I'm Blythe Mansfield with the World Bank, and our team here is a part of the Health and Safety Directorate for the World Bank, and we're presenting on a Global Driver's Medical Clearance Program. We are part of the Road Safety Team, and I'm going to introduce Dr. Goldani Lestarias. She's going to be our first speaker, and then I have Dr. Karen Frith, myself, and then Kimberly Bender. We have no conflicts of interest to declare. So Dr. Goldani Lestarias will start us off by discussing the history of the program, key milestones, types of vehicles that we have, and the collaborative implementation of the program, followed by Kim Bender, who will give you an overview of the program and how it works. And then Dr. Frith will highlight some of the unique challenges of the program, as well as the variability that occurs in different countries and how to manage these. And then I will talk about some of the situations that may arise when evaluating drivers. And then Dr. Goldani Lestarias will wrap us up with some final comments and future enhancements. Okay. Now over to Dr. Goldani Lestarias. Thank you. Thank you very much, and good morning, everyone. So I will talk a little bit about global road traffic safety and also about main milestones in development of our road safety program in the World Bank. So World Health Organization is issuing regular reports on global road traffic safety, and it is estimated that about 1.2 million people annually die on roads around the world, which means that every two to three minutes, somebody dies in a road traffic crash. There are about 50 million injuries estimated. Probably the number is high, especially taking into account mental health effects. So it is really a significant risk for global organizations. It is not equally distributed around the world, although there are only about 50 percent of world vehicles in low- and middle-income countries, there are more than 80 percent of deaths in the same areas of the world. The World Bank Group's global footprint is very large. We have about 70 to 80 percent of staff traveling on business in low- and middle-income countries when the risk is the highest, and also about 50 percent of our staff lives and works in these areas. So we have almost 200 country offices, and they are situated in more than 140 countries in the world. So for our staff, road traffic is the most serious and significant occupational health and safety risk. Of course, for the bank, the staff is the top priority, and we did develop a road traffic program and the management system, actually, which started in 2007 with the establishment of a road safety task force. I was there at that time already, representing health and safety directorate, and I'm still there. So it is a group of all stakeholders in the bank who are in charge of improving road safety for the staff. We did the first road safety risk assessment at that time. We had big all-staff survey that was measuring the exposure to this risk of our travelers, and did some other analysis of insurance and medical claims to assess the risk for the organization. We issued a report that was entered into policy, first policy in 2010. The policy was introduced based on this whole result, but triggered by two very serious road crashes that resulted in life loss and lifelong injuries. The policy was implemented across the bank. It was led by road safety committee, and it still is. Road safety committee is a group of all stakeholders, starting for corporate security, health and safety directorate. There are legal insurance representative, representative from country offices and regions, who make sure that all those who play a role in implementation of road safety directive are doing that well. In 2017, we had another road safety survey, just to understand where are we with implementation, and this survey actually uncovered a lot of gray areas in implementations, and people were not aware of their roles, forgot, not aware of policies. So we updated the road safety directive, and then also we introduced driver's medical clearance procedure, because that was a very sensitive part of it, and rather complex, as you will hear later. So we made sure that all processes are documented, streamlined, and clear to all participants. And thank you now, again, to my colleague, Kim, to talk in more detail. Thank you. Thank you. I'm going to go forward. All right. So just as an overview of our program, and just to give you an idea of what our drivers are driving, they're driving mostly sedans, and then we also have drivers who are driving armored SUVs. These drivers are required to go through a medical clearance before they start work. They're also required to have a repeat clearance every two years for those who are under 60, and for those who are over 60, they have a medical clearance every year. Anyone kind of just like DOT, anyone who has a chronic condition, such as hypertension or diabetes, will also be asked to go through the process annually, even if they're under age 60. So all of our standards align with the DOT standards. There are some exceptions, just based on our global footprint and the limitations that are within some of the countries where our drivers are. All of the country offices pay for these medical exams, and in countries where we have contracted drivers, the contracting agency would pay for the exam. So how do we organize and keep this program going with offices and drivers all over the world, and over 100 offices around the world? The heartbeat of our program is really our road safety coordinator. She manages the day-to-day, behind-the-scenes coordination of the country office focal points, and she's the liaison between them and the drivers, and us back at headquarters. Every office has a focal point. This is a person that's usually a senior driver, or it could be an admin assistant, and they're in charge of scheduling the appointments for the drivers, and keeping data logs, submitting data logs with clearance dates of the drivers, and they communicate directly with the road safety coordinator. As far as the drivers, what we need them to do is just attend their appointments. Sometimes this can be complicated, and some of the country, based on what country they're in, they may not be able to just go to one clinic and have their hearing and their vision and their exam done. They may need to make multiple appointments and multiple trips to get everything accomplished that we need them to. We always ask that the drivers notify the focal point if they have any changes in health that we think could be concerning. The in-country doctors, they perform the medical exams using our forms that we have. We do provide a form. We have it translated in a couple of languages, and some of the local offices have translated it into additional languages. They complete the form and then send the forms either with the drivers to be submitted back to us or they directly send it to our road safety coordinator. So once we receive those forms, me being one of the nurses on the team, we review it for completeness and to make sure that what the doctor's exam findings are are in line with the clearance status. So for example, sometimes we get exams back and entire sections aren't completed. So the hearing might not be completed or the vision might not be completed. So we need to send that back out to that staff member for them to go follow up and get that completed. Other times we do have cases where the clearance certificate says that they are clear, and then we review the exam and see that their blood pressure was 180 over 90. So in that case, we would disqualify them. So how do our forms align with DOT? So this isn't very easy for you guys to see, but our current forms align completely with the 2010 DOT. So it's right in line with that. We have the clearance certificate here as well for the doctor to complete. This currently is translated into Spanish and French. And then some of the local offices have translated it into their local language. And then all the way to the right, this is our driver's medical log. So it doesn't contain any medical information, but this is what the focal point would complete. And it's used for them to track their staff locally to know when the expiration dates are. And it's also submitted back to HQ for us to use for other data purposes. So how could a driver be found unfit? So if the examining provider declares that they're unfit at the time of exam, that would be one way that they could be found unfit. They're also, like I mentioned, if I receive their exam form back to headquarters and either myself or one of the doctors reviews the form and find discrepancies or concerns, then at that time we could also declare the driver unfit. If the driver is found unfit and their staff driver, then they would be eligible to apply for short-term disability or, as we call it, extended sick leave. They're also, if the office has other duties that they can give that staff driver, then they would be allowed to come into office and, you know, maybe do some admin work. And then for our contracted drivers, they would not be able to drive again for the bank until they have completed the medical clearance process and they've, you know, attended any follow-up appointments that were needed and come back. All of their paperwork comes back to us and they're cleared. All right. So Karen's going to come up, Dr. Frith, and talk about our challenges. DR. KAREN FRITH. One of which is not falling off the stage. Hi. Good morning, everybody. So I'm going to chat. We've heard a little bit from Yasminka and from Kim about some of the workings of our program and some of the lessons we've learned over the last 10 years. And I'm going to chat a little bit about some of the challenges and how we solve for these challenges. And I'm going to start, actually, by focusing on the logistics a little bit. So as you heard from Kim, language and culture can be a challenge. And we've solved for that by translating the forms into a few different languages. What's also a challenge sometimes is the language of the driver. So although World Bank, our official language is English, you know, if you think about drivers in multiple locations, there are local staff, they're born there. They may not have the language of, or the necessary language from an understanding of needing to follow up what their medical tests are, et cetera. So we have the challenge of the language for the provider, but also the challenge of the language for the staff member. And one of the ways we solve for that is the road safety focal point in the country office will often help us to talk to the staff member. Now that brings about the medical confidentiality concerns, right? Because then you've got someone who's effectively liaising on behalf of the driver with us. And we're giving, asking the driver to follow up on their blood pressure, or their high sugar, or their diabetes. And so that can be a challenge as well. The arranging medical appointments, we do, when the program was incepted, brought together, we found providers in all the locations where we have drivers to do the medical exams. That's now 12 years ago, right? And so this is part of our challenge, is at what stage do we do an overall, have a look at who are doing the exams, what's the quality of exam coming out? So that's also something we're thinking about on our next iteration. The other thing, as Kim said, the drivers, the cost of the medical exam is actually borne by the office. But if the driver needs follow up, so if they're found unfit and they need further investigation, or further exams, then that is borne by themselves, or borne by their medical insurance. And so that's also got implications for drivers, right? Because that's also an additional burden that we're adding. And then finally, thinking about the sort of centralizing of data, and making sure the fitness certificates are kept current. We have offices where the compliance is fantastic, and we never have a driver who's not fit. And we have offices who, three or four years later, are like, hmm, this is supposed to happen every two years. So there's quite a lot of variability. It is on the office themselves to make sure their drivers are fit. But that can also be a challenge for us. And I think another challenge that I didn't add here, but from a logistical point of view, there's often a big time delay from the time the drivers have their medicals to the time we see the results. So you can imagine if we, as Kim said, if we now see a blood pressure of 180 over 120, for example, which is not impossible, and we do see that, there's a little bit like, oh wow, this was done a month ago. So I hope someone did something to follow this up. So that can sometimes be a little bit nerve wracking for us as well. So I'm going to credit International SOS here, because I've stolen their slide, or their image. But on the left, you have International SOS's medical risk rating for Africa. And the countries that are orange and red are either very high or high risk rating country, or high risk rated countries. And what that means is basically, they take medical risk, and they do a calculation. And they look at things like, what are the actual hazards in the location? So infectious diseases, and things like that. They also look at the number of evacuations done out of location. They look at the availability of outpatient care and inpatient care. It's a little bit of a proxy. It's not a proxy for standards, but it's a proxy for availability of care. And it's a proxy for medical practice. And so if you look at that, the orange and red, and you compare it to the slide on the right, which is Minka, or the image on the right, which is Minka shared earlier, you can see that a lot of our country offices are in high risk and very high risk locations. And that has implications for us for two reasons. The one is, if you think about it, these drivers are born and bred in that country. And so their access to health care through their lives may not have been good. They may not be used to going for routine medicals. They may not have had all their vaccinations. By the very nature of where they live, they may be more likely to be exposed to certain diseases, tuberculosis, malaria, et cetera, et cetera. And malaria doesn't matter so much other than from a driving point of view, but tuberculosis certainly does. And so these are the things that we're thinking about with the medical variability from the driver point of view. And then, obviously, from the provider point of view, we're also thinking about the medical variability for a few reasons. The one is obviously just the, and I said earlier about the language, but the other one is also just thinking about not necessarily the standards that they're following, but the way they're practicing medicine. You know, when I read a blood pressure of 170 over 100, how was that taken? Did they lie him down and check it again afterwards? You know, how worried should we be about this result, right? What about the follow up? So if we've got someone with really complex medical conditions, what's happening, you know, what's happening on follow up? Do they have the same practices? We're going to talk a little bit about diabetes later. But because of these reasons, and I mean, I'm from South Africa, I've worked extensively in Africa. So, you know, I've been to a lot of clinics and a lot of places in these regions, and it is a challenge, right? You know, just from a very practical point of view, when you talk about diabetes, you know, the way diabetes is managed in resource strapped locations is going to be different from how it's managed here with a continuous pump, right? And so these are some of the things that we're taking into account when we're looking at the medical results, and maybe practicing being a little bit more conservative than maybe you would be if you were doing the exam yourself, okay? So that's a little bit about that. I also want to talk a little bit to fitness to drive medical standards, because we do apply the DOT when we're putting our reviewing goggles on, and as far as possible, let me say that we try, we use the principles, which is, it's a great baseline principle, but obviously different countries have different principles, and some countries, as I'm sure you guys know, have absolutely no standards. So depending on where the doctors are from, either they're from, maybe from a country where there are no standards, or they're from a country where there's no expectation of specific standards, right? So then it's really on the individual doctor to determine what would make someone fit to drive, or they're from perhaps another country, or they've learned in a different healthcare system where the standards may be different, or have different principles or practices, and so that's just also something to bear in mind. So when we were preparing for this presentation, and I don't claim to be an expert at all in this, and now I'm not an expert at slide moving either, sorry, we did a little bit of a look at some of the different standards, and it's really interesting. So for example, in the UK, they divide drivers into group one and group two. Group one is light vehicle, group two is what I would call a lorry, or I think you guys would call a semi-trailer maybe, but you know, group two is bus drivers, and those sorts of things. So those meet the definition of group one. In the UK, over the age of 45, you need to have a medical exam every five years. Over the age of 65, you need to have a medical exam every year. But that's what they dictate in the UK. In Australia, it depends state to state. So there are all these sort of tweaks just purely on, you know, just age, for example, which is really interesting. So you can imagine, you know, if I'm a doctor who's been trained in a system, and so for example, I'm from South Africa, our medical system is probably most closely aligned with the UK. You know, the standards that I may be used to are going to be like the UK, if I have any, you know, if I have anything specific in my mind. So that makes for an interesting conversation and interesting challenge as well. As Kim said, when we're talking about who is sort of responsible or accountable for the fitness, ultimately, it is the examining doctor. I mean, they're the person who's there, they've done the examination, they've made the fitness determination. And historically, we would actually only really review, and this was resource constraint reasons, we would review the medicals based on either it was a new driver or if it was a driver who was found unfit, then we would go through all the results. But we'd started an experiment last year and really started going in depth through all our medicals, and we were amazed to see how many drivers were found fit on sort of recurrent medicals that we would not have found fit. And so we've changed our practice, and we now literally review every medical of every person, every driver around the world that we get our hands on, because we do just want to put our goggles on and make sure that there's a good, you know, that it is aligned with what we want to practice, because the last thing we want is if one of our drivers is involved in an accident, that we can't say, well, they were cleared and there's nothing to worry about, right? We want to know that, I mean, that's not the last thing we want. The last thing we want is anyone to be involved in an accident, full stop. So let me just reframe that. But if there was an accident, we want to know for all of us that the driver was safe. So we are really performing a second quality check. And as I said, some of the challenge as well is that, you know, we are only seeing the results a year, I mean, sorry, not a year, like two weeks later, sometimes a month later. And so that can be a challenge. So when we go to the scenarios, which Blythe is going to be talking about, or Dr. Mansfield, you'll see we are a bit stricter than normal DOT principles would have us. So I'm going to give a disclaimer here, because we are obviously talking about scenarios. And as they say in the movies, all characters appearing in this work are fictitious. And any resemblance to real persons living or dead is purely coincidental. OK. So that's our disclaimer for this, simply because obviously we want to respect privacy. You know, we've done, we have eight, how many drivers do we have here, Swenka? Around 700. We have 700 drivers who are all going through medicals at least every two years. So you can imagine we've seen a lot of medicals in the last 10 years, right? So with that, I'm going to hand over to Dr. Mansfield. I'm going to ask if you have any questions or comments during this section, because some of them may be shocking to you. So please hold them till the end, OK? So but yeah, so we'll hand over and go there. OK. That's fine. Thank you, Dr. Frith. OK. So we're going to start with hypertension. So we have a 55-year-old male with stage 1 hypertension. His blood pressure is 146 over 92. So in this type of driver, we would give him a three-month certificate, ask him to see his treating provider for further evaluation. We want to make sure that when his documentation returns that there is a treatment plan and that his blood pressure is less than 140 over 90. So we tend to be more conservative. We don't give temporary certificates for drivers who present with stage 2 hypertension or stage 3. In those cases, they would have to go. They would be disqualified initially. They would have to go to their treating doctor and then, of course, return with documentation. And sometimes this takes a while, just because of where they are. So that's just how we handle those cases. Seizures. So we do follow DOT guidelines for seizures, as they are very complicated in this situation where we would have a 50-year-old female driver with a single, unprovoked seizure. So what we would do is we would follow DOT. However, we do not have an exemption process. We don't have a way to do something like this in every country. I would think it would be very not practical to do this. So in this situation, this person would need to be seizure-free and off meds for five years, which is pretty much aligned with DOT. In most cases, this driver would not likely be able to return unless they were able to have another job within the World Bank outside of driving. They would apply for extended sick leave, which is the same as short-term disability, and would likely go on to long-term disability. So diabetes. As you know, diabetes is very common. So this driver is a 25-year-old male with insulin-dependent diabetes. So because he's insulin-dependent, he would not qualify to drive for our program. And we do this because it's very difficult to track these drivers, especially around the globe. Just due to the complications, there's risk with hypoglycemia, these drivers. And it would be difficult for a driver to go through the same type of process with DOT of submitting logs and that sort of thing. However, in the case of a non-insulin-dependent diabetic, we would make sure that they were stable, their glucose, rather. So sometimes we get urine glucoses, you know, plus one, plus two, plus three. So basically, we will not clear them. We will send them to their doctor, and we will ask for medical documentation that states that this person is well-controlled. We want to know what their treatment plan is. We want to know what medications they're on. Then we would give him a one-year certificate, and they would have to follow up every year. So cerebrovascular accidents. So this one's a little bit more complicated because it really would depend on where this person is located. So this driver, just say if he was in a country, just say in Africa, that didn't have a level of care where they were able to manage him, he would have to be evacuated to another country. And in most cases, these drivers would likely not come back as a driver just because of the amount of time it takes for the whole process for, you know, understanding what the etiology is of the seizure, and then the treatment, and that sort of thing. So more than likely, this driver would apply for extended sick leave and perhaps may go on to long-term disability. However, if this driver presented with the TIA, we have to wait at least one year before they're cleared to drive. And before any driver comes back to drive at the World Bank, when they've been off on sick leave, they would have to go through another medical exam. Monocular vision is pretty straightforward. We align with DOT standards. We have a 34-year-old male with monocular vision, and he would automatically be disqualified due to a number of reasons that presents risk. We don't have an alternate vision standard in our program. It would be very difficult to track this. And some countries may not even have an ophthalmologist available to do the testing. So we automatically disqualify them. And so that one's pretty straightforward. So amputations or limb impairments. So this could be someone, just for instance, this gentleman here is a 40-year-old male, and he had a right leg-ankle fusion. So in this situation, if this driver was having difficulty just with ambulating or pain, you have to understand these drivers are sometimes driving for long periods of time. And so we don't really have a way to judge how this driver is going to do. So we don't have a skills performance evaluation process like the DOT. So most cases, depending on the situation, we would really have to rely on the treating provider for them to tell us if this person is eligible to drive. Otherwise, they would likely be disqualified and would have to go on sick leave. So we do know that there is an impact of aging on drivers as we age. We have deficits with eyesight, peripheral vision. We have more eye diseases. And of course, age-related hearing loss. In addition, chronic diseases are more prevalent, such as arthritis, diabetes, sleep apnea, neurological conditions. And then, of course, we can't forget about medications. Sometimes medications can be sedating and impair cognition. So we have to consider all these things we're talking about aging drivers. And then, of course, the ability to function, motor skills, how much strength, the range of motion, and flexibility do these drivers have. And of course, I think it's really important is the memory, attention to detail, and ability to act quickly. So these are some of the concerns that we really think about when we're looking at these drivers. And so at the World Bank, we have a mandatory retirement. So after 67, at 67, you have to retire. And so if we see drivers that are above 60, 65, in this case, we have a 65-year-old driver, we have to really look at everything. And we do take each driver case by case. We don't make blanket statements about drivers, no matter what condition they have. We look at them on a case-by-case basis. And so we do know that with driving, as drivers get older, there's more chronic conditions present. And studies have shown that drivers over 60 have a higher chance of having one condition. And of course, 65 could be more. So we mitigate this by having drivers do an annual exam instead of every two years after age 60. That way, we're able to track them. We do have a low threshold for further investigation if we feel that a driver has any concerns. But we have to really rely on the treating provider. So road traffic crashes. So road traffic crashes do happen. They don't happen often, which is great due to our wonderful program that we have. But one of the first things that would happen is that the driver would call our security line. We have 24-7 security and support. And it would be determined whether this driver needs to be evacuated somewhere. Sometimes if a driver needs a back surgery, they may need to be evacuated to another country. So that would be the first thing that the driver would need to do. After that, the driver would, once they're stable, they would enter the incident into the data management system just so that it's tracked to know more about the incident. And we would just treat this driver just like anyone else. They would go on sick leave if they needed care. And they would also have to come back with a driver's exam before we clear them to drive if we felt that a medical condition contributed to the incident. And we also provide referrals to our counseling service if they need it. Sometimes it could be traumatic for these drivers. So back pain is our last scenario. In this case, if we had a 30-year-old driver with back pain, it just really depends on the severity of the back pain. Does he need to go to another country for treatment? We would consider that. We have non-emergent evacuations. And some of the things that we would have to consider in these drivers, because this does happen. These drivers are driving for long periods of time. And sometimes they're in a very remote area. So they can't really just get out and stop. They have to stop in some places due to security issues. And so we have to make sure that we look at their mobility. Are they able to sit for long hours? And in addition to sitting and driving, they have to be able to lift luggage. They're carrying passengers. They have to lift luggage. And if they break down on the side of the road, they also have to be able to change a tire. Now, in our armored vehicles, where the doors are really, really, really heavy, I'm not sure how many, 300 kilograms or, yeah, it's, they're pretty heavy. You have to be able to open and close those doors. And I have just, Dr. Lozada has talked a little bit more about the armored vehicles. But we want to consider, you know, what medications are they on? Are they driving with Flexeril, you know, something sedating? And of course, what their prognosis is. And one of the things that we have at the World Bank is a wonderful ergonomic process for back pain. So we would give them a tip sheet. We would give them resources on stretching and exercises and things to prepare for before they start driving. And I'm going to turn it over to Dr. Lozada to close us off. Thank you. So this last scenario was a very good introduction into our innovative and actually very popular ergonomic program for drivers. It's not only reactive after somebody feels back pain and has problem generally with pain and comfort during driving, but it's also meant to be proactive. So we want to make sure that our drivers are sitting and driving in correct position, that they are moving, stretching, and taking breaks during driving. It is not as easy as it sounds, as Dr. Manfield said. So sometimes our drivers have to drive for hours in places where they are not allowed to stop for security reasons. Roads are very bad, traffic is very bad, tense situation. And then, of course, in our fleet of armored vehicles, this space in which they sit is even more confined. And they have to be physically fit sometimes to even leave the car if they have to stop in some place where the car is leaning towards a curb. They definitely have to use both arms and legs to even open the door and get out. So with all that in mind, we are organizing webinars for drivers in country offices. We are also organizing group presentation whenever our ergonomist or other staff is traveling for mission. They meet with group of drivers in this office and talk and hear also their problems. We don't know everything they are facing in this space of ergonomics. We also provide actually virtual assessment, ergonomic assessment of drivers and their position in the car, which is very important because sometimes drivers are not very fluent in your language. You have to be able to show them how to best adjust their position and not hurt their back and generally musculoskeletal system. So this program is relatively new. It is very popular, very, really appreciated. We are proud of it. And then also the tip sheets were mentioned how to stretch and how to sit properly. We equipped all cars in our fleet with this kind of laminated tip sheets. So whoever of drivers, typically there is one car, but maybe two or three drivers, whoever drives is able to have access to the tip sheets and somehow get advice how to move and stretch properly if it is possible and how to sit properly. What we are also preparing and it's coming out very soon is our third road safety survey for staff. We collect valuable information through this kind of surveys. They are smart surveys, so they have various loops of questions. If you are director of country office, if you are road safety focal point, if you are a driver, you are getting set of questions that are related to your role in road safety policy implementation. So we get very good information how all participants in the road safety management system are doing in their roles. And all of them are also responding to questions related to experience the road traffic crashes and near crashes in the past three years. So if they say that they did road traffic crash or near crash, then they have opportunity to describe the situation so we understand in which type of car it happened, what type of driver, was it contracted, was it taxi, was it bank's car. So we get a lot of actionable information from these kind of questions. And then also they help us to compare results with our official reporting system, which is typically concerning to say at least, because we have wonderful reporting system, but people do not report. However when they fill the survey, they kind of, the line of communication is already open and they tell things that they didn't report anywhere. So we, for example, in the last survey we had 800 reported crashes from the survey from 30% of staff who responded to the survey, compared to 60 reported in the regular reporting system at the same time. So it is kind of our check, reality check, and based on these results, since we have typically thousands of respondents, we are able to calculate the rate of crash and near crash per person or per traveler. And based on that rate, we can draw maps and on the map we can spot, we can see the hotspots where the most crashes and near crashes are reported. So that helps, of course, to prioritize our intervention and focus on these areas. Well, there are many successes of the program, so just to maybe mention the most important first collaboration. It's not possible in global organization to have just one group of people in charge of road safety. There are, at headquarters in Washington, D.C., we have a road safety committee, which I mentioned before, which has stakeholders from all parts of the organizations that are involved in road safety, but also we would not be able to function without collaboration with the field, with country offices where we had in each one, we have a road safety focal point. These are our eyes in the field, our optics, what is happening there, our connection with local network of physicians who are actually doing evaluation. So it is crucial to have such a network, otherwise we will have gray spot where we would not know what's happening. Of course, challenge is that this road safety focal points, they are volunteers, they change over time, somebody has to take care that they are informed about their roles when the new ones come, and so on. Nothing is simple, but the system is there and collaboration is crucial in this system. The other important success and challenge at the same time is standardization. So what is the minimum standard for driver's medical clearance? We cannot go by local standards of 140 countries that they have then internally their own. We had to establish standards, minimum standards, that will be applicable everywhere. If it is more than that. Sometimes we get double from what we ask in these medical clearance exams. That's fine. But we cannot go below. So that is why the system was developed, why we have standardized forms. It also sounds simple, but it's not. You have to create them. You have to spread them around. Of course, the local physicians would rather write a note, handwritten note, in local languages driver is okay. Well, that's not okay for us. So it was definitely additional effort to standardize all this documentation, of course, to translate it, to get it back. So standardization was another big challenge. And then in the beginning, the big challenge was that there were almost no physicians who would review medical reports. We had two consultants, part-time, part-time, and part of that part-time was for road safety. So out of that, we now have the whole medical team. Here we are, three doctors, one nurse. There's another nurse who is covering up for us while we are in the conference. And there is another doctor coming. It's not that the whole medical team is doing only road safety, but it is in it and we all know the rules. We can act for each other. So it is a huge success of this program. And not only that, we got program coordinator, Roxanne, here. We didn't have before this physician consultant part-time on road safety had to do all this communication with focal points, with local physician, with the drivers. So now finally we have one person who is doing that, and this is really a lot of work right there. And then we have Sophia and Mike. They are our support in data analytics. You heard 700 drivers. I don't know thousands evaluations. So how to show it in one place, how to monitor compliance, how to see which countries are behind, how to see how many drivers are fit and not fit. So we had developed drivers database where we keep all this information for all staff drivers, which is not in general a problem. But we have consultant drivers whom we have to know about and there are contracted drivers who are locally hired. So we have them all in one database and keeping it thanks to support of this analytics team. So a lot of success, but there are also challenges. We want to improve and streamline our processes. We are continuing working on that. There are some areas that we still have to cover. For example, sleep apnea. I mean, how will you evaluate and treat this in many countries where even power is not constant, power supply is intermittent. So we're kind of keeping this a little bit aside. Or control of drug abuse, alcohol abuse. This is all in works. It is extremely difficult to establish system and to enforce it. It's even worse, as we know. So many more things to do, but here we are and keen to improve further our program. So thank you for your attention and there are 12 minutes for questions and ideas. Please go ahead. Here is a mic. Otherwise, we will not hear you. Microphone. Oh, if you shout like that, yes. We are not doing drug testing at all. Because we cannot enforce that, we cannot standardize it across the globe. So we do that only when we get back reports about problems with driver's behavior or in medical examination it is indicated that there could be a problem. Then we get into it. And we do have some success stories that some of programs in, it was in one of the countries that it worked and driver was recovered from rather difficult situation. But we don't have it on systematic basis. Some countries do this as part of their requirements. So then we get it. No, we don't get the drug testing after accidents either. It is part of whatever medical response is at that country. But again, we ask, we look into clearance from local physicians after road traffic crashes and we don't really have them many, especially not with bank cards. But then for our, then we do our regular clearance to come back to work. I mean, that's certainly something we could look into in our next iteration. The challenge, I think, A, as Jasminka said, we often only hear about accidents later. So the next day or, you know, in which case obviously then it's out. And then obviously the other challenge is in some countries you also need to think what are the implications. So if we do drug testing on a driver and they get locked up because of something we did, that's also, there's also those, so if we put a standard blanket policy and then they're in a country where it's really illegal or something, so there are all those implications we need to think through before we put a policy like that. But that's certainly something as we're thinking about what our next steps look like. Drug and alcohol is something we're very aware of. How we manage it currently, as Jasminka said, is if there is a concern, we would do what we call a fitness for duty, which is the same for all our staff, which would be looking at what the specific concerns were. Yes. Great lecture. I kind of wanted to ask you a question. Are some of your workers unionized or are they legal and patient? It kind of goes with what you're saying. Every country is different. Are there challenges with, you know, this isn't fair? Can they challenge you? Yeah. So the staff drivers, they are compliant to our rules, the same as consultants. For contracted drivers, in order to drive for the bank, they have to sign a contract about transportation services. And in that contract, everything is spelled out, what their obligations are if they work for the bank, including they have obligation to do through medical clearance, through the exactly same program as staff. So once they sign on that, they sign on that. I mean, there is no other unionization. If they don't like it, we find another company. I'm not aware of any problems. I think that these contracts with the bank have very good conditions, especially in the local circumstances. So there is almost competition who will get them, and they are compliant with our rules. So no problems that we experience in that area. Jay, do you want to? Contract lawyers? But we, of course, cannot regulate. And this is a big problem. It's taxi drivers. So we are trying to get our country offices to help us vetting taxi companies. So in terms of the state of their fleet and history of their crashes and near crashes. So they advise which taxi company is more reliable than another. But it's on this advisory level. And the worst problem that we really don't know how to address are Uber and similar transportation companies. Because for them, we have absolutely zero understanding what their health and safety. They can say they are wonderful, but we don't know. And you never know which kind of driver you will get. And there is no talking about medical clearance of Uber drivers. And our staff, when they are traveling all over the world, they are often in a situation that Uber is an elegant solution because they don't have to speak language. It's clear where they go. It is paid without having cash in pocket. So extremely convenient and well used. But we are very nervous about our lack of control of safety of such transportation. Thank you for a most interesting talk. Is there a maximum number of hours that drivers can drive to get your head around fatigue? We do have advisory again how many hours they should drive. And especially that they should stop at least every two hours. But in many cases, it is not possible for them. Again, if they are in countries where for security reasons they are not allowed to stop. Or there is some, I don't know, situation on the road that they cannot move. It is practically impossible to control. But we do have how many hours they should drive per day. And that they should sleep and they should eat. And all this very nicely spelled out. But we are so much aware, especially from this road safety surveys, we have open-ended questions and people talk about what's outside of these numbers. They talk and describe their situation. So very often in this field work that we do in low- and middle-income countries, it's not possible to control anything. This is why we are rather restrictive also sometimes with medical clearance, with drivers with diabetes and so on. Because we know that they could be in many situations where they have no food or nothing regular to maintain. Yeah, sorry. And if I may, you know, we're very keen about data quality and you brought that up. So is there a mechanism to vet the medical examiners and even train them? You mean in the field we have no mechanism to do that? We have a requirement that these are licensed physicians locally, of course. And we have occasionally contact with them when there is something unclear in their medical reports or some follow-up is needed and so on. But we don't regularly communicate with them and we don't have a chance to train them or check how they are trained in terms of medical clearance of drivers. I think to comment, though, we have doctors and nurses based in the field or hubs that work for the bank. So, for example, I started the bank in South Africa. I was regional medical advisor. And so when we're looking at who does the driver's medical exams, part of that is asking our regional doctors to help us decide who would be a good provider. And so in some locations, that is what happens. In other locations, we've used the same doctor for the last 10 or 12 years. Yes, this is what's happened. So for the medical exams themselves, it's probably not as much of an issue as for follow-ups. So the guys who we make unfit, then we're a little bit like, because they can then go to whichever doctor they want to. What we've also done a big overhaul in the last year is really making our forms what we hope is going to be foolproof. So really spelling out, fill this block, use this standard, use this method. So really trying to educate the examiners that way. So that's sort of the other workaround we've been working on. But then another thing, actually, in the forms for medical exams, it is for each examination there's a part of it. It's written what are our standards, with what values, findings they can say the driver is fit or not fit. So the form itself is educational in terms that it contains our requested kind of values and threshold for clearance. So that's the only thing we can provide. If you don't mind, a final question. You know, with widespread availability of technology and you're trying to get your head around crashes and near crashes, are you able to monitor or think about monitoring speed and braking and all those things that could give you that information? There are devices that are considered and we are not in charge of the fleet and of these security measures, so it's part of corporate security. So they are looking into devices that they could make in cars to monitor speed and sudden braking and sudden turning and things like that. So this is not, again, a problem for our fleet, but for contracted cars, again, we will be blind on that. Thank you. Yeah, just to follow up on this one. You tightened your standards, I understand, after you discovered that some of the previous years you missed or a number of things were missed in the exam and the clearance process. Wouldn't you be interested to see what the impact was of these data before versus now after you tighten your standards? Is there any idea to compare maybe this for a route course? Unfortunately, it's a little bit anecdotal, Matthias, because we don't know what we missed. So we didn't used to go through in detail all the exams of the follow-up. I mean, by follow-up, I mean the annual, the routine medicals every two years. So we would always go through, or Jasminka and me in following would always go through every new driver and every unfit driver. But the expectation was the country officers would just provide us with a medical certificate if they were fit. So we don't actually have in a lot of situations the actual results from previous. But what we have noticed since we've been sort of dogmatically going through everyone is how many times someone has been found fit and they actually, we wouldn't have considered them fit, or the entire vision test is missing. And we're like, wow, okay. I mean, in theory, yes, maybe. So that's been the learning, but we don't really have that. But I think anecdotally it's very clear that it was the right decision to change back. So it's interesting, I didn't mention this, but for some of the forms we'll have monocular vision checked off, and then you look at their vision exam and in both eyes it's normal. So there's some countries where English is not their primary language that they're not sure what that is. And they click the box. They just click the box automatically. And horizontal vision is always missing. I mean, that's one of those things that we tend to have to go back and ask for many times. So our forms are really now designed so it's in their face and they can really see this has to be done and circle it. So we were very intentional with our form updates. We should be worried that we are inducing more questions with our responses. But just to show to Matthias, you see these three forms. First one is medical. The second one is just certificate of fitness. So in first years where we had so limited resources, we would look at certificate for fitness only and see fit, temporary unfit, blah, blah. And we would take it as such, considering that in the form there are instructions when the driver is fit, but we were not aware that some of this information there was missing. Now when we are asking both certificate form and medical form, now we sometimes see discrepancies that drivers are declared fit although they have blood pressure over the roof and so on. Anyway, yes. Thank you so much for the presentation on your innovative approach. As we're talking about data and quality, I just had two quick questions. The first one is about the surveys that you've been administering. Have you been administering the same survey over different time points, or have you gone through and revised questions and it's been a more evolved process? My second question is how have you been evaluating the success of the program in terms of any specific metrics that you're looking at or key performance indicators? If not quite there yet, how, looking ahead, would you like to gauge the success of this program and quantify that? Thank you. Yes, thank you. The whole program is actually led by corporate security, so they do have key performance indicators. And then going through medical clearances, one of them, they have also that each country office has to have a road safety program. They have fleet maintenance. They have training, all kinds of this. So this is part of the bigger thing. Internally, we didn't really evaluate quality of the program, except that I don't even know whether there is any attempt to do it. Maybe soon as a part of travel audit, then it will be evaluated. But, yes, survey was the same. And we did notice improvement in terms of, I said, we are calculating rate of crashes and near crashes. So this rate improved from Survey 1 to Survey 2. Now we will see in Survey 3. We also measured usage of seat belts, so it improved. We asked for it even in health and safety regular survey. It's, by year, better and better. So indirectly, we could kind of hope that we are certainly making difference. There is no doubt. But it is sometimes different to put it in numbers. Thank you very much. Thank you. Just to follow up on this, in the same line, when I was comparing before and after with the standards, I was actually comparing it, this one, like the different way of doing it, to the accident and near misses and crashes rate, if that is possible. Would that be maybe possible to see how much the clearance process was influencing maybe prevention of accidents? Yes, that would be ideal. What we can do now only is to compare between bank drivers versus non-bank drivers. So by far, they are much safer because there is so much invested in their training and follow-ups and so on. But, yes, more detail would be even greater. Just as a confounder, every office will have a different ratio of drivers to contracted drivers, right? So if you go to Nairobi, they'll maybe have five or six staff drivers, but then most of the staff coming into Nairobi are going to be using the recommended taxi service. So we don't know how many hours are being driven, so it would be a very difficult comparison. But, I mean, these are all the things we want to think about how we do. Okay, yes, please, one more question, and then we get the red light here. This is our alarm to stop talking, but please go ahead. You know, you mentioned confounder, and, you know, if your program is anything like U.S. Embassy driving program, the drivers are taught to drive defensively, and some crashes are unavoidable. Right, to get the VIPs out of a bad situation. How do you account for that? That's a very valid point. We're probably not on the same level in terms of needing to, you know, I mean, it's not dissimilar. We do drive armored vehicles. We are operating in areas, but it's not quite the same as the U.S. Embassy. But, yeah, I am not aware of us having any high-speed crashes as a result of someone needing to get out of the way, or we're not, you know, we're not driving in mock cars or anything like that. But, yeah. You're right, that's true, and just to say that we are not alone in all this world of global road safety. We work very closely. We are part of U.N. road safety strategy, so there is a whole strategy for all U.N. family because everybody has the same problem, stuff all over the place, and people have to move from one place to another. So we do work with them. We have a ministerial conference on road safety every 10 years. There is action, global action on road safety, led by WHO and other U.N. organizations. So we closely work with them, and our strategy is in line with U.N. strategy. We mostly have cars, these regular vehicles and armored vehicles, but within U.N., for example, World Food Program, they have trucks, they have airplanes, they have boats, they have workshops for all of that. Road safety is really a big deal in global organization, and, again, the biggest occupational health and safety risk for staff. So we are out of time. Thank you very much. Thank you.

World Bank

Global Driver's Medical Clearance Program

Road safety

Global road traffic safety

Implementation

Challenges

Vehicles

Collaboration

Proactive measures

Evaluation