of migraine. After migraine definitions are homogenized among the participating countries, the GenomEUtwin project will provide a powerful resource to identify the genes involved in migraine.

Comparative study on green building supportive policies of pacific-rim countries most vulnerable to climate change

- Problem Climate change is affecting the world in numerous ways such as increased temperatures, sea level rise, and increased droughts and floods. Governments worldwide, especially in the most vulnerable countries, are urged to seek better solutions for sustainable development. The construction industry and buildings have enormous impacts on humans and the environment, meaning green building must be one of the solutions. Government involvement is widely considered as one of the essential and most effective ways to promote green building and drive the construction market towards sustainability. This paper will review green building policy of the Pacific-Rim countries that are most vulnerable to climate change according to the recent Standard and Poor’s ranking, including: Cambodia, Vietnam, Fiji, Philippines, Papua New Guinea and Indonesia. Methodology: This paper will review policy related publications including journal and conference papers, portal websites of governments, legislation documents and reports of international organisations. It will focus on the policies and governmental instruments that support the adoption of green building practices. - Findings All six governments have launched climate change adaptation policies, showing a great concern regarding the damages caused by the phenomenon. All countries except Papua New Guinea have promulgated energy efficiency policy and programs which indirectly promote the adoption of green building practices. The comparison study shows that Philippines and Indonesia motivate the adoption of renewable energy generation, energy efficiency and green building through either financial or advocacy instruments, while other four countries tend to implement regulatory tools to mandate energy conservation. Through comparison, Cambodia and Vietnam – the two countries providing vision to develop green building - can learn from Philippines and Indonesia’s policy and instruments. - Research limitations Language differences between the countries and limit of formal sources may pose difficulties in searching for information. While much English language literature exists, sources from Cambodia, Philippines and Indonesia are less accessible. - Takeaway for practice As the paper provides more understanding about the supportive policy of those countries, it will introduce more opportunities for green property developers to invest in construction markets of those Pacific-Rim countries. - Originality There is little research reviewing green building supportive policies of developing and less-wealthy countries that are forecasted to be most vulnerable and most impacted by climate change. The originality of this paper lies in its investigation on how those countries intend to respond to this phenomenon and whether and to what extent they support the green building market by using policy tools.

Building local capacity to reduce road traffic injury in rapidly motorising countries

Road safety is a significant public health issue - 1.24m killed each year, 20-50m injured, 91% in rapidly motorising low/mid income countries Decade of Action for Road Safety 2011-2020: - National and local actions: “strengthening the management infrastructure and capacity for technical implementation of road safety activities at the national, regional and global levels” - Capacity as a constraint on a country’s action - Emphasis on knowledge/training – understand principles, promote training and education etc

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