Traffic Safety in Low- and Middle-Income Countries

This is a writeup of a shallow investigation, a brief look at an area that we use to decide how to prioritize further research.

In a nutshell

  • What is the problem? Traffic injuries are a major cause of morbidity and mortality around the world, estimated to be responsible for 1.3 million deaths per year, especially prevalent in low- and middle-income countries.
  • What are possible interventions? There are numerous strategies for improving traffic safety, ranging from national or international advocacy for governments to institute better policies to smaller-scale efforts such as distributing helmets to motorcycle riders. We do not have a strong sense of which approaches are likely to be most effective or cost-effective.
  • Who else is working on it? The major philanthropic funders of global traffic safety work appear to be Bloomberg Philanthropies ($25 million/year) and the FIA Foundation ($7million/year), but we are not aware of an overall estimate of funding aiming to support traffic safety work in low- and middle-income countries.


Published: October 2013

What is the problem?

Road traffic injuries are a large and growing cause of death and disability. The Global Burden of Diseases (GBD) project estimates that traffic injuries killed 1.3 million people worldwide in 2010, slightly more than malaria.1 The World Health Organization projects that road traffic injuries will grow to be responsible for 1.9 million deaths in 2030, which would make it the 7th leading cause of death globally (up from 8th in the GBD 2010 estimate).2

Most road traffic deaths occur in middle-income countries, though traffic mortality rates are nearly as high in low-income countries.3 Traffic mortality rates are considerably lower in high-income countries, which may be due in part to more widespread adoption of some of the policies described below. Road traffic deaths are distributed relatively widely across ages, with nearly 60% falling amongst 15-44 year olds.4

What are possible interventions?

The World Health Organization has identified five major risk factors that affect road traffic mortality:5

  • seatbelts
  • child restraints
  • motorcycle helmets
  • speed
  • drinking and driving.

The WHO’s Unintentional Injury Prevention (UIP) Team works to address these risk factors by:6

  • Advising ministers of health on areas related to road safety.
  • Assisting with legislative reviews to determine how road safety laws and enforcement of these laws could be improved.
  • Developing social marketing campaigns to encourage good behaviors and discourage negatives ones.
  • Evaluating and improving the quality of post-accident care, from pre-hospital care to acute care to rehabilitation.

  • Publishing a global status report every few years on the state of road safety around the world.

The vast majority of the Unintentional Injury Prevention Team’s funding comes from outside the WHO, and additional philanthropic funding could be used to expand their efforts to new locations.7

Other potential uses of philanthropic funding include:8

  • helmet distribution and education
  • police training and enforcement programs
  • advocacy to governments to change road safety laws9
  • road infrastructure improvements, including advocacy to major funders of infrastructure to better incorporate safety concerns10
  • international advocacy to prioritize road safety more highly (e.g. the UN Decade of Action for Road Safety)11
  • mass media campaigns (e.g. to encourage seatbelt or helmet use)12
  • monitoring and evaluation of road safety issues13

We do not have a sense of which of these strategies is likely to be most effective or cost-effective.

Cost-effectiveness

Bloomberg Philanthropies commissioned a forward-looking projection for the potential impact of their $125-million, 5-year project to improve road safety in 10 countries.14 While acknowledging the limited evidence base to incorporate into their projections, the authors expect the Bloomberg Philanthropies program to save roughly 10,000 lives over five years.15 This implies a cost-per-life saved that is considerably higher than our estimates for the most cost-effective global health interventions (such as bednets to prevent the spread of malaria), though for a very different population (i.e. most of the lives projected to be saved by Bloomberg’s road safety work are adults in middle-income countries, while most of the lives projected to be saved by bednets are children in low-income countries).16 Because of the normative and empirical uncertainty underlying this comparison, we do not regard it as dispositive.

Who else is working on this?

The UN has declared 2011-2020 to be the UN Decade of Action for Road Safety.17 This has involved the creation of a Global Plan of Action to guide governments and national stakeholders in improving road safety in addition to regular monitoring of global progress towards road safety targets. 18

The two largest philanthropic funders of road safety work appear to be Bloomberg Philanthropies and the FIA Foundation.

Bloomberg Philanthropies are currently supporting a $125-million, 5-year project to improve road safety in 10 countries.19 Bloomberg Philanthropies works with a consortium of other groups, including:20

  • Association for Safe International Road Travel
  • EMBARQ
  • Global Road Safety Partnership
  • Johns Hopkins Bloomberg School of Public Health
  • World Bank Global Road Safety Facility
  • World Health Organization

The FIA Foundation spends roughly $7 million/year on global road safety,21 working with many of the same groups as Bloomberg Philanthropies. In addition, they also support:22

  • International Road Assessment Program (iRAP)
  • Amend
  • Asia Injury Prevention Foundation

According to T. Bella Dinh-Zarr of the FIA Foundation, there are a a number of other organizations—typically smaller and more locally focused—working to address road safety issues.23

Our understanding is that government aid agencies (such as USAID or the UK’s DFID) and development banks, such as the World Bank, support some work on road safety as well, though we do not have a strong sense of how much.24

We are not aware of any overall estimates of resources devoted to improving road safety in low- and middle-income countries.25

Questions for further investigation

Our research in this area has been relatively limited, and many important questions remain unanswered by our investigation.

Amongst other topics, further research on this cause might address:

  • How strong is the evidence in favor of the road safety interventions supported by the WHO? How cost-effective have historical efforts to implement those interventions been?
  • What has the track record of Bloomberg Philanthropies’ support for traffic safety issues been? Our understanding is that monitoring and evaluation data is being collected for their efforts, and some portion of it may be available publicly within a year.26
  • How should we weigh the differences in the populations typically aided by traffic safety improvements and other global health interventions?

Our process

We decided to look into road safety issues because we had heard that they were a large and growing cause of mortality globally and that they receive relatively little philanthropic funding. Our investigation mainly consisted of speaking with three individuals with knowledge of the field, including:

  • Margie Peden, Coordinator, Unintentional Injury Prevention, World Health Organization
  • T. Bella Dinh-Zarr, Director of Road Safety, FIA Foundation for the Automobile and Society

We also reviewed several documents that the individuals we spoke with shared with us and did some limited independent desk research.

Sources

Document Source
Esperato, Bishai, and Hyder 2012 Source (archive)
Global Status Report on Road Safety 2013: Supporting a Decade of Action Source (archive)
Leading the Worldwide Movement to Improve Road Safety Source (archive)
Lozano et al. 2012 Source (archive)
Notes from a conversation with Margie Peden, 8/13/13 Source
Notes from a conversation with T. Bella Dinh-Zarr, 8/2/13 Source
Projections of mortality and causes of death, 2015 and 2030 Source (archive)
  • 1.

    • Lozano et al. 2012, Table 2. Road injuries are estimated to have killed 1,328,500 people in 2010, with a 95% uncertainty interval stretching from 1,050,900 to 1,747,000, while malaria was estimated to be responsible for 1,169,500 (95% UI: 916,500-1,526,900) deaths.
    • By comparison, the World Health Organization’s Global Status Report on Road Safety 2013: Supporting a Decade of Action estimates 1.24 million traffic deaths in 2010: “This report shows that there were 1.24 million deaths on the world’s roads in 2010,1 similar to the number of deaths in 2007. This plateau in the number of global road deaths needs to be viewed in the context of a corresponding 15% global increase in the number of registered motorized vehicles.”
  • 2.

    Projections of mortality and causes of death, 2015 and 2030, ‘Global summary projections’, ‘Top 20 Causes’ sheet. This is roughly 22.4 per 100,000 population, up from the GBD estimate of 19.5 in 2010 (though the GBD figure is age-adjusted, and we are not clear on the impact that has on the estimate).

  • 3.

    “The overall global road traffic fatality rate is 18 per 100 000 population. However, middle-income countries have the highest annual road traffic fatality rates, at 20.1 per 100 000, while the rate in high-income countries is lowest, at 8.7 per 100 000 (see Figure 4).
    Eighty per cent of road traffic deaths occur in middle-income countries, which account for 72% of the world’s population, but only 52% of the world’s registered vehicles. This indicates that these countries bear a disproportionately high burden of road traffic deaths relative to their level of motorization (see Figure 5).”


    Global Status Report on Road Safety 2013: Supporting a Decade of Action, pg 4.
  • 4.

    “Young adults aged between 15 and 44 years account for 59% of global road traffic deaths. More than three-quarters (77%) of all road traffic deaths occur among men, with this figure highest in the Western Pacific Region.
    Regional variations are evident but mostly follow the same pattern (see Figure 9), except in high-income countries, where the proportion of deaths among those over 70 years is noticeably greater than
    in low- and middle-income countries. This difference is most likely related to longevity in these countries, combined with the greater risk posed by reduced mobility and increased frailty.”


    Global Status Report on Road Safety 2013: Supporting a Decade of Action, pg 7.

  • 5.
    “[The WHO’s Unintentional Injury Prevention Team] targets five major risk factors: drinking and driving, speed, seatbelts, motorcycle helmets, and child restraints. It assists with legislative reviews to determine how road safety laws and enforcement of these laws could be improved.” Notes from a conversation with Margie Peden, 8/13/13
  • 6.

    Notes from a conversation with Margie Peden, 8/13/13

  • 7.

    Notes from a conversation with Margie Peden, 8/13/13:

    • “UIP receives relatively little of its funding from the UN. 90% of its funds come from external sources. It was originally funded by the FIA Foundation. Recently, UIP’s biggest donor has been Bloomberg Philanthropies, which has pledged $125 million over 5 years to a consortium of partners to work on road safety. On a smaller scale, UIP has received funding from a few high-income countries, including Sweden, the Netherlands, the US, and Australia.”
    • “UIP is currently working only in select parts of the 10 countries funded by the Bloomberg Philanthropies program. If more money was available for this work, UIP could expand its work to more cities and regions within these countries.”
  • 8.
    Notes from a conversation with T. Bella Dinh-Zarr, 8/2/13:

    • “The FIA Foundation funds proven, cost-effective programs that prevent injuries and save lives, such as helmet distribution/education programs, police/enforcement programs, road infrastructure improvements, policy changes within countries, and school zone improvement programs that may include reflective backpack distribution. Reflective backpack distribution programs are targeted at children in developing countries who often walk to school early or late during low light hours.
      The FIA Foundation spends about $1 million per year on helmet distribution and education programs in Cambodia and Vietnam (through the Global Helmet Vaccine Initiative). It collaborates on some projects with other philanthropic or corporate donors. But total philanthropic spending on road safety in Cambodia and Vietnam is still only a few million dollars per year, not enough for a public health threat that causes such a large number of deaths and injuries in these countries.”

    • “In addition to the International Road Assessment Program (iRAP) described in more detail below, the FIA Foundation supports low-cost infrastructure efforts through Amend (an NGO) to improve road safety, such as placing speed bumps and crosswalks in high- risk school zones. Amend identifies dangerous school zones using police reports and hospital records related to traffic fatalities. Amend is working with several hundred schools near Dar es Salaam, Tanzania and Accra, Ghana. It collaborates with the Tanzanian and Ghanaian governments. The FIA Foundation has received preliminary reports suggesting that these programs have been successful.”
  • 9.

    “The FIA Foundation runs the Road Safety Scholars Program, which trains up-and-coming leaders in developing countries on road safety. Former Road Safety Scholars have risen to prominent leadership positions in their countries and are champions for safe roads in police departments, governments, and prominent NGOs.
    The FIA Foundation supports the Global Helmet Vaccine Initiative (GHVI), through the Asia Injury Prevention Foundation (AIPF), which was instrumental to a successful lobbying effort that persuaded the Vietnamese government to pass a law requiring motorcyclists to wear helmets. Compliance rates were high; within the first year, helmet use rates changed from less than 10% to greater than 90%. Deaths due to motorcycle crashes fell by about 25%, and hospital admittance due to motorcycle crash injuries fell by more than 25%. The FIA Foundation is expanding similar campaigns to other countries such as Cambodia and Thailand, places where Bloomberg Philanthropies is also working.
    The FIA Foundation also works to pass seatbelt laws and drunk driving laws. It has worked with the Costa Rican government and auto club to help support the passage of a seatbelt law along with enforcement measures in Costa Rica. It has provided information and materials to a grassroots group called Mothers in Black that persuaded the Guyana government to pass the country’s first ever drunk driving law by having mothers of drunk driving victims stand before the Parliament in a silent vigil.”
    Notes from a conversation with T. Bella Dinh-Zarr, 8/2/13

  • 10.

    “The FIA Foundation collaborates with governments, development banks, and NGOs to improve international road assessment.
    It grants about $1 million per year to the International Road Assessment Program (iRAP), a non-profit composed of engineers who evaluate the quality of roads in 60-70 developing countries and recommend safety improvements to governments. Unfortunately, countries often do not have enough funding to implement iRAP’s suggestions, but more foreign aid and philanthropic contributions may help with this problem.
    Development banks, such as the World Bank, the Inter-American Development Bank, and others, spend about $4 billion on infrastructure in the developing world each year. However, the roads that development banks fund are not always safe. For example, the World Bank built a new $10 million road in Bangladesh, but an independent evaluation found it to be one of the most dangerous roads in the country. The FIA Foundation is a donor to the World Bank’s Global Road Safety Facility in hopes that future roads are built safely.”
    Notes from a conversation with T. Bella Dinh-Zarr, 8/2/13

  • 11.

    “After noticing a lack of political capacity to work on road safety issues, the FIA Foundation worked closely with the United Nations (UN) and WHO to make road safety a higher priority, resulting in the declaration of the UN Decade of Action for Road Safety 2011-2020. The Oman Mission to the UN, and later Russian Mission to the UN, along with prominent members of the FIA Foundation’s board, especially Rt. Hon. Lord Robertson of Port Ellen, played an important role in establishing the Decade of Action.
    About 100 countries co-sponsor or support the UN Decade of Action for Road Safety, which focuses on 5 pillars of action:

    • Road infrastructure — ensuring that roads are built in a safe manner and that there are adequate crosswalks, safety barriers, and other safe infrastructure design on the roads
    • Vehicle safety — ensuring that vehicles are built safely
    • Changing behavior — reducing drunk driving, increasing use of seatbelts and helmets
    • Post-crash care — reaching and providing medical care for traffic victims as soon as possible after crashes occur
    • Capacity building and management — supporting training and management within countries to create capacity for sustainable road safety efforts

    The WHO, as the primary agent of the UN, is the FIA Foundation’s key partner in guiding the UN Decade of Action for Road Safety.

    Though important gains have been made in the first 2 years of the Decade of Action, at the current rate of improvement, the ambitious goals for the Decade cannot be met without more government involvement and wider public awareness of the issue. Road safety is still a neglected issue that is not widely recognized, despite causing more than 1.2 million deaths a year and at least 20 million serious injuries, resulting in devastating effects on people’s lives.”
    Notes from a conversation with T. Bella Dinh-Zarr, 8/2/13

  • 12.

    Leading the Worldwide Movement to Improve Road Safety, pg 10.

  • 13.

    Leading the Worldwide Movement to Improve Road Safety, pg 10.

  • 14.

    Esperato, Bishai, and Hyder 2012

  • 15.

    “From the evidence base reviewed, only 13 studies met our selection criteria. Such a limited base presents uncertainties about the potential impact of the modeled interventions. We tried to account for these uncertainties by allowing effectiveness to vary ±20 percent for each intervention. Despite this variability, RS-10 remains likely to be worth the investment. RS-10 is expected to save 10,310 lives over 5 years (discounted at 3%). VSL and $/LYS methods provide concordant results. Based on our estimates of each country’s VSL, the respective countries would be willing to pay $2.45 billion to lower these fatality risks (varying intervention effectiveness by ±20 percent, the corresponding range is $2.0–$2.9 billion). Analysis based on $/LYS shows that the RS-10 project will be cost-effective as long as its costs do not exceed $5.14 billion (under ±20% intervention effectiveness, the range = $4.1–$6.2 billion). Even at low efficacy, these estimates are still several orders of magnitude above the $125 million projected investment.
    Conclusion: RS-10 is likely to yield high returns for invested resources. The study’s chief limitation was the reliance on the world’s limited evidence base on how effective the road safety interventions will be. Planned evaluation of RS-10 will enhance planners’ ability to conduct economic assessments of road safety in developing countries.” Esperato, Bishai, and Hyder 2012, abstract.

  • 16.
    • Esperato, Bishai, and Hyder 2012 (quoted above) project that the program will save roughly 10,000 lives from an investment of $125 million, implying a cost-per-life saved of about $12,500.
    • We estimate a cost-per-life saved of around $2,500 for the Against Malaria Foundation: http://www.givewell.org/international/top-charities/AMF#Costperlifesaved
    • However, as expressed above, we believe it is inappropriate to take these figures at face value. We do these relatively quick cost-effectiveness estimates as a way of getting a very general sense of the possible magnitude of the problem and cost-effectiveness of the solution. We haven’t considered these at the same level of depth that we have our cost-effectiveness estimates for our top international aid charities.
  • 17.

    “After noticing a lack of political capacity to work on road safety issues, the FIA Foundation worked closely with the United Nations (UN) and WHO to make road safety a higher priority, resulting in the declaration of the UN Decade of Action for Road Safety 2011-2020.” Notes from a conversation with T. Bella Dinh-Zarr, 8/2/13.

  • 18.

    “In order to guide countries on taking concrete, national-level actions to achieve this goal, a Global Plan of Action was developed (5). This provides a practical tool to help governments and other national stakeholders develop national and local plans of action, while simultaneously providing a framework for coordinating activities at regional and global levels. National activities are based around five key pillars, as indicated (Figure 2).

    The UN General Assembly resolution also called for regular monitoring of global progress toward meeting targets identified in the Global Plan of Action. These targets are, in part, based on data highlighted in the first Global status report on road safety in 2009,1 and to this end, the resolution calls for the publication of further reports to provide and disseminate this information (6). This report, the second Global status report on road safety, meets this request and will provide the baseline data (from 2010) for monitoring progress through the Decade of Action.” @Global Status Report on Road Safety 2013: Supporting a Decade of Action, pg [email protected]

  • 19.

    Notes from a conversation with Margie Peden, 8/13/13:

    • “Bloomberg Philanthropies is funding a consortium of partners, including UIP, to work on road safety in 10 countries. The program ran pilot projects in 2008-2009 in Mexico, Vietnam, and Cambodia. The pilot projects were a success, particularly in Vietnam, and the program was scaled-up to 10 countries. These 10 countries account for about 60% of global road traffic deaths.
      The 10 countries were picked jointly by Bloomberg Philanthropies and UIP using a number of criteria, including the magnitude of the local problem, whether the country was at a “tipping point” for road safety, whether the country had good political will and governance, and whether the ministries of health and transport had the capacity to institute good practices. Within the selected countries, UIP had consultations with the ministries of health and transport and the implementing agencies to determine where the highest incidence of road traffic crashes were, and whether the capacity and political will existed to do road safety campaigns in those areas. There has been varying success in the 10 countries, with the most successful ones being those that met all of the initial criteria.
      In general, UIP has found that human capacity and political will are the bottlenecks to better road safety, rather than funding. UIP works with countries to determine where capacity and will exist and funding would be useful. As the program expands, political will increases because political leaders observe the success of the program in nearby areas and research is generated on the benefits of the program.”

    • “Recently, UIP’s biggest donor has been Bloomberg Philanthropies, which has pledged $125 million over 5 years to a consortium of partners to work on road safety.”
  • 20.

    Leading the Worldwide Movement to Improve Road Safety, pg 13.

  • 21.

    “The FIA (Fédération Internationale de l’Automobile) Foundation for the Automobile and Society is an international foundation based in London that was established in 2001. It donates about $7 million per year. Most of its grantmaking is for improving road safety in developing countries, though it makes grants for environmental issues related to transportation as well.” Notes from a conversation with T. Bella Dinh-Zarr, 8/2/13

  • 22.
    Notes from a conversation with T. Bella Dinh-Zarr, 8/2/13:
    • “In addition to the International Road Assessment Program (iRAP) described in more detail below, the FIA Foundation supports low-cost infrastructure efforts through Amend (an NGO) to improve road safety, such as placing speed bumps and crosswalks in high- risk school zones. Amend identifies dangerous school zones using police reports and hospital records related to traffic fatalities. Amend is working with several hundred schools near Dar es Salaam, Tanzania and Accra, Ghana. It collaborates with the Tanzanian and Ghanaian governments. The FIA Foundation has received preliminary reports suggesting that these programs have been successful.”
    • “The FIA Foundation supports the Global Helmet Vaccine Initiative (GHVI), through the Asia Injury Prevention Foundation (AIPF), which was instrumental to a successful lobbying effort that persuaded the Vietnamese government to pass a law requiring motorcyclists to wear helmets. Compliance rates were high; within the first year, helmet use rates changed from less than 10% to greater than 90%. Deaths due to motorcycle crashes fell by about 25%, and hospital admittance due to motorcycle crash injuries fell by more than 25%. The FIA Foundation is expanding similar campaigns to other countries such as Cambodia and Thailand, places where Bloomberg Philanthropies is also working.”
    • “It grants about $1 million per year to the International Road Assessment Program (iRAP), a non-profit composed of engineers who evaluate the quality of roads in 60-70 developing countries and recommend safety improvements to governments. Unfortunately, countries often do not have enough funding to implement iRAP’s suggestions, but more foreign aid and philanthropic contributions may help with this problem.
      Development banks, such as the World Bank, the Inter-American Development Bank, and others, spend about $4 billion on infrastructure in the developing world each year. However, the roads that development banks fund are not always safe. For example, the World Bank built a new $10 million road in Bangladesh, but an independent evaluation found it to be one of the most dangerous roads in the country. The FIA Foundation is a donor to the World Bank’s Global Road Safety Facility in hopes that future roads are built safely.”
  • 23.
    • “Eastern Alliance for Safe Sustainable Transport (EASST) — Eastern European partnership of NGOs and government officials that facilitates cross-border projects on sustainable transport and road safety.
    • Institute of Road Traffic Education (IRTE) — NGO formed by an interdisciplinary group to make the Indian roads safer through training, research, and policy.
    • Fundación Gonzalo Rodríguez (FGR) — Uruguayan-based NGO with a focus on road safety for children and vehicle safety.
    • Many other NGOs also work on road safety issues and belong to the UN Road Safety Collaboration (organized by WHO), but funding is a concern for all of them because safe roads are not a widely recognized issue publicly or politically.”

    Notes from a conversation with T. Bella Dinh-Zarr, 8/2/13

  • 24.

    “The WHO, World Bank, and other development banks are major international institutions involved in road safety issues, but it is a very small, usually less influential, part of these institutions that work on road safety.” Notes from a conversation with T. Bella Dinh-Zarr, 8/2/13

  • 25.

    “It is difficult to track total funding available for developing world road safety. The FIA Foundation and the Global Burden of Disease researchers have done some work on this.” Notes from a conversation with Margie Peden, 8/13/13

  • 26.

    “John Hopkins is conducting monitoring and evaluation of the Bloomberg Philanthropies program, which is currently 3.5 years into a 5-year timeline. The data will have metrics such as number of lives saved. Some data should be made public by the end of the year. UIP hopes that this data will be helpful in convincing mayors and governors to take on UIP projects.” Notes from a conversation with Margie Peden, 8/13/13