Good practices from different countries
Motorcycle helmets in Vietnam – a success story
Global Road Safety Partnership, January 2008
As of October 2005, Vietnam had around 16 million registered motorcycles, which accounts for approximately one motorcycle per five persons. In the same year, 70 per cent of the 17,000 road crashes involved motorcyclists, and hospital reports suggest that 88 per cent died as a result of head trauma. Surveys carried out for the Global Road Safety Partnership (GRSP) at the end of 2006 showed that, in cities, only 10 per cent of motorcyclists wore a helmet. On major inter-city roads, wearing rates were higher – around 60 per cent. At the time of the surveys, helmet wearing was only enforced on some inter-city roads. There was a marked reluctance amongst the public to wear helmets – known colloquially as ‘rice cookers’ – in the hot and humid summer climate of Vietnam.
Everything changed on 15 December 2007. A new Government resolution came into effect, making helmet wearing mandatory on all roads. Anecdotal evidence suggests nearly 100 per cent wearing on the streets of Hanoi and elsewhere. The police are enforcing the new law vigorously and hospitals report much lower levels of admission from traffic crashes and lower levels of head trauma. How was this change achieved?
No one organisation can claim all of the credit. The Government, and particularly the National Traffic Safety Committee (NTSC), must be applauded for its political leadership. Several organisations have been lobbying, undertaking demonstration projects and putting solid evidence to the NTSC to provide the basis for policy. Notable amongst these are the Asia Injury Prevention Foundation, the Red Cross, the World Health Organisation and GRSP. The collective efforts of all these organisations, exemplifying the power of partnership, can be seen as providing the support government needed in order to enact legislation which would be unpopular, but in the interest of the public’s safety and the national economy.
Under the Global Road Safety Initiative (GRSI), Vietnam is one of the ASEAN countries with which GRSP has been working to address critical road safety issues – in this case motorcycle helmet wearing and standards. With GRSI support, GRSP lead a multi-sectoral workshop in Hanoi in December 2006. This proved to be a landmark event, producing an action plan to increase motorcycle helmet wearing in the country. The action plan was endorsed by the Government, and – as acknowledged by the NTSC – was an important factor in the introduction of the helmet wearing law.
The Costa Rican experience of promoting road safety
WORLD REPORT ON ROAD TRAFFIC INJURY PREVENTION, 2004
Costa Rica has a population of around 4 million, some 900 000 vehicles and a road network of 29,000 km, 9,000 km of which are surfaced. Only 20 per cent of the surfaced roads are in a satisfactory state of repair. In Costa Rica, traffic crashes and their consequences are clearly a public health problem. They are the leading cause of violent deaths, the leading cause of death in the 10–45 years age group, and the third leading cause of years of life lost due to premature death. The cost to the country of traffic crashes amounts to almost 2.3 per cent of the gross domestic product.
Because of the seriousness and complexity of the road safety problem, a set of coordinated interventions, cutting across many sectors and disciplines, has been formulated. The National Road Safety Council, attached to the Ministry of Public Works and Transport, has been in existence for 23 years. A national road safety plan, aimed at reducing the mortality rate by 19 per cent during the period 2001–2005, was implemented, providing for action in the fields of traffic laws, police surveillance, education, infrastructure and research.
Traffic laws and police surveillance
The law has been changed so as to better protect pedestrians, and new laws have been introduced making the wearing of safety-belts by drivers and passengers compulsory. The police have stepped up operations to check for excess alcohol among drivers, to control speeding and to check on the wearing of seat-belts.
Ongoing campaigns emphasize the importance of observing speed limits and wearing seat-belts, and discourage drinking and driving, in support of police enforcement campaigns. Special campaigns take place during the Easter week, when large numbers of people take to the roads. A specific safety campaign is aimed at pedestrians. The medical examination that drivers require has been updated and strengthened. Within primary and secondary schools at all levels, the national plan provides for educational modules on road safety.
Under Costa Rica’s road safety plans, new infrastructure is being put in place to protect vulnerable road users, including pedestrian bridges, cycle tracks and protective railings and pavements along dangerous portions of roads. New and better road signs and traffic lights are being installed.
Systematic data on road traffic crashes and on the victims of crashes are compiled. Studies are also under way nationally on a range of issues, including:
— the safety of road travel to and from schools;
— risk behaviour among drivers and pedestrians;
— the wearing of safety-belts;
— the vulnerability of road users visiting health centres;
— safety audits of roads, and the identification of high-risk crash sites; and
— the financial costs and economic consequences of traffic crashes.
Cost-effectiveness of traffic enforcement: Uganda
In October 2004, the Ugandan Police department deployed enhanced traffic safety patrols on the four major roads to the capital Kampala to assess the costs and potential effectiveness of increasing traffic enforcement in Uganda.
Prior to 2004, traffic enforcement in Kampala, Uganda’s largest city, had primarily consisted of stationing foot patrols on traffic islands in busy intersections. In 2004, the police department acquired four patrol cars and equipped them with speed detecting radar. They hired and trained 20 traffic officers to be deployed in mobile teams. In October 2004 they began daily enforcement of traffic regulations on the four main roads leading into Kampala city.
The following monthly events were recorded by the police: (1) number of fatal crashes; (2) number of people killed; (3) number of total crashes; (4) number of serious crashes; and (5) number of minor crashes. Fatal crashes were defined as dead on the scene, which undercounts the total number of fatalities. This case definition was unaltered before and after the intervention.
Uganda is a sub-Saharan African country of 25 million people experiencing a rising epidemic of road crashes. The annual number of road crashes for Uganda in 2005 was estimated at 19,528, of which 1,732 were fatal and resulted in a total of 2,034 deaths. The number of crashes represents a 7 per cent increase over 2004. The estimates of the annual cost of the enforcement operation estimated at 129 million Ugandan Shillings or US$72,000 in 2005. Fuel and personnel costs accounted for the largest expenses.
The police reported issuing traffic citations in 2005 that would have been worth a total of $327,000 if there were 100 per cent collection. None of the key informants in the police department were in a position to estimate the percentage of this revenue that the Ugandan treasury successfully collected. Given the estimate of an average annual volume of 160,000 vehicles per year traveling the roads studied in 2005, the enforcement intervention averages roughly $0.50 per year per vehicle.
The leading three reasons for all violations were speeding (19 per cent), breach of license (18 per cent), and dangerous loading by trucks (16 per cent). Careless driving was also cited in 14 per cent of cases. Data from the Ugandan Ministry of Works indicated an average annual rate of growth of vehicles traveling on each road at 5 per cent annually. If one uses the official estimates of traffic volume as the denominators to compute annual estimates of crashes per vehicle, then crash rates per 1,000 vehicles dropped from a rate of 18.5 crashes per 1,000 vehicles pre-intervention to 16.3 crashes per 1,000 vehicles post-intervention. This shows that the intervention period has a negative association with fatal crashes, total crashes and the number killed.
Applying the incidence rate ratio of 0.727 estimated for the intervention would predict that in a year subsequent to the intervention there would be 313 deaths, or a total of 118 lives saved. If one divides the $72,000 annual programme costs by the projected number of lives saved, one derives an estimated cost per death averted of $603. The average age of road crash victims in Uganda is reported at roughly 27. The life expectancy at age 20 is 35 additional years. With discounting at 3 per cent, the additional 35 years per death averted is worth 22 discounted years for each of the 118 lives saved. Thus, the cost per death averted can be converted to $27 per discounted life year saved. At a 10% discount the cost per discounted life year saved approximately doubles.
The costs of traffic safety enforcement are low in comparison to the potential number of lives saved and revenue generated. Increasing enforcement of existing traffic safety norms can prove to be an extremely cost-effective public health intervention in low-income countries, even from a government perspective.
The finding that traffic enforcement saves lives at a cost of $27 per discounted life year saved would rank this intervention among the most cost-effective public health interventions.
Cost-effectiveness of road traffic injury interventions
Intervention* Cost per DALY (US$)
Improved enforcement (LMIC average) 5.25
Speed bumps at top 25 percentile dangerous junctions
Bicycle helmets (China) 107
Motorcycle helmets (Thailand) 467
Enforcement in Uganda 27
*Data from Disease Control Priorities in Developing Countries, Chapter 39 (www.dcp2.org)
The success of traffic law enforcement in low-income countries can be markedly different from that in higher-income countries due to differences in the effective functioning of legal and administrative systems. Thus simply improving the laws around speed limits, without substantial investments in enforcement of speed limit laws may have much less effect in a low-income country.
Another example is the challenge of using laws and law enforcement to improve occupant protection vehicles in low-income and middle-income countries when the vehicle stock has few functioning seat belts. A review of the economic analysis of road traffic injury interventions highlighted the fact that studies in high-income countries assumed enforcement and compliance; while this could not be the case in low-income countries where the costs of such enforcement might be substantial. This study provides one case study from Uganda to empirically support that premise.
An obvious limitation of this work is that benefit estimates neglect all impact of the intervention on non-fatal injury; and the cost estimates neglect all cost offsets due to savings to the medical system. If each death averted also averted medical costs and vehicular damage in excess of $603 it would make the intervention cost-saving from the perspective of society.
It seems plausible that fatal crashes would typically be associated with vehicular damage costs of at least this magnitude, but the data collected did not assess these costs. The events that were studied are subject to under-reporting, because many crashes, even serious ones, are never reported to the police. The method of comparing pre- and post-intervention crash rates is vulnerable to bias from secular trends other than the enforcement intervention that could have been responsible for lowering the number of crashes.
However, according to the police that were interviewed and the Ugandan research team, there were no other major interventions on these roads or in the popular media or educational system that coincided with the timing of the intervention. There were no interventions targeted toward improved pre-hospital care on these roads other than the presence of the police patrols themselves.