1st Safe Community-Conference

on Cost Calculation and Cost-effectiveness in Injury Prevention and Safety Promotion Co-sponsored by the World Health Organisation

CONFERENCE - REPORT

Viborg County, Denmark • 30 September - 3 October 2001

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Contents

Welcome .....................................................................................................

5

Programme .................................................................................................

6

International Scientific and Planning Committee ......................................

10

Local Organizing Committee .....................................................................

10

CV - Key-note Speakers / Reflection Team .................................................

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Key-note lecturer Session A2 ........................................................................................... Session A4 ........................................................................................... Session B2........................................................................................... Session B3........................................................................................... Session C2 ..........................................................................................

17 39 57 63 69

Abstracts Session B1........................................................................................... Session C1 ..........................................................................................

81 99

Posters Session A3 ...........................................................................................

117

Authors index .............................................................................................

136

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Mr. Bent Hansen, County Mayor, Viborg County Council

Mr. Leif Svanström, WHO-Collaborating Centre on Community Safety Promotion

Mr. Arne Rolighed, Minister of Health, Denmark

It is with great pleasure that we here in Viborg County invite you to the international conference „1st Safe-Community Conference on Cost Calculation and Costeffectiveness in Injury Prevention and Safety Promotion“. The conference has been organized in cooperation with „WHO Collaborating Centre on Community Safety Promotion“ and the Karolinska Institute, Sweden. Injuries and deaths as a result of accidents are one of the major global health problems. Therefore knowledge of and accessibility to cost calculation models in connection with accidents is very important. These calculations are - with all due respect for the right to and equity in health - a decisive factor when making the best

possible priorities in the field of health politics.

Welcome to the 1st Safe Community Conference on Cost Calculation and Costeffectiveness in Injury Prevention and Safety Promotion in Viborg, Denmark, 30 September - 3 October 2001. The conference is organized in collaboration between Viborg County, „WHO Collaborating Centre on Community Safety Promotion“ and the Karolinska Institute, Sweden. In Prague in the autumn of 1999, a gathering of experts and practitioners from all parts of the world decided to draft a “ Manual for Cost Calculations in Safe Communities”.

The Manual is now tested by group of interested communities and by an expert group as well. The result of the test will be presented and discussed during the Conference in Viborg. I welcome you to actively take part in the further development of the Manual, but also to present studies of Cost of Injury type as well as on cost-benefit and costefficiency. But above all – those of you who have an interest into the area of Cost and Injuries you should attend.

It is with great pleasure that I send this invitation to the international conference: 1st Safe Community-Conference on Cost Calculation and Cost-effectiveness in Injury Prevention and Safety Promotion.

The subject of the conference is very essential. Prevention of injuries and accidents is important: Above all to avoid human suffering, but also to limit the cost of repairs.

The conference is organized by Viborg County in co-operation with „WHO Collaborating Centre on Community Safety Promotion“ and the Karolinska Institute, Sweden, and it takes place in Viborg, Denmark, 30 September – 3 October 2001. It will bring together decision makers, administrators, researchers and policy planners in the spirit of debate, discussion and exchange.

I am looking forward to welcoming you in Viborg, where I hope for participation from all the world. I hope that we will have a both a profitable and intellectually stimulating conference and a pleasant social event.

Thus, the largest possible benefit is ensured for society as well as for individuals in the form of fewer injuries and a higher level of safety. In this important area the conference will act as a forum of learning, contact and exchange of experiences for experts and decision makers. Viborg County hosts a post-conference during which we will introduce Viborg County - A Safe Community. I look forward to welcoming you to Viborg County at the most beautiful time of the year in Denmark.

Welcome.

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Programme

Sunday, 30 September 2001 08.30 Registration. Golf Hotel, Viborg 10.45 Guided bus tour / Welcome-lunch. (Departure: Golf Hotel / Arrival: Hotels)

18.45- Reception/Concert The City Hall of Viborg/The Cathedral of Viborg (Music: Det Jydske Ensemble - Carl Nielsen)

Tuesday, 2 October 2001 Monday, 1 October 2001 09.00 Session A1 - Plenary (Chair: Søren Kølster; Viborg County, Denmark) • Opening session • Opening - Danish Minister of Health, Arne Rolighed • Welcome - County Mayor Bent Hansen, Viborg County, Denmark • WHO, Collaborating Centre, Leif Svanstrøm • Viborg County-injury prevention and safety promotion - County Mayor Bent Hansen, Viborg County, Denmark • General introduction / information 10.00 Coffee 10.30 Session A2 - Plenary (Chair: Jes Søgaard, Denmark) • Cost calculation (why - when - how - elements) Costs and accidents - an overview of the main issues. Kjeld Møller Pedersen, Denmark • Cost calculation (viewpoint: political - cultural - administrative - ethical - socio-economic) The Role of injury costing in the World Health Organization’s violence and injury prevention activities. Alexander Butchart, Switzerland Safety Promotion - Individual or societal approaches and community participation Katharina Purtscher, Austria Social costs of Road Traffic Crashes in India. Dinesh Mohan, India 12.30 Lunch 13.30 Session A3 Poster presentation 15.00 Coffee 15.30 Session A4 - Plenary (Chair: Diana Hudson, USA) • Cost calculation - Methods: cost - direct/ indirect/intangible (data - methods - strength/ weakness - relation to vulnerable gruoups) Development of a model for continuous monitoring of direct medical costs Saakje Mulder, The Netherlands Computing and presenting injury costs Ted R. Miller, USA 6

09.00 Abstract session B1-1: Traffic Chair: Bo Henricsson, Sweden. B1 – 1-1 Evaluation of Social Costs of Road Traffic accidents in Bangladesh Alam, Jobair Bin, Bangladesh B1 – 1-2 Cost of road accidents in Kerala State of India Chand, Mahesh, India B1 – 1-3 Road Traffic Injuries. A major public Health problem in Egypt El-Sayed, Hesham, Egypt B1 – 1-4 Increased bicycle-helmet wearing reduce injuries and save costs. Experiences from Sweden Ekman, Robert, Sweden Abstract session B1-2: Traffic Chair: Kim Borden, Canada. B1 – 2-1 Computerisation of road traffic accident cost – pilot study in Bangalore City Krishnamurthy, Nagaraja, India B1 – 2-2 The economic impact of Road Accidents in theUnited Arab Emirates Haj Ahmed, Mohammed Elsadig, United Arab Emirates B1 – 2-3 The development in injuries following severe road traffic accident with motor vehicles Larsen, Lars Binderup, Denmark B1 – 2-4 Road traffic accidents in Republic of Macedonia Tozija, Fimka, Macedoni Abstract session B1-3: Models/Programme Chair: Hanne Bonne Jørgensen, Denmark. B1 – 3-1 Costs of injury in a Safe Community region in Austria – a pragmatic approach to injury costing Bauer, Robert, Austria

B1 – 3-2 Calculation of the projected costs of a South African Home Visitation Programme Bender, Susanne, South Africa B1 – 3-3 Cost effective injury control programme Ramalingam, Alagu Muhtu, India B1 – 3-4 Medical Care Cost of non-fatal injuries in Taiwan Pai, Lu, Taiwan

10.30 11.00

12.30 13.30

Abstract session B1-4: Violence/Work Chair: Carol Eamer, Canada. B1 – 4-1 Cost Calculation of Violence (Incidence) Dalal, Koustuv, India B1 – 4-2 Domestic violence against adolescents in Bangladesh Rahman, M. Mizanur, Bangladesh B1 – 4-3 Cost of Occupational Accidents in companies: Activity Based Analysis and Information System Integration Rikhardsson, Pall, Denmark. Coffee Session B2 - Plenary (Chair: Bjarne Jansson, Sweden) • WHO Safe Community The Value of being a Safe Communities Where did we come from and where are we going? Leif Svanström, Sweden Cost calculations and Safe Communities - A Manual Leif Svanström, Sweden • The Cost Calculation Manual (idea-contensdemonstration-test-future) The Story behind - The Cost Calculation Manual Michal Grivna, Czech Republic The Cost Calculation Manual - Demonstration Kent Lindquist, Sweden Lunch Session B3 - Plenary (Chair: Leif Svanström, Sweden) • The Cost Calculation Manual (idea – contents – demonstration - test - future) A manual for cost calculation in safe community practice - results from two field studies. Bjarne Jansson, Sweden

The Cost Calculation Manual - Test - Future Kent Lindquist, Sweden 15.00 Coffee 15.30 Session B4 • Discussion of the Manual (3 parallel sessions: Asia - Nordic - Rest of the World) 18.30 Gala Banquet/dance Designation: Viborg County - A Safe Community Tinghallen, Viborg (Music: Prinsens Livregiment tabel music / Collage - popular music)

Wednesday, 3 October 2001 09.00 Abstract session C1-1: Traffic Chair: Søren Kølster, Denmark. C1 – 1-1 A Study on the Cost Effectiveness of Road Safety Measures in Preventing Socio-economic losses to the Indian society Reddy, T. S., India C1 – 1-2 Disaggregated Costing of Road Traffic Accident: Implication for Developing Countries. Hoque, Mazharul, Bangladesh C1 – 1-3 How would setting policy priorities according to cost-benefit analyses affect Elvik, Rune, Norway Abstract Session C1-2: Models/programme Chair: Martha Stowe, USA. C1 – 2-1 Societal Perspective and Cost effectiveness of health and safety promotion Intervention Johansson, Pia, Sweden C1 – 2-2 Cost Calculation of Traffic Accidents in lowincome countries: Some methodological issues” Rahman, Fazlur, Bangladesh C1 – 2-3 Who gets the benefits from injury prevention in Tartu Uusküla, Lenno, Estonia C1 – 2-4 Trauma Care is a costly affair at Bangalore City, India – Few tips to bring it down. Krishnamurthy, Nagaraja, India

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Abstract Session C1-3: Models/Programme Chair: Diana Hudson, USA C1 – 3-1 Costing an Arm and a Leg: A Review of the South African Injury Costing Literature in Three Dimensions Bowman, Brett, South Africa C1 – 3-2 Cost Estimation of Injury among Community and at a major hospital of Delhi Verma, Pramod Kumar, India C1 – 3-3 Cost-effectiveness in childhood injury surveillance systems. A preliminary analysis Concepcion, Tomas, Spain C1 – 3-4 Measurement Criteria for Evaluating Success? Safer City Program Calgary, Alberta, Canada Eamer, Carol, Canada Abstract Session C1-4: Work Chair: Birger Aaen-Larsen, Denmark. C1 – 4-1 Prevention of Occupational Accidents and the economic Consequences Jørgensen, Kirsten, Denmark C1 – 4-2 Cost of work-related injuries among injured workers in Lebanon 1998 Fayad, Rim, Lebanon C1 – 4-3 A Study of Variables Contributing to accidents among coal workers Dehdashti, Alireza, Iran C1 – 4-4 A Study on the Application of Industrial Ergonomics in the Workplace: Its Implication to Social Health Services. Escorpizo, Reuben, Philippines 10.30 Coffee

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11.00 Session C2 - Plenary (Chair: Ted Miller, USA) • Priority models (equity - distribution of costs) Cost-effectiveness analyses to set priorities and financial decisions in safety promotions. Jes Søgaard, Denmark Valuing Road Traffic Safety - A comparison of methods for estimating costs for fatal casualty in different countries. Ulf Persson, Sweden Cost calculation and injury prevention - issues of science, rationality and ethics. David Ball, United Kingdom 12.30 Lunch 13.30 Session C3 - Plenary (Chair: Leif Svanström, Sweden) • Discussion (delegates - keynote speakers Reflection Team) 15.00 Session C4 - Plenary (Chair: Søren Kølster, Viborg County, Denmark) • Closing session (Future of the Manual - Safe Community value - Closing)

Reflection Team Børge Ytterstad, Ass. Prof., MD, PhD Harstad Hospital, 9400 Harstad, Norway [email protected] Finn Kamper Jørgensen, Director, MD National Institute of Public Health, Svanemøllevej 25, 2100 København Ø, Denmark [email protected]

Programme (accompanying person)

Sunday, 30 September 2001 08.30 Registration, Golf Hotel, Viborg 10.45 Guided bus tour / Welcome-lunch (Departure: Golf Hotel / Arrival: Hotels)

Monday, 1 October 2001 10.00 Guided walk in the City of Viborg (Departure: Golf Hotel / Arrival: Cathedral Place) 13.00 Guided bus tour in Viborg City and surroundings (Departure: Cathedral Place / Arrival: Hotels) 18.45 Reception/Concert The City Hall of Viborg/The Cathedral of Viborg (Music: Det Jydske Ensemble - Carl Nielsen)

Tuesday, 2 October 2001 09.00 Guided bus tour to the City of Århus 18.30 Gala banquet/dance Disignation: Viborg County - A Safe Community Tinghallen, Viborg (Music: Prinsens Livregiment tabel music / Collage - popular music)

Wednesday ctober 2001 ednesday,, 3 O October Free

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International Scientific and Planning Committee

Søren Kølster, Coordinator - Prevention and Health Promotion,Viborg County, Denmark, (Chairman). [email protected] Robert Bauer, MD, SicherLeben, Austria. [email protected] Alex Butchart, Prof. University of South Africa. South Africa. [email protected] Carol Eamer, Calgary Injury Prevention Coalition, Canada. [email protected] Michal Grivna, MD, MPH, Charles University, Czech Republic. [email protected] Bo Henricson, MD, Norbotten County Council, Sweden. [email protected] Diana Hudson, MPH, The Alaska Injury Prevention Center, USA. [email protected] Kim Borden, Data Manager, Alberta Centre for Injury Control and Research, Canada. [email protected] Doug Langtry, Rainy River Valley Safety Coalition, Canada. [email protected] Lars Lindholm, Ph.D, Umeå University, Sweden. [email protected] Kent Lindquist, Ass. Prof., Linkøping University, Sweden. [email protected] Saakje Mulder, MSc., Consumer Safety Institute, Netherlands. [email protected] Marthe Stowe, Injury Prevention Centre of Greater Dallas, USA. [email protected] Leif Svanstrøm, MD, PhD, Prof., Karolinska Institutet, Sweden. Chairman. [email protected] Wendy Watson, Researcher, Monash University, Australia. [email protected] Ted R. Miller, PhD, Director, Pacific Institute for Research and Evaluation, USA. [email protected] Katharina Purtscher, MD,Austrian Committee for Injury Prevention in Childhood, [email protected] Moa Sundström, Coordinator, Karolinska Institutet, Sweden. [email protected] Jes Søgaard, Prof., Director, Danish Institute for Health Services, Research and Development, Denmark. [email protected] Hanne Bonne Jørgensen, Head of Section, Ministry of Health, Denmark. [email protected] Sandrine Turbide, WHO, Denmark. [email protected] Birger Aaen-Larsen, MD, MPH, Consultant, Viborg County, Denmark. [email protected]

Local Organizing Committee Søren Kølster, Viborg County, Denmark. Chairman. [email protected] Karin Kristensen, Viborg County, Denmark. Secretary. [email protected] Helle Schapiro, Viborg County, Denmark. [email protected] Roar Ploug, Viborg County, Denmark. [email protected] Finn Møller, Viborg County, Denmark. [email protected] Jette Bjerring, Viborg County. [email protected] Charlotte Kastbjerg, Viborg Tourist Office, Denmark. [email protected]

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1st Safe Community-Conference Viborg County, Denmark 30 September - 3 October 2001

CV Key-note Speakers Reflection Team

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Key-note Speakers

Kjeld Møller Pedersen Age: 51 Positions: • 1975 – 1987: Odense University • 1985: professor of health economics • 1987 – 1991: CEO, County Health Service, County of Vejle • 1991 – 1999: the LEGO Group • 1991 – 1994: senior vice president, LEGO System AS, (finance, IT, HR) • 1994 – 1999: executive corporate vice president, LEGO A/S, the mother company of the LEGO Group, Corporate Affairs(IT HR, PR) • 1999 : professor, health economics and health policy, University of Southern Denmark, Odense). Research • 80+ articles and reports (solo or co-authored) • 5 books Committees & board numerous appointments past and present, governmental as well as private sector.

Alexander Butchart Dr. Alexander Butchart is a scientist at the World Health Organization, where he is Team Leader a.i. for Violence Prevention within the Department of Injuries and Violence Prevention. Prior to commencing work with WHO in May 2001, he was an Associate Professor in the University of South Africa’s Institute for Social and Health Sciences. After completing his MA in Clinical Psychology in 1986, he worked as coordinator of a neurotrauma outpatient clinic until 1989 when he coordinated the first epidemiological study of non-fatal injuries in Johannesburg, South Africa. In 1994 he was a steering committee member of the Goldstone Commission’s investigation into the impact of political violence on children. He completed his doctorate in 1995, with a focus on the sociology of western clinical medicine, psychology and public health as applied to Black South Africans over the nineteenth and twentieth centuries. In 1999 he was visiting scientist in the Karolinska Institutet’s Division of Social Medicine, where he researched the global epidemiology and macro-determinants of youth violence. From 1998 to April 2001 he was lead scientist of the South African Violence and Injury Surveillance Consortium, and in collaboration with the Uganda-based Injury Prevention Initiative for Africa has participated in 12

training violence and injury prevention workers from a large number of African countries.

Katharina Purtscher Child and Adolescent Psychiatrist, Psychotherapist Working at the Department of Pediatric Surgery as a psychotherapist for children and adolescents since many years. Focusing on psychological impact and of severe trauma (unintentional and intentional injuries). Member of the Austrian Committee for Injury Prevention in Childhood. Research on psycho-social risk factors of childhood injuries. Founding member of ESCON (European Safe Community Network)

Dinesh Mohan Professor Dinesh Mohan obtained his Bachelor’s degree in Mechanical Engineering from IlT Bombay, Masters degree in Mechanical & Aerospace Engineering from University of Delaware and Masters and Ph.D. in Bioengineering form University of Michigan. He worked at the University of Michigan Transportation Research Institute and then at the Insurance Institute for Highway Safety in Washington D.C. before joining IlT Delhi. He has been involved in research on safety issues for the last three decades and is the Secretary General of the 5th World Conference on Injury Prevention and Control to be held in Delhi 5-8 March 2000

Saakje Mulder Mrs Saakje Mulder is epidemiologist and manager of the Unit of Epidemiology of the Consumer Safety Institute in Amsterdam, the Netherlands. She is as such responsible for collecting and analysing injury surveillance data, indepth injury research, developing indicators for prioritysetting (including costs of injuries), and standardisation of injury classifications. She is project leader of several national and international projects on all aspects of injury epidemiology (feasibility of injury surveillance systems, policy concerning injury surveillance systems, data analysis, national household surveys, costs of injury studies, classifications, in depth studies, minimum data sets on injuries, etcetera). She also

chairs several national and international working groups and committees concerning injury epidemiology.

Ted R. Miller Internationally recognized safety economist Ted R. Miller, Ph.D., directs the 45-person Public Services Research Institute of the Pacific Institute for Research and Evaluation. PIRE is a 25-year-old non-profit policy research organization. A University of Pennsylvania graduate, Dr. Miller has 30 years of experience in economics and operations research. Dr. Miller is among the most widely published analysts of injury costs and prevention savings, with more than 100 articles and books. He began working in the area in 1982. From the start, his cost estimates included the value of pain, suffering, and lost quality of life, as well as out-ofpocket costs and work losses. They are used extensively in regulatory analysis. His violence and gunshot wound costs are featured in legislative debates in Canada and the U.S. His highway crash costs and other unintentional injury costs are the standards for the U.S. government, most State governments, British Columbia, and New Zealand, as well as Mothers Against Drinking and Driving, the National SAFE KIDS Campaign, and the National Safety Council. He built the US Consumer Product Safety Commission’s injury cost model and recently completed an occupational injury and illness cost model. Four publications of Dr. Miller’s seem especially relevant to this conference. The first, in the book Injury Prevention and Control (Taylor and Francis 2000), presents the basics of injury costing and reviews national injury costing efforts worldwide. The second, in the May 2000 issue of the Journal of Transport Economics and Policy, estimates what people are willing to pay for safety in almost 50 countries. The third, in the June 2000 issue of Medical Care, compares return on investment for 84 safety interventions. The last, in the December 1997 issue of Injury Prevention, is a primer on cost-benefit methods. Dr. Miller is a Fellow of the Association for the Advancement of Automotive Medicine. In 1996, Nationwide Insurance honored him with an On Your Side Highway Safety Award for developing and leading the Children’s Safety Network Economics and Insurance Resource Center. In 1999, he received the Excellence in Science Award from the Injury Control and Emergency Health Services Section of the American Public Health Association. He serves on the editorial boards of Accident Analysis and Prevention, the Journal of Safety Research, and the Journal of Forensic Economics.

The Washington Post calls Dr. Miller a national oracle on the financial damage caused by substance abuse and injuries. His work shows convincingly that safety saves money as well as lives.

Leif Svanström M.D., Ph.D. Professor Dr. Svanström has spent more than thirty years in Social Medicine and Health and Safety Promotion. His principl line of research and teaching is Injury Epidemiology and Safety Promotion. In the 1960s he conducted a number of descriptive and analytical studies, and in the 1970s began studying home and occupational injuries. In 1974 he introduced the community approach to safety promotion; this, the „Falkoping Model“, has heavily influenced Swedish and international community safety work. He chaired the First World Conference of Accident and Injury Prevention held in Stockholm, Sweden 1989 and is a member of the International Organization Committee for the following World Conferences. At present Dr Svanström is involved in WHO‘s Global Programme on Injury Control and is the Head of the WHO Collaborating Centre on Community Safety Promotion at the Karolinska Institute in Stockholm, Sweden.

Michal Grivna M.D., M.P .H., Director of Center for Childhood Injury Epidemiology and Prevention, and Assistant Professor 2nd Medical School, Charles University, Czech Republic. He graduated in Medicine at Charles University, Prague, Czech Republic and in Public Health at Medical College of Virginia -Virginia Commonwealth University , Richmond, USA. His research includes injuries in childhood, f.e. bicycle related, playground injuries. Dr. Grivna is involved in pre- and post-graduate medical education. He coordinates Safe Community movement in the Czech Republic. He serves as Chairman of Childhood Injury Prevention Board of the Czech Pediatric Association.

Kent Lindkvist Born 1948 B.A. (with among other things 80 points sociology), Uppsala : University, 1970. Master ofPublic Health, Nordiska Vårdhogskolan, Gothenburg, 1988. Doctor of 13

Medicine, Linkoping University, 1995. Senior lecturer, Linkoping University, 1999. Employments: Low income living standards investigation 1970-72 as demonstrator. Spri 1973-74 as planning assistant. Inquiry secretary, Ha1mstad county hospita1, 1975-77. Acting director of Motala general hospital, 1978-92 and as research leader 1993-94. Linkoping University 1995ongoing as demonstrator. Responsible for the injury research group at the Department of Social Medicine and Public Health Science, Institution of Health and Environment, Linkoping University. Responsible for scientific development of Motala Safe Community according to the agreement with WHO Collaborating Centre on Community Safety Promotion at the Karolinska institute, Folkhälsoinstitutet, the County Council of Östergötland, Mota1a municipality and Linkoping University. Responsible for the execution of the county action plan for the prevention of accidents in Östergötland, entailing - among other things - coordination of injury registration for health care establishments in Östergötland. Member of the County Council’s Folkhälsoråd (public health board) and also the County Council’s expert in questions of prevention of injuries. Chairman of the Swedish action group for Safe Community within Folkhälsoinstitutet’s national injury’s program.

Bjarne Jansson PhD from Karolinska Institutet(medical faculty)in 1988, associate professor in community medicine (1991) at the dept of Public Health Sciences, division of Social Medicine. Course director for the Master of Public Health Program at Karolinska Institutet, Stockholm, Sweden. The principle line of research is evaluation of injury surveillance systems and implementation and evaluation of safe community practice including models for quality assurance. Also experiences from research on occupational and environmental hazards and prevention focusing chemicals in industry, dioxin (TCDD) from municipal incinerators, radon and lung cancer, UV exposure and skin cancer, teratogenic surveillance and redistributive effects of social insurance reimbursements. Currently, focusing on vulnerable groups for injuries related to epilepsy, drugs and alcohol, repetitive injuries, gender inbalance, and costs of injuries and savings. Responible

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for planning of short courses and full programs in public health sciences at the Nordic School of Public Health and Karolinska Institutet.

Ulf Persson M.Sc. in Economics, Ph.L., is responsible for the research program on Valuation of Risk and Safety at the Department of Technology and Society, Lund Institute of Technology, Lund University and Program Director for Economic Evaluations & Pharmaceutical Economics, with particular regard to the introduction and utilization of medical technologies, at the Swedish Institute for Health Economics (IHE).

Jes Søgaard Director and Professor Born 29 July 1954 Education: MSc (Econ), Odense University, 1980/81 Positions: Scholar Student, Research Fellow, Assistant Professor and Professor at Odense University. Assistant Professor at University of Aarhus and Visiting Professor at University of Linköping. Since 1998 Director of DSI Danish Institute for Health Services Research. Has published internationally and in Danish, on topics within health services research in general and health economics in particular. In 1994, received the prize “health service researcher of the year” from the Health Insurance Fund

David Ball David Ball is Professor of Risk Management in the School of Health, Biological and Environmental Sciences of Middlesex University in London. Previously he was Director of the Centre for Environmental and Risk Management at the University of East Anglia. David has worked on many different safety issues including nuclear power, the offshore sector, transportation, leisure, food safety and environmental protection. Although a physicist by training, he has strong interests in psycho-social, cultural, economic and legal aspects of safety decision making

Reflection Team

Børge Ytterstad

Finn Kamper-Jørgensen

04 15 43. MD, PHD. Private address: Ervik 9400, Harstad, Norway Consultant surgical dept. Harstad Hospital 9400, Harstad Associate professor University of Tromsø, Norway

Director MD, Ph D National Institute of Public Health Svanemollevej 25 2100 Copenhagen Denmark phone: + 45 39 20 77 77 Fax +45 39 20 80 10 e-mail: [email protected] www.dike.dk

Clinical work: Surgical work for 30 years. Specialist in general surgery and urology. Work abroad: Work as surgeon in Nigeria (former Biafra), Lebanon, Sweden and Spain. Honorary Research Fellow at Injury Prevention Research Center. University of Auckland. New Zealand. Publications: Over 30 publications, mostly on injury prevention. Awards: Received 22 September 1997 “Karl Evangs pris for helseopplysning” for 1997 (A national award for health information and promotion). U.S. Department of Transportation, Washington DC. National Highway Safety Administration awarded Børge Ytterstad, representing the Harstad Injury Prevention Study: International Safe Community „Traffic Safety Partnership Award“. Awarded at the 5th World Conference on Injury Prevention and Control in New Dehli, India 7. mars 2000. International work: Participated in a number of scientific committees for national and international conferences. Chaired the ICCH11 in Harstad Norway June 2000. Presently board member for the IUCH (International Union for Circumpolar Health) and Norwegian Safety Forum.

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1st Safe Community-Conference Viborg County, Denmark 30 September - 3 October 2001

Plenary Session A2 Monday, October 1st 2001

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Costs and accidents - an overview of the main issues Kjeld Møller Pedersen Professor of health economics University of Southern Denmark Presented at the 1st Safe Community Conference October 1, 2001 Viborg

Table of contenst Introduction .................................................................................................................................................... Cost-of-illness studies (cost-of-accidents and injuries studies) ........................................................................ - the elements of cost-of-illness analyses (cost of accidents analyses) ................................................................... - data requirements ...................................................................................................................................... - Example: direct costs .................................................................................................................................. Total cost .................................................................................................................................................... - Cost-calculation in practice ......................................................................................................................... - average and marginal costs .......................................................................................................................... - example: indirect costs ................................................................................................................................ And the use of COI? ........................................................................................................................................ Brief history of COI ........................................................................................................................................ Cost-effectiveness analysis ................................................................................................................................ - example: Cost-effectiveness analysis of a nurse delivered home exercise programme to prevent ........................ falls .............................................................................................................................................................. How should CEA results be used? ................................................................................................................... Bibliography ....................................................................................................................................................

Introduction Accidents are always associated with human, material or monetary costs – sometimes negligible but increasing with the severity of the accident. Through the years there has been a steady stream of analyses of the costs of accidents of type X or Y. However, many of them lack focus in the following sense: what is the intended use of the analysis? Is it intended to help decision makers allocate resources to various accident prevention activities, or is it aimed at getting an estimate of the total (societal, sectoral, or private) costs of injuries of type X or Y? The importance of clarifying the precise objective of a costing exercise is related to the simple fact that different cost concepts and categories apply depending on the precise objective of the costing study. Many erroneous conclusions have been drawn from cost analyses because this simple relationship is neglected. In the background statement for the conference it is noted that accidents and injuries are a major public health problem and that the diverted costs account for a considerable economic burden. The assessment of the cost and effectiveness of prevention programmes is crucial because resources for the different programmes are limited, and decision makers need to understand the cost-effectiveness of injury prevention. The statement finished by noting that to decrease the burden of illness and to improve the health status of the population, resources should be allocated as far as possible according to scientifically determined priorities

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2 3 3 5 7 9 9 13 15 16 19 19 20 20 22 24

The aim of this paper is to look at one part of the scientific enterprises surrounding accident prevention, namely the main issues surrounding costing. They will be introduced and evaluated critically. However, in order to do this it is necessary to look at the two major uses of cost analyses: cost-of-illness and cost-effectiveness (cost-utility analyses). As indicated in the first paragraph one cannot separate the objective of a costing exercise and the various cost concepts. Hence, a major issue is to show which cost concepts are relevant when and in which context. Furthermore, it will also be shown why investing time and effort in burden of illness studies, better known as cost-of-illness studies, COI, should be discouraged. Nevertheless, for expository reasons a rather thorough presentation of these studies will be made because many key notions can be introduced in this way. Furthermore, conditions under which they may be of some value will be identified. Following this basic ideas of cost-effectiveness analysis are introduced. There are many types of accidents and injuries, for instance: • traffic • occupational • leisure, e.g. sports and play ground accidents • Home accidents, e.g. falls, cuts • Violence, e.g from wife battering to bar brawls These categories can be subdivided by which body parts are inflicted, e.g. hip fractures, head/skull injuries, spinal core injuries, dislocations/sprains, and also by their seriousness, where a number of seriousness scales are available for categorization.

While recognizing the importance of the above distinctions, they are basically disregarded in the following because the basic ideas carry over regardless of classification. The only thing one should notice is: the more fine graded accidents and injuries one wants to analyse, i.e. neck of femur, ankle or MAIS3+ (= maximum abbreviated injury scales, where 3 and upwards indicate very serious injuries, with 6 being deadly), the more data demanding the costing exercise will be – or the more misleading the results may be if one relies on numbers related to ‘the average injury’ (be it whatever it may be) thinking that such numbers also are valid for the more finely graded injuries.

Cost-of-illness studies (cost-of-accidents and injuries studies) For almost 50 years it has been rather popular to calculate the costs of a disease, e.g. cancer, health damaging substances, e.g. tobacco or alcohol, or incidents damaging to health, e.g. accidents or violence. The term cost-ofillness, COI, has become the established term for this type of studies (eventhough WHO unfortunately more recently has tried to market the term burden-of-disease, BOD). - the elements of cost-of-illness analyses (cost of accidents analyses) A cost-of-illness analysis has two major cost categories: • direct costs • direct costs include medical costs related to diagnosis, the immediate and continued treatment of the disease (fractures, wounds etc. if we look at accidents), e.g. hospital costs (in-patient and outpatient), costs of GP services, rehabilitation, home care, nursing home, medicines plus non-medical costs, but still directly linked to the disease/ accident related injury, e.g. transport, special dietary needs, help from relatives • indirect costs • indirect costs are also known as productivity costs. They represent the value of forgone future production resulting from premature death, morbidity or disability caused by the disease/injury. These production losses are related to the market, e.g. a 39 year old person who is permanently disabled and cannot work gainfully for the rest of the normal ‘occupational life’, for instance to the expected retirement age of 62. But it may also be non-market production, for instance a 46 year old house wife who is permanently disabled. These costs can be calculated based either on • a prevalence approach • or • an incidence approach

The two approaches utilize roughly the same economic concepts, but are fundamentally different in their approach. The rationale of and thinking behind the prevalence approach is that disease and injury costs should be assigned to the years in which they are borne or are directly associated. This means that under this approach, direct costs and indirect cost (productivity losses) are assigned to the years in which they occur, and lost expected future earnings resulting from premature mortality are assigned to the year of death. In other words, during any one year, the focus is on the prevalence population, i.e. a stock concepts In contrast, the incidence approach follows the principle that the stream of costs associated with a disease or injury should be assigned to the year in which the stream begins. Both direct and indirect costs are ‘present-valued’ and assigned to the year where the injury or disease first appeared. For instance, if a person dies in a traffic or occupational accident this persons’ future earnings are discounted back to the year of death. The incidence approach will lead to an estimate of the costs in 2001 of the new cases that appeared during 2001 (or any other time period). Thus, under the incidence approach the focus is on the incident population, i.e. a flow concept. It is the approach that best provides an estimate of costs avoided if a case, e.g. an accident, can be avoided and thus appears to be the most relevant for accident and injury cost studies. But it is also rather data demanding, because ideally it requires good projections of the likely pattern of the disease from onset to death.. This may, however, be easier for injuries than for many diseases, i.e. a permanent disability probably does not change. But the projection of future treatment needs may be far more difficult to project reliably. In principle one can think of a third approach that may be termed ‘present year approach’ where one calculates the direct and indirect costs for a given year, e.g. 2000 . The numbers for direct costs will be (roughly) consistent with the actual costs for the health care sector if all major diseases and injuries are included. The indirect costs are made up of the value of output lost in 1975 due to mortality and morbidity in 1975 and previous years (to the extent that they carry on into 1975). But future losses are not included. In this approach discounting is not relevant. There are virtually no examples of this approach. It has been included here for contrast and logical reasons. The three approaches will give roughly the same numbers if one looks at acute conditions with short duration and no future effects. The discrepancies between results from the three approaches will grow with the average duration of the disease or condition. Based on a numerical example and logical reasoning Hartunian et al.(9) notes the prevalence approach results will be larger than those of the incidence approach. This will generally be the case 19

for diseases and injuries that produce long-term consequences. To the above two distinction we can now add a third, namely that of perspective. A calculation can be carried out from a societal perspective, a private perspective (the injured person, or that of the company employing a person injured in an occupational accident) or a sectoral budget perspective, i.e. in the Scandinavian countries it could be the effects of injuries and accidents on the public sector budgets in their totality or just for instance the health care budget, disregarding disability pension that are found on the social sector budget. There are distinct differences in terms of which and how many costs categories to include under each perspective. - data requirements Basically three types of data are needed to calculate the (total) costs-of-injuries. • P -> number of persons (‘cases’) afflicted (prevalence or incidence). Let Pi denote person i • X -> the quantity of services provided per case/person during the relevant stages: ambulance transport, diagnosis, treatment, rehabilitation, on-going ‘support’ treatment etc.. Let Xji denote services of type j provided to person i • C -> unit costs. Let Cji denote unit costs of service j.provided to person i, or Cji is the annual occupational income of person i For the first step this results in the total cost, TC, equation TC =

i

j

PiXjiCji i=...n, j=...m

Often analysts are interested in average cost per case (which for all purposes is equivalent to costs per injury). This is simply TC/n. To this we now add discounting – the present value formula. – This adds two new elements: the idea of a time profile (from onset to either death or normally expected withdrawal from the labour market) and the discount rate, i.e. the interest rate to be applied. Due to the future dimension we must also add the probability, p, that a person will alive at given ages (basically to be drawn from existing life tables). Discounting is simply an exercise reflecting the fact that future revenues and costs matter less and less the further into the future they occur and more and more the closer to the present they are. One may say that there is a time preference regarding the time stream of costs and revenues. An alternative way at looking at it is to consider it to be the opportunity costs of funds. However, irrespective of interpretation, the basic formula for discounting is the same. C stands for costs, r is the interest rate and k is the time period. 20

k

discounted - amount (present - value) =

Ck(1+r)-k

k=1

where k is the time period over which discounting takes places. For indirect costs k can be rather large. If a young person of 29 years dies in a traffic or occupational accident k will most likely be around 31 if expected time in the labour market is to around the age of 60. The effect of discounting over such a long time period is dramatic. 100 DKr discounted with 5% over 30 years is equal to 23 Dkr. There is some debate surrounding the ‘right’ discount rate, r. Should on simply pick the official interest declared by the Central Bank – at the time of writing 4.25% per year in Denmark – or should one opt for the one that most governmental Ministeries of Finance declare as the official. Today often around 5%. Or, is there a more theoretical satisfying rate that may be used? Theoretically it can be argued that one should use the socalled real rate of interest, i.e. an interest rate corrected for the fact that inflation expectation is often part of the interest rate. For instance, if inflation is expected to be 2%, then one should deduct this from any official rate. One practical way to get around the issue of picking the ‘true’ interest rate is simply to base your calculation on several interest rates, say a high, low and intermediate rate and see whether it substantially alters your calculations. A further consideration is whether or not your analyses are compared with other analyses.. In this case the base of comparison should at least be the same interest rate. To facilitate the following it will be centered around a recent Danish example, (1). It is a good piece of work with much careful data collection and sound reasoning. It is an analysis of the treatment costs following traffic injuries placed on or above MAIS3+ (maximum abbreviated injury scale where level 3 is serious, 4 is very serious, 5 is critical and 6 is fatal) - Example: direct costs Data collection was, among other things, based on a questionnaire mailed to a sample of traffic injured patients attending the Accident and Emergency Department (where all patients are seen before admitted to inhospital treatment) at Odense University Hospital, register information from the patient system at the hospital, use of primary care health services, use of social services etc. This information mainly pertains to quantities of services used. Cost information.was collected from a variety of sources – more on this later. There are three good practical pieces of advice to follow: • Try to describe typical treatment patterns/flows • Identity average quantities of services (separately from costs) at each point of the stage/flow chart • Identify unit costs. Being clear on these three points will facilitate comparison of studies, help identify sources of possible differences

and may make the cost data useful in other contexts than cost-of-illness analyses, e.g. cost-effectiveness analysis. It is always a good idea to try to make a small flow chart of the possible treatment paths for a typical injured patient and use it as a check list, i.e. from arrival in the accident and emergency department to number of days in the hospital, subsequent outpatient treatment and/or consultations with own GP or specialist, rehabilitation using for instance a physiotherapist, possible aids (crutches, wheel chair etc), help from relatives, medicines/ drugs etc.. This is basically an inventory of possible services that a patient may receive – and the purpose is to get an average picture of service utilization by the average injured patient (of given severity, bodily location of injury etc.) Based on detailed information about average quantities of services and unit-costs the following table was produced showing the average direct costs for MAIS3+ traffic casualties. Example of detailed break down of cost in a Danish study, table 5.11.1 (1)

Cost categories:

Hospital: • In-patient • Out-patient Miscellaneous • Other (health) care providers • Medicines/drugs • Rehabilitation/ Nursing home • Home help/aid • Aids/equipment • Transport • Private help • Misc. costs (legal aid, material damages) TOTAL AVERAGE COST PER CASE

Costs the first 2-3 years following accident, Dkr.

Expected costs in remaining life time DKr.

Total cost Dkr

101,746 1,026

0 0

101,746 1,026

218 927

495 10,882

713 11,809

20,884 8,175 2,068 4,277 815

296,898 73,767 8,974 17,392 0

317,782 81,942 11,041 21,669 0

499

0

499

142,686

427,189

569,875

Note: Dkr. 569,875 roughly equal $68,700 (exchange rate 1$ = 8.40 DKR) The fact that remaining life time is considered indicates that the incidence approach is used.

- Cost-calculation in practice Many think that unit costs – e.g. cost per bed-day, cost per discharged patient (‘case’), cost for an X-ray or labtest, cost for a consultation with a general practitioner or cost per hour of home aid – are easy to obtain. Simple! – Just go and ask the financial department at the hospital, right?. Wrong – in the majority of cases!

Why not just use market prices? In many countries there is no real market price for many health care services. This is true in for instance the Scandinavian countries and the UK, and in many other countries ‘charges’, for instance bed day prices for hospital stay, are not anything approaching real market prices. Often charges for a variety of reasons do not reflect the underlying costs. The reasons may by anything from accounting conventions to strategic considerations, for instance cross subsidizing certain activities to penetrate the market. As a fairly general rule one can say that charges do not reflect costs, and one should be careful in using charges as approximations of costs. One exeception are prices for medicines. There is a market price and it should be used, but it rarely reflects perfect competition but rather monopoly pricing if the patent is still valid or oligopolistic competion if the patent has expired. In sum then, a careful analysis requires a hard look at costs/costing. First one should consider whether the relevant unit cost concept is average or marginal cost and can one get it. Secondly, one should check how the concepts are operationalised and calculated in practice. There is a considerable divide between the theoretical correct and what is obtainable in practice. Economists have great theoretical concepts (in their mathematical model world)– but often have a hard time to find a reasonable approximation for it in practice. Practitioners doing COI and other forms of economic analyses should be aware of this as should users of the analyses. The process of calculating unit costs will be discussed in some detail to call attention to the often shaky ground (= many compromises during allocation) on which unit costs are calculated – but communicaed without many reservations. Figure 1 illustrates one of the standard approaches to calculating unit costs (‘product costs’) in a hospital. It is a model that is or has been frequently used in private industry. In many respects one can say that cost allocation and hence calculation of unit costs is an art. The tricky part is allocation of the so-called overhead costs (also called indirect or fixed costs, i.e. costs that do not vary in the short and intermediate term with production/ activity volume and as such do not have a direct causeand-effect relationship with the final outputs of the organization: diagnosis, treatment and nursing of patients). An important assumption to be made at the outset concerns capacity utilization. Is the hospital working at 70, 80, 90 or 100% capacity utilization? It makes a dramatic difference whether incurred costs are allocated across 7000, 8000, 9000 or 10000 units (cases, patients etc).

21

Figure 1: One approach to calculating unit costs (‘product costs’)

There are many choices to be made in the allocation process, choices dictated by pragmatic reasons and rarely can one identify ‘right’ solutions (whereas it is possible to identiy clearly wrong solutions). The basic idea is to try to allocate all costs to the products/outputs placed to the far right in the figure. This is done by proceeding in a step-wise fashion, left to right, hence the term step-down allocation. In the figure hospital departments are placed based on how close a relationship (‘cause-and-effect’) there is with the final output activity (treatment of patients). It is clear that management activities, building maintenance, engineering etc. are far removed whereas lab. tests and xrays are closer, and the bed departments and out-patient departments are where diagnosis, treatment and nursing take place. The chart of accounts and the bookkeeping done accordingly is the point of departure. All running/operational costs are registered in the bookkeeping office based on the chart of accounts. The type of chart of accounts used in many respects determines the additional effort needed to calculate unit costs. If the chart of accounts is detailed, i.e. major cost categories, for instance wages and materials, are initially allocated not only to major hospital departments but to subunits, i.e. a section of a bed department, life is made much easier when allocating – and if, on top of this, there is a purpose code (patient treatment, research, maintenance etc.) things are great. This is indicated by the ‘directly allocated departmental costs’ in figure 1. The next step is to allocate costs one step further, namely to the ‘final cost bearer’, i.e. the departments where 22

patients are treated. This is usually not done automatically but is part of the ‘costing exercise’. . For instance, it is possible to allocate much of the kitchen costs in this way and most of the costs in the clinical service departments. The critical point is on which basis to allocate those costs. The allocation basis should be relevant, i.e. reflecting treatment activities, and (fairly) easy to obtain. One way to allocate for instance kitchen costs would be to use the average number of patients in the bed departments over a period of time. This is, however, not a precise allocation but probably a more detailed allocation could not justify developing a more detailed allocation basis and the associated increased data registration. Obviously, departments using many special diets etc. do use more kitchen resources, but is it worthwhile to do full justice? For the laboratories there usually exist two type of registrations: 1. which departments (and most often actually named patients in a given department) have received how many tests, and 2.a weighting system for lab tests so that tests requiring more analyzer time, ingredients, and laboratory technician time is assigned higher weights. In this way lab. costs can be carried forward to bed departments and out-patient departments using number of weighted lab tests as the allocation basis. How are ‘true’ overhead costs allocated, those costs that bear no direct cause-effect-relationship to treatment, i.e. management, reception, building maintenance, heating, water-and electricity etc. Together a rather important component of total hospital costs. To this one could add building depreciation and depreciation for much of the equipment, e.g. IT, but not analyzers in the labs or x-ray machines. In what is called full costing these costs are allocated to the final cost bearers. The allocation is somewhat arbitrary because the direct relationship to patient treatment cannot be established. However,

management costs may be allocated using number of patients treated thus assuming that there is a proportional relationship. Similarly, heating and building maintenance may be allocated based on number of square meters used by a department (or there may be ‘heating meters’ in each department registering exactly how heating the department is using – the same may hold for electricity).

least is balance between revenues generated through charges (bed day prices, DRG-prices etc.) and costs incurred. It is for this reason that one should try to understand how costs are calculated in practice and through this understanding try to get relevant data, for instance some ‘intermediate’ results of the process described above.

After that costs step by step have been moved to the final cost bearers (departments carrying out treatment) those costs are then divided by a measure of output, e.g. patients, bed-days, out-patient visits and one arrives at the average cost per unit. Often one does not distinguish between the various types of output but just assumes a homogenous output, for instance bed days. More recently the introduction of DRG (diagnosis related groups – a system whereby patients are divided into roughly 500 groups and in principle costed separately) has introduced attempts to maker finer distinctions. It is in the final step that the question of capacity utilization comes up. Should one divide by last years’ number of bed days or patients treated? Maybe capacity utilization was only 75% - but in principle it could be increased to 85% at negligible costs. It makes a difference and it is a difficult choice.

The marginal cost is the cost of producing one extra unit of output. Marginal costs then are lower than average costs.

- average and marginal costs Often the point of interest in many analyses is a simple question: what happens if we reduce the number of patients/bed days/out-patient visits etc? What are the savings? Or conversely, what happens if we increase activity because a new treatment is introduced. For instance, the implied argument behind many cost-ofinjury analyses is that if the direct costs are so and so, then one can save this amount if the injury type is eliminated or at least it is reduced in proportion to successful prevention activities. Similarly, in costeffectiveness analyses to be discussed below, one is interested in the net costs of introducing a new treatment. Net costs are the costs of introducing the new treatment corrected for possible savings due to elimination of other treatments. If one has a situation where an orthopaedic department treats for instance 3,500 patients per year, and the number of patients is reduced by 100 per year (3%) due to a successful injury prevention programme, it is fairly obvious that the savings (cost reductions) are not going to be equal to 100 times the average cost per patient. Rather it is much lower. For many purposes it is this number one is interested in and should use in actual cost of accident analyses. In the above example where the average costs per injury were calculated to roughly 0,5 million DKr, it is obvious that this is not the amount avoided if the number accidents are reduced by one – or by10 or 50 for that matter. It is important to remember that most cost accounting systems are not set up to be used for this purpose. Rather, cost accounting is carried out to established cost-based charges based on the assumption that the hospital must recover all costs, i.e. that there at

The typical step-down analysis results in average costs, but in principle one should use marginal costs. However, whether one can get a fair approximation of marginal costs is quite another issue. If we look at the costallocation process above, one first approximation would delete from the unit costs that are not directly (causeeffect) related to patient treatment. It is still a very crude approximation but shows why insight into the underlying cost-allocation process is important. Maybe one can get without much additional effort this ‘marginal’ information and not the average. Consider the example in the box below where the authors’ argue for the use of average costs. It follows the standard text book line of reasoning, but is really of much less or no relevance in the short run, and for practical decision making it can be grossly misleading. Which type of intervention for instance, would have an effect of reducing the size of a hospital. Possibly the elimination of cancer or cardiovascular diseases. The point is probably that the authors have been able to obtain average costs and then try to justify that. Note also that the full ‘path of costs’ are not included – for understandable and practical reasons, but nevertheless raising the question of the relevance of such an exercise. Example of arguments for use of average cost and data collection Conclusion in article on ‘Estimating the costs of hip fracture and potential savings’, (37): ‘The estimated hip fracture cost for an average woman between 50 and 100 years ranged from SEK 142,000 to SEK 406,000. For women who survived, cost savings were present in all ages and ranged from SEK 107,00 to SEK 346,000’ (p. 264). The argument for using average costs rather than marginal/incremental costs runs as follows: ‘The values (…quantities) … were then multiplied by the average unit costs, which include both variable and fixed costs. It is important also to include fixed costs using a long-trem perspective, because in the long run all costs become variable. (For example, by preventing fractures it may be possible in time to decrease the number of hospital beds and to eventually build smaller hospitals). And how cost data were collected: The average unit cost for orthopaedic and other acute hospital care were extracted from the Huddinge University Hospital patient-related accounting system, whereas the average unit cost for geriatric care was calculated by the geriatric department the Huddinge 23

University Hospital. The average unit costs for nursing home, home for the elderly, group residence, and municipal home help were collected from the social welfare authority. … Due to limitations in the data, it was not possible to include all relevant costs in the analysis’ (p. 256-57). – It should be noted that details on costing were reported in a separate article, (38). - example: indirect costs To finalize the discussion of cost-of-accidents analyses there only remains to address briefly the indirect costs of injuries. As an illustration a Danish cost-of-occupational injuries and diseased will be used, (2). The pertinent numbers are shown in table 2 where the direct costs are also shown to illustrate a ‘complete’ analysis. Table 2: Cost-of-occupational injuries and diseases, prevalence approach (indirect costs) Discounted by 4%, Denmark 1992-cost level

Direct costs

Indirect costs (lost production costs)

Hospital treatment Medicines and misc. other treatment/rehab. Sickness absence Disability pensions (premature) deaths

TOTAL……………………………………..

Billion Dkr.

% cent of total COI

2.3

10

1.8

8

4.5 12.3 2.0

20 54 9

22.9

101

societal perspective a disability pension is a redistribution of income (from the well to the disabeled/sick) – not a real change in the production (‘wealth’) of society. (just make a simple private parallel: a family is neither poorer or richer if the weekly allowance of the children are increased. Family income is merely redistributed. However, if mother or father for some reason cannot work and earn an income, the total economic situation of the family is worsened) It is noteworthy that the largest cost component of the total costs is the indirect costs.

And the use of COI? What can the total COI-numbers be used for? According to the authors of the Danish report, (2), p. 7, a COI can provide an answer to the following question: ‘how many social/societal resources are wasted every year due to occupational accidents and diseases’. The number indicates a magnitude of order for the work environment related problems and can be compared to the national economy, i.e. Gross national product. No more, no less! It really amounts to a statement about the following: it is information, an attempt to illustrate the size of a problem illustrated in monetary terms. But note that it is not claimed that such an analysis – (and all other cost-ofillness analyses for that matter) – can be used for making resource allocation decisions. And such a claim should never be made.

(rounding)

Note: exchange rate – 1 US$ = 8.50 Dkr., i.e. about 2.7 billion dollars. It is seen that the indirect costs are made up of three components: sickness absence, disability pensions and premature deaths. The human capital method is used to estimate those costs. In the human capital approach it is assumed that these costs are equal to the (potential) production lost by those three ‘causes’ and the value of this production is estimated by applying the wage rate, i.e. the wage rate reflects the value of the production lost. We are not going to elaborate on this (questionable) assumption, but just note that this is the thinking applied Neither are we going to discuss an alternative – and also somewhat questionable method - the friction method, (14,12,10,13). If a person dies at age 41 in an occupational accident, the indirect costs of this is equal to the discounted sum of his occupational earnings to the age of retirement, that is about 60 years. Similarly if the person is ‘only’ disabled. With regard to the latter one has to be careful not to make a common mistake and use the disability pension or (even worse) do double counting: lost production and disability pension. This is where one has to be careful about the perspective of the study. From the perspective of the public budgets the disability pension is an expense –but from the societal perspective the real costs are the production lost valued by the income. Viewed from the 24

The scope of use of COI is severely limited. Pressure groups love them because they provide ‘large numbers’ and in a time and age where some numbers are better than no numbers in order to catch the attention of policy makers and the public, pressure groups consider them relevant tools. This is probably the reason that such analyses still are carried out. For resource allocation purposes they are basically without value. An underlying problem wit the use of COI is that is often implied that the numbers indicate the scope of possible benefits (= costs avoided) if an intervention is put in place. However, one must at all costs avoid such hints. First of all, the effectiveness and cost of a good intervention is not addressed directly (this in done in a costeffectiveness analysis, see below), secondly, usually average costs are used – and as shown they really indicate nothing about real costs avoided if an intervention were to take place. Thirdly, the value of the lives saved or the disabilities avoided through an effective intervention are estimated in a theoretically wrong way and has many possible distortionary effects. To witness: if a pensioner aged 71 is killed in a traffic accident, there are no indirect costs associated with this because a pensioner is not active in the labour market, hence no production forgone is involved. Now, compare this to a situation, where the traffic casualty avoided is a 45 year old man. If killed, one would allow at least 15 years of lost occupational income as an indirect cost. Thus, in trying to set up a traffic injury prevention programme and looking at

possible cost savings (direct and indirect costs) the decision would be biased to the advantage of the 45 year olds. The reader can consider the issue of children (low value due to discounting), housewives or unemployed. If one were to carry out such an analysis the relevant concept to use for valuation of lives and disabilities would be the willingness to pay for a reduction in the probability of injuries/traffic accidents. Great strides have been made in this filed over the last 15-20 years. However, despite of this, there still exist methods where COI of (traffic accidents) are turned into ‘savings’ (= benefits) of interventions, but realizing the incompleteness of the valuation of life and limb, there is an add on, namely welfare loss. The Danish Road Directorate under the Ministry of Transport uses this procedure. From a cost-of-illness of traffic accidents the following table is calculated: Table 3: Modified COI resultat to be used in ‘costbenefit analyses’ Per reported killed,

Per reported serious injury,

Dkr.

DKr.

Per reported slight/less serious injury, DKr

Person related costs (derived from a COI)

1 990 000

357 000

91 000

Welfare Loss

3 980 000

119 000

6 000

Total, person related costs + welfare loss

5 970 000

476 000

97 000

Source: The Danish Road Directorate, (33). It is part of an ongoing update of a study dating back to 1983, (34)

The welfare loss is totally arbitrary, and it has not been possible to obtain reliable information on what basis it has been calculated/decided. Of passing interest one can note that for persons killed the amount is equal to the double of the person related costs, a third for the serious injuries and 7% for less serious injuries. These numbers are used when making rough estimates of costs and benefits of contemplated road investments, e.g. if two fatal traffic accidents are avoided, 10 serious accidents avoided and 15 less serious accidents are avoided because of an investment in improved traffic safety, the ‘benefits’ are 2*5 970 000 + 10*476 000 + 15* 97 000 =18 155 000 Dkr.. With knowledge of investment costs and the benefits it is a simple exercise to calculate the internal rate of return and to use this rate in rank ordering possible investments. However, the basic point here is, that such an exercise is totally unfounded in economic theory of cost-benefits analysis and hence basically invalid. It would be far better to avoid the human capital calculation and the welfare loss+ add on and instead substitute estimates of willingness-to-pay for reduction in the probability of traffic accidents. In a Danish context it can noted that work has been carried out, (11) and the WTP

is considerable higher than used in the example just given. The median values show that a reduction in the risk of 30% and 20% respectively was valued at Dkr. 12.1 and 18.2 millions respectively. Brief history of COI What was later to become known as cost-of-illness studies were pioneered by the actuary L. Dublin. In 1920 he published an article ‘On the cost of tuberculosis’,(6), and a quarter of a century it was followed by ‘The money value of a man’(5). However, the approach at that time was without a firm foundation in economic theory. Rather, the issue was approached from an insurance perspective, i.e. what compensation for an injury (loss of limb, invalidity etc.). The relevant economic foundation was developed in the late fifties and early sixties. The theory was called human capital and was initially applied to schooling, i.e. education/knowledge was looked at like an investment, (28,29), but was quickly applied to health, (20,35,36). A number of studies were carried by D. Rice for the federal US Government in the early sixties – some of them published in the governments Health Economics Series, (23,25,28,29) – other published in journals. By the late sixties the methodology (see below) was firmly established and an increasing number of studies appeared in the seventies and eighties, e.g. (9,16). It became one of the examples of the ‘usefulness’ of the emerging subdiscipline of economics, health economics. . Studies have continued to appear in the nineties, e.g. (1,15,17,18,30,2). It is impossible to provide an exhaustive list since the studies are almost too numerous to list. From the early eighties and onwards criticism of the COI analyses began to appear, (3,4,8,22,24,31,32). The major point of criticism was that COI analyses cannot and should not be used for resource allocation decisions – and if not, what is really the meaning of doing such analyses? One of the theoretical issues underlying the criticism is the rejection of the human capital approach to ‘value of life’. In human capital ‘the value of life’ is estimated in terms of discounted wages lost due to death, short term or long term disability. If the costs estimated were look at as potential savings and subsequently were used as a measure of benefit in a cost-benefit analysis, CBA, one would be making a serious mistake, because ‘proper’ benefit assessment in CBA is done through willingness-to-pay, WTP, (19), i.e. the willingness to pay to reduce the risk of certain types of accidents. In WTP one does not focus as such on an average person, but rather on the statistical issues, risk change and the willingness to pay for such a change. Economists generally agree that WTP is the proper way to look at CBA and in consequence of this estimates involving human capital thinking is rejected. AT the same time it is also made clear why COI studies do not have a place regarding resource allocation.

Cost-effectiveness analysis Much of the ground work for the following has been laid in the critical discussion of COI, in particular the issue of costing, marginal and average costs, and discounting. These observations apply in the following. Therefore the expositions is rather short and concentrated.. We now turn to cost-effectiveness/cost utility analysis which is the proper tool to use when one is interested in resource allocation. The purpose of a cost-effectiveness analysis is to compare two or more alternative programs, e.g. experimental vs. do nothing/or do the usual, in order to identify the best alternative. The comparison involves both costs and effectiveness. The overall objective of the whole exercise is simply to get ‘the most value (health effect)’ per invested Dkr/$/£ etc.. A cost-effectiveness analysis is 25

squarely and unambiguously aimed at allocating resources in such a way that health benefits are maximized. The term cost-effectiveness analysis, CEA, is used when a one-dimensional effectiveness measure is used, e.g. falls prevented, accidents prevented. The term cost-utility analysis is used when the measure of health benefit is quality adjusted life years, QALYs. QALYs combine the time in a particular state, i.e. partially disabled moving into a state, where there may be permanent limping with the quality of life in that state, i.e. degree of mobility and pain. The focus here, however, is not any particular health benefit measure, but cost computation and the logic behind cost-effectiveness analysis (cost-utility analysis). A cost-effectiveness analysis requires • Good quality evidence on effectiveness of an intervention, e.g. prevention of falls among the elderly, use of hip proctors, bicycle helmets or speed limits o From randomized or controlled studies, e.g. (26) o Meta-analyses or reviews of studies, e.g.(7,21) o (and occasionally, but not recommended) expert estimates • Data on the (marginal) costs of the intervention – if it can be considered marginal in the relevant context and marginal savings in treatment costs. • A decision rule – the cost-effectiveness ratio. The basic idea of a cost-effectiveness analysis will be presented using a recent (March 2001) article in the British Medical Journal, (26). - example: Cost-effectiveness analysis of a nurse delivered home exercise programme to prevent falls Data on effectiveness come from a randomized experiment, (26),where 121 New Zealander participants received a newly designed exercise program and 119 received the usual care. Participants were 75 years or older. Outcome measures were number of falls, number of injuries resulting from falls. The statistical power calculations were based on expected reduction in the proportion of elderly people who fell once or more in a 12 months period from 0.50 to 0.30, allowing for a 20% drop out from the programme. The overall result was that falls were reduced significantly by 46%. Five hospital admissions were due to injuries caused by falls in the control group and none in the exercise group. Regarding the effectiveness the conclusion is that the home exercise program delivered by nurses is effective in reducing falls – supporting an earlier experiment where the exercise program was delivered by a physiotherapist. Another New Zealand controlled trial of exercise programmes (for persons aged 80 years and older), confirms the results just described, (27). It is rare to have such a firm base for the effectiveness side of a CEA – but ideal, and desirable. 26

Collection of cost-data was an integrated part of the study – following the idea of distinguishing between quantities and unit costs. Again a fairly ideal and desirable situation. However, average costs were used in that a 21.9% add on for (average) overhead costs were used for the implementation/operational costs of the exercise program. It is debatable whether this is relevant. However, with this information it is possible to adjust the costs accordingly and approach a more marginal cost point of view. Regarding hospital admissions a ‘hospital path’ was followed: emergency room, theatre, ward, physician, radiology, laboratory, and blood services, pharmacy products, hospital social workers, physiotherapy and each hospital cost item included overhead like cleaning, heating, lighting, telephone, laundry, orderlies, computing, and depreciation, following the accounting conventions of the particular hospital (showing the point emphasized above, that one should be careful about accounting conventions followed). When costing is an integrated part of a research project it is important for CEA purposes that for instance the costs of doing research, recruiting etc. are not included in the cost side of a CEA. One is interested in the expected operational costs of an actual day-to-day programme. The average cost per participant for 1 year programme was calculated to 432 New Zealand $. The idea of a cost-effectiveness ratio brings together data on effectiveness and cost. If one wants to maximize the given health effects, e.g. reduce falls in the elderly population 74+ years, one simply has to pick the program alternative with the lowest costs per averted fall. Here it is extremely simple, because there is only two alternatives: the ‘status quo’ and the experimental exercise programme. Costs per fall prevented was $NZ 1629 if only the exercise programme costs was included, and $140 if net costs were used so that savings due to a reduced number of hospitalizations were deducted. The costs are calculated using fall events per 100 person years to adjust for variable follow up times for individuals in the trial. The analysis is careful in also reporting numbers without (extra) overhead costs – thus getting closer to something akin to marginal costs. The respective amounts without overhead are: $NZ 1337 and $NZ – 153 (alas a saving). The last two numbers are probably the relevant one to report and use. Numbers for the age group >79 years are also reported resulting in the larger savings in the net-cost ratio because the hospitalizations took place in this age group. This study is almost a model case – and fairly simple because the phenomenon and the outcome measure is simple: exercise and (subsequent) reduction in falls in the target group. Costing is as transparent as it can be within the limits of a published journal article, including sensitivity analyses where numbers are reported for the 125th and 75th percentiles of the total costs.

How should CEA results be used? In most cases an isolated cost-effectiveness ratio is not of much use. However, in the case of outright savings like in the above case, the message is clear: Programmes like the exercise programme should be implemented right away. In other cases one ideally would do the following: provided that it has been decided (politically) to allocate X-million to prevention of injuries, one must ideally imagine that there are several studies like the one just discussed and that all are candidates for the X-millions. In principle – if the studies are comparable – on then should proceed as follows: rank order the alternatives based on costs per accident (fall or whatever outcome measure is used) avoided starting with the lowest costeffectiveness ratio (‘cheapest’ alternative) and placing the highest ratio lowest on the list. Then one should start

using the X million from the top and stop when the amount is exhausted. In this way one has maximized the health benefits from the X-million. This is the ideal process in line with the thinking behind CEA. However, things are not ideal – and in the real world there has been a somewhat unfortunate, but probably unavoidable, tendency to use ‘cut-off-values’ of CEA, i.e. for instance 20.000 Dkr. per avoided accident (or whatever outcome measure is used) and declare programmes that have ratios below this cut-off number as ‘cost-effectiveness’. Obviously this is an arbitrary cut-off value – but may reflect the fact that one expects to find so many programme-alternatives with ratios below the cutoff value that they can easily exhaust whatever imaginable amount made available for the particular activities.

Bibliography 1. Andersen CK and Kidholm K: Analysis of treatment costs associated with MAIS3+ injuries from traffic accidents (in Danish only: Undersøgelse af behandlingsomkostninger ved personskade med MAIS3+ ved trafikulykker): 2. Arbejdstilsynet: The ‘invoice’ for the occupational injuries (in Danish only: Regningen for arbejdsskaderne): 3. Currie G, Kerfoot KD, Donaldson C, and Macarthur C: Are cost of injury studies useful?: 2000, 6 (3): 175 4. Drummond M: Cost of illness studies. A major headache?: 1992, 1 - 4 5. Dublin LI and Lotka AJ: The Money Value of a Man: 6. Dublin LI and Whitney J: On the cost of tuberculosis: 1920, 17 441 - 450 7. Gardner MM, Robertson MC, and Campbell AJ: Exercise in preventing falls an d fall related injuries in older persons: a review of randomised controlled trials: 200, 34 (1): 7 - 17 8. Goddeeris JH: Theoretical considerations of the cost of illness: 1983, 2 (2): 149 - 160 9. Hartunian NS, Smart CN, and Thompson MS: The incidence and economic costs of major health impairments. A comparative analysis of cancer, motor vehicle injuries, coronary heart disease, and stroke: 10. Johannesson M and Kerfoot KD: The friction cost method: a comment: 1997, 16 249 - 255 11. Kidholm K: Estimation of betalingsvilje for forebyggelse af personskader ved trafikulykker (in Danish only: Estimation of willingness-to-pay for prevention of person injuries in traffic accidents).: 12. Koopmanschap MA: Cost of illness studies. Useful for health policy: 1998, 14 143 - 148 13. Koopmanschap MA, Rutten FFH, van Ineveld BM, and van Roijen L: The friction cost method for measuring indirect costs of disease: 1995, 14 171 - 189 14. Koopmanschap MA and van Inevel BM: Towards a new approach for estimating indirect costs of disease: 1992, 34 (9): 1005 - 1010 15. Leigh JP, Cone JE, and Harrison R: Costs of Occupational Injuries and Illnesses in California: 2001, 32 393 - 406 16. Lindgren B: Costs of illness in Sweden 1964-1975: 17. Max W, Rice DP, and MacKenzie EJ: The lifetime cost of injury: 1990, 27 (4): 332 - 343 18. Miller TR and Galbraith M: Estimating the costs of occupational injury in the United States: 1995, 27 (6): 741 - 747 19. Mishan EJ: Evaluation of life and limb: a theoretical approach: 1971, 79 687 - 705 20. Mushkin S: Health as an investment: 1962, 70 129 - 157 21. Parker MJ, Gillespie LD, and Goddeeris JH: Hip protectors for

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preventing hip fractures in the elderly (Cochrane Review): 2001, 2 CD001255 22. Pedersen KM: “... there is more to be said for rough estimates fo the precise concept thatn precise estimates of economically irrelevant concepts” - OR IS THERE? - cost-ofillness analysis and cost benefit analysis: Rice DP: Estimating the cost of illness: Rice DP: Cost of illness studies: what is good about them: 2000, 6 (3): 177 - 179 Rice DP and Cooper BS: The economic value of human life: 1967, 57 (11): 1954 - 1966 Robertson MC, Devlin N, Gardner MM, and Campbell AJ: Effectiveness and economic evaluation of a nurse delivered home exercise programme to prevent falls 1: randomised controlled trial: 2001, 322 697 - 701 Robertson MC, Devlin N, Gardner MM, and Campbell AJ: Effectiveness and economic evaluation of a nurse delivered home exercise programme to prevent falls 2: controlled trial in multiple centres: 2001, 322 701 - 704 Schultz TW: Capital formation by education: 1960, Schultz TW: Investment in Human Capital: 1961, 1 - 17 Sedrine WB, Radican L, and Reginster J-Y: On conducting burden-of-osteoporosis studies; a review of the core concepts and practical issues. A study carried out under the auspices of a WHO Collaborating Center: 2001, 40 7 - 14 Shiell A and Donaldson GK: Cost of illness studies: an aid to decision-making?: 1987, 8 317 - 323 Tolpin HG and Bentkover JD: Economic cost of illness: decision-making applications and practical considerations p. 165198 in Scheffler RM and Rossiter LF (eds): Advances in health economics and health services research, London 1983: Vejdirektoratet (Road Directorate): Trafikøkonomiske enhedspriser. Prisniveau 1997 (in Danish only: Traffic economic unit prices, price level 1997): Vejdirektoratet (the Road Directorate) and Laboratory for community medicine and health economics at Odense University: Trafikuheldsomkostninger - faktiske trafikuheldsomkostninger i Danmark 1980 (in Danish only: Traffic accident costs in Denmark 1980): Weisbrod B: The valuation of human capital: 1961, 69 425 - 436 Weisbrod BA: The economics of public health: Zethraeus N and Gerdtham U-G: Estimating the costs of hip fractures and potential savings: 1998, 14 (2): 255 - 267 Zethraeus N, Strömberg L, Jönsson B, and et al: The cost of a hip fracture: estimates for 1,709 patients in Sweden.: 1997, 68 13 - 17

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THE ROLE OF INJURY COSTING IN THE WORLD HEALTH ORGANIZATION’S VIOLENCE AND INJURY PREVENTION ACTIVITIES Alexander Butchart, PhD, Injuries and Violence Prevention, Noncommunicable Diseases and Mental Health, World Health Organization

Road crashes cost approximately 1 to 3 percent of a country’s annual Gross National Product (GNP). These are resources that no country can afford to lose, especially those with developing economies. It is estimated that developing countries currently lose in the region of $100 billion every year. This is almost twice as much as the total development assistance received worldwide by the developing countries (World Bank, 2001). WHO’s Department of Injuries and Violence Prevention (VIP) used this piece of information in its June 2001 Meeting of Interested Parties, a 14 day series of presentations where each organizational cluster and department gets the chance to convince donor countries and agencies that their public health area should be funded. VIP placed the information about the costs of transport injuries in developing countries alongside other simple but strategically vital messages. One was that vulnerable road users (such as pedestrians, passengers and others too poor to own and drive a vehicle) are at highest risk in most parts of the world. The second message was that many of these injuries are readily prevented through interventions that probably cost much less than treating victims, such as the building of pedestrian crossing bridges, the modification of roads to reduce vehicle speed, and the use of child safety seats. Together, the information about the costs of road traffic injuries, the population sector most affected, and the existence of low-cost, highly effective interventions, constitute an irrefutable argument for investment in injury prevention. This is only one concrete example of how WHO uses injury costing information, but it illustrates a number of points common to other situations. First, the simplicity of the message and shortness of the argument. Often, meetings where there is the greatest likelihood of persuading influential parties provide only a brief window of time to argue the case for injury prevention. Second, it illustrates the point that data on the costs of injury alone are less powerful an argument than cost-benefit information. Injury prevention competes for money against diseases such as polio, blindness and malaria, where the interventions are extremely cheap and have guaranteed effectiveness in almost every case. In the traffic example the notion of prevention strategies being cheaper than the costs of injuries was implicit only, and if we had had concrete figures on savings the argument would have been considerably stronger. Third, the example illustrates the value of macro-level, non-detailed costing information, which often may be all that is available for those of us who are attempting to begin the building of local level safety promotion programmes. 28

The Department of Injuries and Violence Prevention While many departments at WHO (e.g. Child and Adolescent Health, Gender and Women’s Health, Evidence and Information for Policy and Mental Health) contribute to injury prevention and safety promotion, the focal department is the Department of Injuries and Violence Prevention. The organisational context of WHO is, of course, no exception to the rule that money counts, and even in making the case for the department, injury costing information plays a key role. For instance, presentations that compare the global burden of disease due to injuries with WHO’s percentage spend on injuries and violence prevention are arguments for increased investment in the department, since they show a large but slowly diminishing gap between the magnitude of the injury problem and the size of WHO’s investment in preventing it. The VIP Department has five main activities. Three areas (surveillance, pre-hospital care, and advocacy) are relevant to all causes of injury, and two areas (violence prevention and traffic injury prevention) are cause-specific. The costing of injuries and computation of cost-benefit ratios in respect of interventions are relevant to all activities, as explored in the subsequent descriptions.

Injury Surveillance Costing and cost-benefit research is linked to VIP’s surveillance activities in two ways. First, we recognise that injury surveillance data are an important source of input data for the calculation of injury costs, since it is through surveillance data that the magnitude of the problem and demographic attributes of the affected population is established. Second, VIP is interested in studies that compare the costs of surveillance with the costs of injury and the savings of surveillance-driven injury prevention programmes. For instance, a South African study noted that “the annual costs of fatal injury surveillance for all of the estimated 60 000 non-natural deaths in South Africa amounts to 1.6 million SA Rand (US$250 000). Assuming that a single homicide costs the economy SA Rand 44 000 US$8 100), this means that if the system were to help prevent approximately 37 homicides [out of an annual total of around 24 000 homicides] its costs to the national economy would already be recouped” (Violence and Injury Surveillance Consortium, 2000). Of course, this tells only part of the story, and additional information on the costs and effectiveness of surveillance-driven prevention programmes is required. However, showing the minuscule costs of surveillance relative to the huge

costs of the problem is in itself useful, and VIP is costing all injury surveillance capacity development programmes where it is directly involved (e.g. Mozambique, Uganda, and Ethiopia).

Pre-hospital Care The pre-hospital care programme at VIP aims to develop effective and sustainable systems of pre-hospital care to ensure that all victims of injury receive the best possible treatment before reaching hospitals. The programme is aimed at ensuring that at least a minimum of services are available to people hurt in the high-injury, low-resource contexts where these programmes are most needed. The pre-hospital work applies to victims of all injury causes, although a substantial amount of funding for work in the area is received from donors interested in assisting victims of land mine blasts. Costing arguments are frequently encountered in this area, such as the observation that whereas a landmine costs three to five US dollars, medical treatment costs range from 5,000 to 10,000 US dollars per victim. As in all other areas of VIP’s work the pre-hospital care team requires more costing and cost-benefit data. For instance, while studies suggest that rapid and effective pre-hospital and trauma care can substantially reduce death and disability following injury (e.g. Mock et al, 1998), there is little evidence about the costs of such care and the savings it would yield, which presumably would accrue from fewer lost earnings and lower costs associated with caring and compensating for long-term disabilities.

Advocacy Advocacy involves raising the visibility of the injury problem and awareness of its preventability so that more financial and human resources will be committed to prevention. For WHO’s VIP department, advocacy occurs chiefly at the level of other UN organizations, donor countries, and international donor agencies. Information about the costs of violence and injuries and the savings that could be achieved through effective prevention is crucial to this advocacy work. The introductory example of the argument about the costs of traffic injuries as presented to the WHO Meeting of Interested Parties is a good example of the Department’s use of costing information for advocacy. Another example is taken from the recent VIP publication Small Arms and Global Health, where, for instance, it is stated that “the costs of firearm mortality and morbidity in Canada have been estimated to exceed the equivalent of US$ 4 700 million per year” and, “in Brazil, approximately 10% of annual GDP is consumed by treating victims of violence and increased policing. In Colombia, the figure rises to 25%. In both countries over 80% of all violent events are committed with firearms” (WHO, 2001). Within the report, these data occur alongside information about the epidemiology and preventability of firearm injuries.

Violence Prevention The World Report on Violence and Health was commissioned in 1999, and involves over 100 experts in the prevention of all types of violence from around the world. In 2002 the World Report on Violence and Health will be launched around the time of the World Health Assembly. The Report aims to raise awareness about violence as a global public health problem, highlight the contributions of public health to understanding and responding to violence, and increase the level of response taken by the public health community to preventing violence. While the report does address the economic dimensions of violence and violence prevention, there was little data on this area, indicating that more work on the costing of violence and violence prevention is needed. The work of VIP’s Violence Prevention Team is organised around a framework for the prevention of interpersonal violence. Collective and self-directed violence are addressed indirectly, in so far as they are linked to interpersonal violence as risk factors or by common risk factors (e.g. alcohol, small arms, rapid social change). Development of the framework is an ongoing project, and the objective is to consolidate the public health contribution to reducing the disease burden arising from deaths and injuries due to interpersonal violence. As well as helping to organise the Team’s work, the framework is intended to provide guidance to countries and to donor agencies interested in investing in violence prevention. Violence Prevention activities fall into three main areas. First, development of the violence prevention framework itself, through extensive consultation with other UN agencies, NGOs, and across the different disciplines relevant to violence prevention. Second, the production of capacity development resources, such as policy and practitioner guidelines covering the different types of interpersonal violence and all levels of prevention. Third, the implementation at country level of pilot violence prevention programmes. The role of costing and cost-benefit research within these violence prevention activities is best defined with reference to the chain of violence prevention. This is one of the main dimensions of the violence prevention framework, and identifies the necessary conditions for violence prevention to occur. These consist of two sets of logical conditions. First, the conditions that make up the chain of prevention. Second, those conditions necessary to create the will to prevention. The chain of prevention requires that: i) the violent events are predicted; ii) the causes of the violent events are known; iii) agents potentially able to influence the causes exist; iv) the predicted events and known causes are communicated to those agents, and v) the agents act to disable the causes of the predicted violent events. The will to prevention requires that: i) the benefits (ethical, economic, social, political) of disrupting or eliminating the causes of violent events are seen by potential prevention agents to outweigh the costs (ethical, economic, social, 29

political) of their continuation, and ii) the activities aimed at the causes are seen by potential prevention agents as highly likely to be effective. The working assumption of the framework is that violence prevention will occur if and only if the will to prevention exists and is linked with the chain of prevention. While acknowledging that there remains much work to be done in establishing information systems that can make violence predictable and specifying the risk factors which lead to violence (especially in low- to middle income countries), we believe that the major need is for information and arguments aimed at generating the will to prevention. This is precisely the area of costing and cost-benefit studies, which therefore occupy a fundamental position in WHO’s violence prevention activities.

Traffic Injury Prevention VIP’s work on the prevention of traffic-related injuries is built around a five -year WHO Strategy on Road Traffic Injury Prevention, produced following a global consultation in April 2001. One of the strategy objectives is to promote epidemiological studies on the economic and social impact of road traffic injuries by developing training guidelines for assessing the economic and social costs of road traffic collisions and injuries, and conducting training in less resourced countries on cost-related epidemiological studies. Compared to violence, there is considerably more data on the cost dimensions of traffic related injuries, although data for low- to middle-income countries is poor, and there remains very little information from any countries about the cost-effectiveness of interventions. In a summary of recent studies, the Transport Research Laboratory indicated that road crash costs expressed as a percentage of GNP ranged from 0.3% in Vietnam to almost 5% in the USA, Malawi and Kwa-Zulu Natal, South Africa. The report also produced a crude estimate of global and regional costs, assuming that the annual cost of road crashes is about 1% of the GNP in “developing” countries, 1.5% in “transitional” countries and 2% in “highly motorised” countries. A global estimate of US$518 billion was produced (Jacobs et al, 2000).

Discussion Information on the costs of injury and the findings of cost-benefit studies are an integral part of all the work done by WHO’s Department of Injuries and Violence Prevention. Indeed, the demand for costing information always exceeds the supply, and the Department supports in whichever way it can initiatives to improve the scientific quality and quantity of information about the costs of injuries and injury prevention. It must, however, be emphasised that costing information constitutes only a part of the arguments used to advance injury prevention. Ethically, WHO is aware of the danger attaching to what can be termed ‘economic reductionism’. By this is meant the valuing of individuals, populations 30

and interventions in monetary terms only. The danger is that the intangible dimensions of human suffering are lost, and the humanitarian motive to reduce and eliminate such suffering for its own sake is erased. In practical terms this could, for instance, be manifest in a formula that prescribes less rather than more injury prevention resources for marginal and vulnerable social groups (e.g. children, elderly, unemployed) since their value in terms of earning potential is less than that of high-income groups. To guard against economic reductionism, WHO’s VIP Department aims in all its work to blend ethical and rights based arguments for injury and violence prevention with the economic perspective. This is easier in some areas where considerable work on international law and human rights has already been done (e.g. violence against children and women), but more difficult in areas where the rights perspective has been largely ignored (e.g. youth violence and traffic-related injuries). In the final analysis, however, it is reasonable to conclude that the danger of erasing the humanitarian dimensions of violence and injury by an overemphasis on the economic aspects is remote. In fact, the opposite may be true, and unless the field of violence and injury prevention makes rapid moves to catch up with its more traditional public health competitors in terms of cost-benefit research, the advances made over recent years using epidemiology alone may be lost. The Safe Community work on injury costing, and its contribution of the manual for the community-based measurement of injury costs and prevention programmes, seems bound to fill an important gap in the capacity of violence and injury prevention workers at a local and national levels. This lays the foundations for a new wave of costing and cost-benefit research. Alongside an increasing body of studies showing the impact of prevention programmes, this will make it more and more difficult to refute the claims of injury prevention and safety promotion practitioners to the resources they require and warrant in terms of the size of the problem, the costs of the intervention, and the likelihood of success.

References Jacobs G, Aeron-Thomas A, Astrop A. Estimating global road fatalities, TRL Report 445, Crowthorne, 2000. Mock CN, Jurkovich GJ, Amon-Kotei D, Arreola-Risa C, Maier RV. Trauma mortality patterns in three nations at different economic levels: implications for global trauma system development. Journal of Trauma, 1998, 44(5): 804–812. Violence and Injury Surveillance Consortium. A sustainable violence and injury surveillance programme, unpublished technical document, Cape Town, 2000. World Bank. Road safety. At http://www.worldbank.org/transport/ roads/safety.htm (accessed 20 July 2001). World Health Organization. Small arms and global health. Report WHO/NMH/VIP/ 01.1, Geneva, 2001.

Safety Promotion - Individual or societal approaches and community participation Katharina Purtscher, MD., Graz, Austria

The history of injury control and the efforts to prevent and protect individuals and groups of a society from harm goes back thousands of years. Nevertheless, injuries are still the leading cause of death in children and young adults and a major public health problem all over the world. In Europe health expenditures are utilising a sizeable part of Gross Domestic Products (GDP). The direct and indirect costs of injuries count for a major part of the annual health care expenditures in various societies. Not surprising, that controlling health care expenditures is on the political agenda for decades. In the European Union, three-quarter of total health spending is financed either through health insurance contributions and/or taxes. In Europe the average total expenditures on health were 8.7 % of GDP in 1998. Whereas price increases in the private health sector appear to have slowed recently perhaps due to more competitiveness, prices in the public health sector seem to exceed the general price level. Several investigations and documents report the need for reducing direct and indirect societal costs of injuries by prevention programs. A recent report from 1999 of the Institute of Medicine in Washington documents some of the needs to provide cost-effective injury prevention measures (1). Many of the preventive measures and campaigns in the tradition of Health Promotion are addressing the individual in terms of changing behaviour or lifestyle, whereas the approaches in the tradition of Safety Promotion are more community or society oriented and focusing on public policies, environmental changes and legislation. Increasing economic welfare could lead to more individual responsibility concerning safety awareness and providing appropriate precautions. On the other hand we see increasing safety demands in societies to be organised from the public. Safety in terms of recognised risks but also possible or estimated risks is expected and often claimed for products, the environment and in regard to the social and economic situation. In the framework of an ethical principle of justice some social and economic inequalities are accepted as long as the greatest benefit of the least advantaged is perceived. This egalitarian concept implies that each citizen should have equal access to the health system and a fair opportunity of safety. Equity has different social and economical implications insofar as resources are allocated, the way health care services are obtainable, and in the way those services are paid for (2).

Psychological impact of trauma and psycho-social support Psychological and ethical considerations in terms of safety as a human right have become more recognised aspects of health and safety promotion during the last decade, unfortunately enforced by war situations, mass emergencies and frequent disasters. Many people who survive traumatic injury have lost abilities due to brain or spinal cord damage, may have lost functioning of limbs, lost sensory function, and suffer from distortion by lost digits or limbs or by scars. These patients, and of course additional others, are affected psychologically, socially, and economically. There is substantial evidence of fears and anxiety disorders, mood disorders, of family breakup and disruption, and of economic problems. These sequels contribute to personally less satisfying lives, less school performance or less productive working lives, and often increased dependency. It has been shown that these effects represent more than 50% of the total disease costs on average (3). The quantification and cost calculation of these effects resulting in indirect costs of injuries is a challenge to clinicans as well as scientists. Still, these calculations would not refer to “human costs” like physical and mental sufferings of the victims and their families (4). In contrary to immediate somatic treatment after trauma in terms of tertiary prevention most efforts of psychological support and counseling are not received immediately after trauma. Several studies of psychological outcome after trauma are directed long-term intervention after trauma as well as for victims and rescue personnel. Only little efforts are made in providing education and training to cope with stressful events and to prevent burn-out and posttraumatic psychological disorders. The nature and extent of psycho-social needs in traumatic situations are such that they exceed the individual coping capacity of the victims or the community as a whole and that they can not be covered by every-day resources. Yet, experience shows that it is important to meet the „basic human needs“ of trauma victims as early as possible to prevent further distress. This requires a specific approach that is essentially preventive and collective in nature. A community oriented approach to meet the practical, emotional, informational and psychological needs requires anticipation and pro-active offering of well co-ordinated multidisciplinary support. An expert group of national correspondents of the different EU member states is preparing an European policy paper on guidelines and general management principles for psycho-social interventions in the aftermath 31

of major accidents and disasters . The perception and the feeling of safety as the result of safe products, environments and social interactions can be hardly identified. The individual’s or community’s perception of danger or safety does not necessarily reflect the epidemiological situation of physical, material or emotional threats in a community. Public safety awareness, information management and communication on the one hand and societal prejudiced notions on the other are important contributing factors to the feeling of safety or the perception of being endangered, quite often in contrary to evaluated data and facts.

References 1 Institute of Medicine: Reducing the Burden of Injury: Advancing Prevention and Treatment. Ed.: Bonnie R.J., Fulco C.E., Liverman C.T., Washington DC, National Academy Press, 1999 2 World Health Organisation: Equity in Health and Health Care. Geneva, 1996 3 E.F. v. Beeck et al.: Medical Costs and Economic Production Losses due to Injuries in the Netherlands. The Journal of Trauma, 1997, 1116-23 4 World Health Organisation: European Health Care Reform. Analysis of Current Strategies. Regional Office for Europe, Copenhagen, 1997

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Social cost of Road Traffic Crashes in India Dinesh Mohan, Henry Ford Professor for Biomechanics and Transportation Safety Transportation Research and Injury Prevention Programme, Indian Institute of Technology, New Delhi

Issues and concerns A very large number of high income countries (HICs) have been estimating the costs of road traffic crashes over the past three decades. The methods used and costs allocated have generated a great deal of discussion and debate, in particular because of the difficulty of putting monetary values on pain and suffering. Calculation of direct and indirect costs of injuries, deaths and damage due to road traffic crashes started in the 1970s and many such analyses have been done in USA and Europe The main objective of assessing costs has been to provide an objective tool for help in selecting more cost-effective countermeasures for road safety and also to justify expenditures for the same. However, critics like Hauer question the very basic principles of cost-benefit analysis where human lives, pain and suffering are involved. Professionals like Hauer working in this area take the position that putting a monetary value on human life is ethically unacceptable As far as the liberal economists are concerned the objective of cost-benefit analysis is welfare maximisation. The process is neutral with respect to distributive outcomes and is insensitive to how the impacts are distributed between various groups of the population. For example, in India a large proportion of the pedestrians who get killed would come from the low income strata of the population and car drivers from the high income strata. If a cost-benefit analysis is attempted for increase in speeds of cars in urban areas then the increase in costs due to higher incidence of deaths among poor pedestrians could be offset by time saving of rich drivers. Most people would consider such a justification immoral and unacceptable. However, governments, municipalities, and car and companies do incur costs when human beings are injured or killed in traffic crashes. For these institutions costeffectiveness analyses does provide a powerful tool for decision making. As long as the cost-benefit or costeffectiveness analysis does not force us to chose between benefits accruing to different classes of road users or against those who are disproportionately at risk, then we can use such calculations effectively. In particular, costbenefit analysis is particularly suited to problems that are not adequately solved by the market mechanism. This includes programmes designed to provide better health care, reduce environmental degradation or reduce road traffic crashes. Elvik gives the following guidelines for doing such work; · Policy objectives need to be clearly stated to support a cost-benefit analysis. · If road safety is treated as a basic right and an issue involving fairness in distributive justice, then costbenefit analysis is less suited as a tool. It is much better to use it as purely a technical too to assess the

most cost-effective measure to reduce traffic crashes. · All economically relevant impacts of policy must be valued in monetary terms. Unless they are, a costbenefit analysis can give misleading results.

Methods used for assessing costs of accidents The above discussion shows that costs of injuries, deaths and damages due to road traffic crashes cannot be estimated unless there is a clear perspective regarding the objectives and this must be in consonance with the prevailing society’s perspective. These costs would of necessity include all costs associated with injuries—costs to victims, families, government, insurers, and taxpayers and property damage suffered by all. Costs can be prevalence- or incidence-based. Prevalence-based costs measure all injury-related expenses during one year, regardless of when the injury occurred. Incidence-based costs sum the lifetime costs that are expected to result from injuries that occur during a single year. Incidencebased costs are computed by multiplying the number of injury victims times lifetime cost per victim. They measure the savings that prevention can yield. Miller summarises the burden of injury losses into the following categories: 1 Medical Costs include emergency transport, medical, hospital, rehabilitation, mental health, pharmaceutical, ancillary, and related treatment costs, as well as funeral/coroner expenses for fatalities and administrative costs of processing medical payments to providers. 2 Other Resource Costs include police, fire, legal/court, and victim services (e.g., foster care, child protective services), plus the costs of property damage or loss in injury incidents. 3 Work Loss Costs value productivity losses. They include victims’ lost wages and the replacement cost of lost household work, as well as fringe benefits and the administrative costs of processing compensation for lost earnings through litigation, insurance, or public welfare programs like food stamps and Supplemental Security Income. As well as victim work losses from death or permanent disability and from short-term disability, this category includes work losses by family and friends who care for sick children, travel delay for uninjured travelers that results from transportation crashes and the injuries they cause, and employer productivity losses caused by temporary or permanent worker absence (e.g. the cost of hiring and training replacement workers). 4 Quality of life includes the value of pain, suffering, and quality of life loss to victims and their families. The most difficult and contentious costs to estimate are those for death, disability and quality of life. Miller suggests that pain, suffering, and lost quality of life for 33

fatalities are best valued in dollars using an approach economists call willingness to pay. This approach derives the value of pain and suffering by asking people what they are willing to pay (called contingent value surveys) or by studying what people actually pay for small changes in their chance of being killed or injured. In the Indian context, it is not very easy to access data which is needed to assess all costs based on above principles. It would be very interesting to calculate the costs based on willingness to pay. Many families in India get destroyed financially in the process of obtaining treatment for road accident victims and the future education and career opportunities of family members suffer in the process. These costs would have to be included in the willingness to pay model. No such efforts at calculating the real costs of accidents in India have been attempted yet. Therefore, most cost calculations for road accidents in India would be gross under estimates.

International Estimates Of Costs Of Road Traffic Crashes No matter what methods are used, the economic costs of traffic crashes turn out to be so high that it becomes easier for professionals to justify higher expenditures in promoting road safety. A recent report commissioned by the Global Road Safety Partnership of the World Bank summarises the efforts in the area and concludes that Aoverall it does appear that in most countries, costs exceed 1 per cent of GDP which may now be considered to be an underestimate of national accident costs@.

Table 1 shows recent estimates of economic costs of road crashes summarised by Jacobs, Aeron-Thomas and Astrop 42. Expressed as a per centage of GDP the costs range from 0.3 per cent in Vietnnam to almost 5 % in USA. According to a more recent estimate from OECD the total annual economic loss resulting from road deaths and injuries is estimated to at around $US 450 billion or about of 2% of GDP in OECD countries. The policy makers regard this as a Acost that society should regard as unacceptable@. The values shown in the Table 1 indicate that the estimates for LICs as a per cent of GDP are in general lower than those in HICs. We need to be careful in drawing conclusions from such numbers as that would mean that road safety measures have a higher justification in HICs than in LICs. The more recent estimates for HICs are based on more detailed and comprehensive calculations including the willingness to pay, QALYs and DALYs, etc. On the other hand, to the best of our knowledge, such concepts have not been used in making estimates in LICs. We have mentioned earlier that the official estimates for traffic crash injuries in India could be underestimated by an order of magnitude. If the willingness to pay concept, effect on quality of life, etc. is properly accounted for, it is likely that the road crash costs in India would also be 2 per cent of the GDP or greater. At the intuitive level, this makes sense also for the following reasons:

Table 2.10 Recent Estimates of Economic Costs of Road Crashes. Country LAC Brazil

Study year

Costing method

% GDP Value US$mil (1997)

Source

1997

HC

2.0%

15,681

IADB Review of Traffic Safety

Asia Vietnam Bangladesh Thailand Korea Nepal Kerala, India Indonesia

1998 1998 1997 1996 1996 1993 1995

HC HC HC HC HC HC HC

0.3% 0.5% 2.3% 2.6% 0.5% 0.8% —

72 220 3,810 12,561 24 — 691-958

Technical Note: Accident Costing IDC Economics Working Paper Accident Costs SWEROAD Road Safety Master Plan Report Elvik, 1999 Road Maintenance Component, TN Accident Costing 1996 Chand ‚Cost of Road Accidents in India-reference to Kerala‘ Accident Costs in Indonesia: A Review June 1997 (Draft Copy), TRL/IRE

Africa KwaZulu Natal Tanzania Zambia Malawi MENA Egypt

199? 1996 1990 1995

HC HC HC HC

4.5% 1.3% 2.3% 15%). This is critical, because with improving health standards individuals are active and provide very useful social functions well beyond the age of 62. • Costs have again been taken from government hospitals, which are not the real costs. The real costs if taken from private hospitals would be much higher. The 36

major statistical error, however, is the underestimate of injuries and vehicle damage in this latest study. For 1995 they use the figures of 68,351 for fatalities and 266,541 for injuries. This is a ratio of 1: 3.9 for fatalities:injuries. • If a conservative ratio of 1:15:70 for fatalities:seriousinjuries:minor injuries is taken and a 5 per cent under count for fatalities we get the figures as shown in Table 3. The cost of injuries alone according to this estimate is approximately Rupees 322,000 million against a total estimate of Rupees 69,502 million by the Tata Consultancy report. This revised estimate indicates the road accident costs to 3.2 per cent of the GDP of India in 1995. Table 3. Revised estimates for costs of road traffic crash injuries in India for Injury severity

Estimated number of persons Fatalities 71,948 Serious-major injuries 1,079,220 Minor injuries 5,036,360 Total Total cost as per cent of GDP

Estimated cost in 1995 Rs 38,527,362,572 188,698,379,340* 94,960,567,800 322,186,309,712 3.2 per cent

* Note: cost of serious injuries is taken as the average of serious and major injuries (Rs.174847.5) as stated in the in the TCS report .

• Vehicle damage costs are probably underestimated also since the authors assume that there were 2,14,397 road accidents in the country as recorded by the police. It is common knowledge that most of the minor injury and damage only accidents are not recorded in India. However, the contribution of vehicle damage costs to the total of road accident costs in India may be lower than that in HICs as a higher proportion of crashes involve VRUs in which vehicles may suffer less damage. The above discussion shows that the economic costs of road accidents in India is many times the 0.69 per cent of GDP as reported by the TCS to Ministry of Surface Transport. If we take the increases between 1995 and 2000 as 45 per cent for cost of living, and 72,000 to 85,000 for fatalities, then the figure for cost of road traffic injuries and deaths for 2000 can be extrapolated to Rupees 550,000 million. The GDP of India in 2000 is estimated to be Rupees 1,772,183 million, which gives us the cost of road crash injuries as 3 per cent of GDP. This indicates that the real cost of road accidents in India is more than 2 per cent of the GDP, which is similar to the values calculated for OECD countries. This makes sense for the following reasons: • The total number of road crash fatalities in India is approximately 80 persons per million per year whereas in the USA it is approximately double that amount (161 persons per million). Since loss of income, etc. are based on per capita incomes of a society, then if everything was equal then the health burden of accidents in the USA would be double that of India as

a proportion of the GDP. But costs of similar levels of medical care as a proportion of per capita income would be much higher in India than those in the USA, and productivity of injured and disabled persons would be lower in India. Therefore, injury costs as a proportion of the GDP in India as compared to USA may be similar. • The cheapest car in India costs about 12 times the annual per capita income of an Indian, whereas the cheapest car is about one third of the average income of an American. Or, we can say that a car is about 24 times as expensive in India as far as per capita incomes are concerened. Therefore, loss of a vehicle in a crash or associated repair costs in India would be relatively higher compared to those in HICs. More family time is wasted in India in taking care of accidents and injuries and so these costs would be higher than in HICs. In light of the above, it is clear that the economic costs of road traffic crashes in India (as a proportion of the GDP) would be at least of the same order of magnitude as in the OECD countries if not higher B greater than 2 per cent.

Problems with using a simple economics approach for poor communities The experience of poor communities in coping with medical catastrophes is very different than that experienced by economically well off communities. The special problems faced by poor families can include the following: • Inappropriate or absence of treatment leading to complications and longer treatment time • Reallocation of labour of family members and reduced productivity of whole family • Permanent loss of job for the victim even if he/she survives • Loss of land, personal savings, household goods. • Poor health and educational attainment of surviving members • Dissolution or reconstitution of household None of the above issues are factored in the standard economic calculations done for estimating the cost of road crashes in poor societies. When someone in a poor family is injured and is bed ridden at home or the hospital, the whole family gets involved in the care of the patient. This results in the reallocation of labour of all family members – those on daily wages lose their income; children may not go to school; and older family members may spend less time in the care of children and infants. The household has to cope with the time and financial demands of the situation and this can have a permanent affect on the health of children and infants in the family. This can be the result of loss of income, less attention, worsening hygiene at home, etc.

income. In cases of prolonged treatment or death of the victim, the family may end up selling most of their assets and land and getting trapped into long-term indebtedness. Investment in treatment of a seriously ill family member stops only when all assets get sold. A study from Thailand shows that 60% of involuntary land sales were t finace treatment of a family member. Death of a male head of household creates a household headed by a woman. Such families have to suffer serious social and economic hardships and can have negative health effects on children. It is clear that the outcome of a serious injury or death of a family member in poor communities has many longterm effects, socially, economically and psychologically on all the other family members and the community. Many of these outcomes are permanent and soul destroying for individuals and possibly for the larger community. There is very little work done to understand to understand these issues. Therefore, we must not stop at the calculation of losses in purely monetary terms. For poor communities, our methods do not even capture the economic losses in all their complexity. The effect of injury and death on the family structure, crushing of hopes and aspirations of future generations, and the psychology of the community are just not factored in. We’ll have to take these issues much more seriously in the future and not neglect them just because they cannot be monetised.

References 1.

2.

3.

4.

5

6.

7.

8.

9.

10.

11.

12.

Since a very large number of poor households depend on daily wages and temporary jobs, don’t have health insurance, or the assistance of social welfare schemes, a serious injury can result in permanent reduction of

13.

14.

Hauer, E. (1994). Can One Estimate the Value of Life or is it Better to be Dead Than Stuck in Traffic? Transportation Research Series A, 28, 109-118. Miller, T. R. (2000). Assessing The Burden Of Injury: Progress And Pitfalls. In Injury Prevention and Control, Eds Mohan, D. and Tiwari, G., Tay;or and Francis, London. Jacobs, G., Aeron-Thomas, A. and Astrop, A. (2000). Estimating Global Road Fatalities. TRL Report 445, Transport Research Laboratory, Crowthorne, U.K. Road Deaths Cost OECD Economies the Equivalent of 2 % of GDP (2000). http://www.oecd.org/media/release/nw99-80a.htm. OECD, Paris. Gururaj, G., Thomas, A. A., Reddi, M. N. (2000). Under Reporting Of Road Traffic Injuries In Bangalore: Implications For Road Safety Policies And Programs, Injury Prevention and Control, Proceedings 5th World Conference, Macmillan India Ltd., Delhi. Varghese, M. and Mohan, D. (1991). Transportation Injuries in Rural Haryana, North India. Proceedings International Conference on Traffic Safety, New Delhi, 326-329. Macmillan India Ltd., Delhi. Martinez, R. (1996). Traffic safety as a health issue. Traffic Safety, Communication, and Health. Stockholm, Sweden. Evans, L. (1991). Traffic Safety and the Driver, Van Nostrand Reinhold, New York. Srinivasan, N.S., Hingorani, D.V. and Sharma, B. M. (1975). Economic Costs of Road Accidents, Journal of the Indian Roads Congress, 36-2. Natatrajan, T. (1980). Costs of Road Accidents. M.E. Thesis, Deptt. of Traffic and Urban Engineering, College of Engineering , Guindy, Madras. Road User Cost Study in India (1982). Final Report, Central Road Research Institute, New Delhi. Evaluation of Road Accident Costs - Research Digest (2000). Indian Highways. 28:2, 27-44. The World Health Report:Health Systems-Improving Performance (2000). World Health Organisation, Geneva. Bose, A. (1996). India=s Basic Demographic Statistics. B.R. Publishing Corporation, Delhi.

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16

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Over, M., Ellis, P. E., Huber, J. H. and Solon, O. (1992). The Consequences of Adult Ill Health. In The Health of Adults in the Developing World., Eds Feachem, R. G. A., et al., Oxford University Press, New York, pp. 161-207. Pryer, J. (1989). When Breadwinners Fall Ill: Preliminary Findings From a Case Study in Bangladesh. IDS Bulletin, 20:2, pp 49-57.

1st Safe Community-Conference Viborg County, Denmark 30 September - 3 October 2001

Plenary Session A4 Monday, October 1st 2001

39

New directions in injury surveillance: development of a model for continuous monitoring of direct medical costs Published as: Mulder S, Beeck EF van, Meerding WJ. New directions in injury surveillance : development of a model for continuous monitoring of direct medical costs. International Journal for Consumer Safety 1999;6:11-23.

Abstract Information on the costs of injuries is an important additional instrument in setting priorities for injury prevention. The importance of this instrument is increasingly being recognised by health policy makers. The objective of this study was to develop a model which continuously monitors the direct medical costs of injuries in the Netherlands. This model should provide information on the direct medical costs of injuries at any time and for any selection of accident categories. It is an incidencebased model according to the ‘bottom up’ principle. Homogeneous patient groupings with respect to health care use are defined. The groupings are based on existing classifications from the literature and the experience of medical experts, and are defined by means of seven criteria: nature of care provided, body region of the injury, type of injury, severity of injury, age, complications, and sex of the patient. Several cost elements are distinguished (e.g., general practitioner help, hospital care, nursing home care). For each cost element, relevant patient groupings are determined. The new Dutch Injury Surveillance System (LIS) for injuries treated in an Accident and Emergency department is an important source for incidence data. This article presents the design of the model as adopted by the Working Group on the Costs of Injuries of the European Consumer Safety Association.

1 Introduction Injuries are a major public health problem, all over the world, which is expected to increase in the 21st century.1 They are an important cause of death and disability in the population and also involve high costs to society. In the Netherlands (almost 16 million inhabitants), the health care costs due to injuries are estimated at NLG 2.5 billion or approx. 1.2 billion US dollars.2 This means a share of 4% of the health care costs in the Netherlands, and even 8% of the indirect costs.3 Information about costs is an important supplement to the basic information about the incidence of injuries as recorded by several surveillance systems throughout the world. High costs involved in a certain accident category is an argument for policy makers to put extra effort into injury prevention. Moreover, information about costs can be used as a first step in assessing the cost effectiveness of possible intervention strategies that will reduce the burden of injuries. The need for information about the costs of injuries is underlined in several countries. In a policy document of 40

the Dutch Ministry of Health, Welfare and Sports,4 the explicit intent is mentioned to develop a model which will be able to calculate the socio-economic costs of accidents and injuries. In Denmark, the use of costs of accidents for priority setting is described in a report from the Danish Road Directorate.5 And in the United States, the costs of injuries have been reported to congress.6 Costs can be divided into three main categories; direct costs, indirect costs and human costs. Direct medical costs are costs incurred by the health care sector in diagnosing, treating, nursing and caring for patients. Direct nonmedical costs are costs directly linked to illness or the treatment thereof and which are not borne by the medical sector. These expenses are often made by the patient and/ or his family and friends in connection with the treatment, such as travel expenses (to and from the hospital), time costs and the costs of informal care, but also include expenses connected with reintegration in the employment process, or special education as a result of a complaint or disorder. Indirect costs are the costs of the production loss as the result of absenteeism due to illness, long-term work disability and/or mortality. Human costs reflect the lost quality of life of injury victims and their relatives and friends due to physical and mental suffering. The optimal result will be obtained from cost of injury studies if they lead to reliable results that are comparable for different injury categories, nationally as well as internationally. Unfortunately, the studies conducted so far have usually led to non-comparable results. First, because different methods are used, like the inclusion of different cost categories (direct, indirect, human). Secondly, the scope of the study often differs. Sometimes, studies are limited to (subsets of ) road accidents or home and leisure accident. The Dutch Ministry of Health recently initiated a study into the cost of injuries in the Netherlands, because they need the results for priority setting in the field of injury prevention. They want a model that can continuously monitor the cost of specific groups of accidents. This is possible, because on January 1, 1997 a new surveillance system, the Dutch Injury Surveillance System (LIS) was launched. This hospital-based system provides the necessary basic information on the incidence of injuries treated at Accident & Emergency (A&E) departments (admitted and not admitted). It is a continuous surveillance system providing information with the level of detail necessary for comparisons between accident subcategories.

The national and international incomparability of cost calculation of injuries was also noted at two conferences of the European Consumer Safety Association (ECOSA) about priority setting in accident prevention.7 8 This was the reason for setting up a European Working Group on the costs of injuries. The aim of this Working Group is to develop a tool to assess the social costs of injuries in Europe as an aid to priority setting and risk management decision making in injury control in general, and home and leisure accident control in particular. The objectives are to develop a European injury cost model, to develop a framework for reporting the results of injury cost calculations to European as well as national policy makers and health administrations, and to enable international comparisons of injury costs in Europe and identify factors contributing to variation between countries by means of a model that is applicable in all countries. However, it will be of great help to standardise procedures and the information needed as much as possible. The primary objective of the Dutch project is the development of a computerised model which can be used to calculate continuously the direct medical costs of acute physical injuries in the Netherlands (in total, per category and per accident subcategory). The secondary objective is to design methods to calculate other societal costs, based on the model to be developed. We also aim at making the model useful in drawing up future cost-effectiveness analyses of interventions. The objectives of the Dutch project are in line with those of the ECOSA Working Group. The Dutch model can be seen as a first step in a comprehensive European effort. This first step focuses on the continuous monitoring of direct medical costs. The European effort aims to include other societal costs as well. This article presents the general characteristics of the Dutch model, which were also adopted by the international ECOSA Working Group. In the first section, we explain the design of the model, followed by information on patient groupings and cost elements, and on the injury surveillance data that are needed. The way that the costs will be calculated is subsequently explained. The discussion section will address the limitations of assessing only direct medical costs for priority, and reference is made to possible future extensions.

2

Incidence-based approach

The demands to be met by the new Dutch model were formulated at the start of the project: - It should, in any event, enable the calculation of direct medical costs. - It should be sufficiently detailed to make possible not only the calculation of costs for the total grouping of accidents, but also per accident category and for the larger accident subcategories. - It should provide continuous information on costs. This information should be comparable over time to allow for trend analyses. - Costs of categories and subcategories of accidents

should be comparable, even if the completeness of information on costs differs per category. - The model should be relatively simple to maintain, so that the results can be regularly updated. Figure 1: The ‘top-down’ approach. Total costs of diseases by health care sector

Costs of Cardiovasular diseases

Costs of cancer

Costs of injuries

Costs of traffic accidents

Costs of injuries to passenger car occupants

Costs of injuries to pedestrians

Etc.

Costs of non-traffic accidents

Etc.

Estimating medical costs can be realised via either the ‘bottom-up’ approach or the ‘top-down’ approach (see Figure 1). In the Netherlands, the ‘top-down’ approach was first applied by Koopmanschap et al.,9 and later repeated by others.2 3 To determine the costs per illness, these authors divided health care into sectors (such as physiotherapy, dentistry); then, using a distributive code, the total costs were calculated per sector according to diagnosis (based on the International Classification of Diseases, ICD) and the age and sex of the patient. With this method, determining the costs of specific subcategories of injuries gives rise to extra problems because of the anomalous classification of diagnoses. Because of the numerous premises, classification into injury categories ultimately yields inaccurate information. The ‘top-down’ approach is therefore only suitable for larger groupings that are more homogeneous with regard to diagnosis. Given the demands placed on the model, we selected the ‘bottom-up’ approach. This is an ‘incidence-based’ approach, which builds on all new injuries that occur in a certain period. Generally speaking, this approach works as follows. Various types of injuries are classified in a number of patient groupings which are expected to be homogenous with respect to health care use. Next, an estimate of the average costs per patient is made separately for each patient groupings. This is done for the various cost elements (such as outpatient care, admission to hospital) on the basis of data on volume units (for instance, hospital days) and unit costs. The costs per patient grouping are then calculated by multiplying the average costs per patient by the incidence. The general 41

structure of the model is shown in Figure 2, using several examples.

3

Patient groupings and cost elements

The basis of the cost model is a classification in medically recognisable and economically homogenous patient groupings. These are groupings for which it may be assumed that the ‘life-time’ health care costs (i.e., the costs incurred from the moment of the injury up to the moment of recovery or mortality) are roughly the same for each patient. In order to develop a system of patient groupings, we studied the international literature on patient classifications with regard to costs of injuries and long-term consequences of injuries. In addition, we consulted medical experts in traumatology, orthopaedic surgery, rehabilitation medicine and emergency care to check the classifications. Epidemiological data provided extra starting points by identifying patient groupings with high frequencies of A&E treatments, hospital admissions, short-term absenteeism and long-term work disability. Both the literature and interviews with medical experts showed the following main predictors of variation in injury costs: - criterion 1: nature of the care provided - criterion 2: region of the injury - criterion 3: type of injury - criterion 4: severity of injury - criterion 5: age - criterion 6: complications - criterion 7: sex Figure 2: The general structure of the model (‘bottom-up’ approach). Total costs of injuries

Costs of open wounds

Costs of intracranial injuries

X Standard Resource Costs (SRC)

Incidence of open wounds*

X SRC

Incidence of intracranial injuries*

* by age, sex and injury severity

42

Costs of hip fractures

X SRC

Incidence of hip fractures*

Etc.

X SRC

Etc.

Table 1: Application of selected volume units. Cost elements 1. Physician care, incl. sports physicians and company doctors 2. Hospital care: Emergency care Outpatient care: rehabilitation other outpatient care

cost elements and Volume units

Consultation per type* Consultation per type Consultation; treatment Medical procedure, consultation

Inpatient care: rehabilitation Treatment medical procedures Medical procedure normal care Hospital day intensive care IC-day 3. Nursing homes Nursing home day 4. Physical therapy (paramedical care) Treatment 5. Patient transport: ambulance Ride helicopter Flight other patient transport Ride 6. Aids and appliances Aid; appliance 7. Professional home care Hour of care 8. Other expenses * e.g. normal consultations, consultations including minor surgery, home visits Table 2: Classification of patients by body region and type of injury. 1. Head injury concussion other skull-brain injury open head wound 2. Facial injury eye injury facial fracture open facial wound 3. Spinal column, spinal cord injury fractures/luxations/distorsions whiplash spinal cord injury 4. Trunk injuries injury to internal organs fractured ribs/sternum 5. Injury to upper extremity fractured clavicle/shoulder fractured upper arm fractured elbow/lower arm fractured wrist fractured hand/fingers luxation/distorsion/shoulder/elbow luxation/distorsion/wrist/hand/fingers peripheral nerve injury arm/hand complex soft tissue injury arm/hand 6. Injury to lower extremity fractured pelvis fractured hip fractured thigh fractured knee/lower leg fractured ankle fractured toes/foot luxation/distorsion/knee luxation/distorsion/ankle/foot luxation/distorsion/hip peripheral nerve injury leg/foot complex soft tissue injury leg/foot 7. Skin/subcutis superficial injury (inc. contusions) open wounds (ex. head/face) 8. Burns 9. Intoxication 10. Polytrauma

11. -

Other injury foreign body no injury on examination other and non-specified injuries

In practice, the model will never use all the criteria for all cost elements. For each cost element, the relevant criteria will be selected separately. The number of selected criteria per cost element should be as small as possible in order to make the collection of information and the maintenance of the model achievable. Therefore, the model has been detailed as a tree diagram, whereby: - ever more refined classification levels can be used, based on a simple basic classification; and - the data that need to be collected, and for which classification levels, can be decided per cost element. On the other hand, the availability of data creates restrictions on what can be achieved in practice. In the Netherlands, valid data are available on the incidence of injuries by initial type of medical care, body region affected, type of injury, age and sex, whereas information on injury severity and complications should become available in the future. Especially for developing useful instruments to measure the injury severity, international cooperation is important. In the Dutch model, a central place is occupied by the criteria 2 (body region) and 3 (type of injury). Table 2 shows which patient groupings, by body region and type of injury, are distinguished. The model offers the possibility to aggregate several groupings as well as to further specify them by splitting them up by initial type of care, age and/or sex. The proposed classification is compatible with surveillance systems using the International Classification of Diseases (ICD-9CM or ICD-10).

4 Injury surveillance data The most important source of input for the model is the Dutch Injury Surveillance System (LIS). LIS started on January 1, 1997 and is a uniform surveillance system of all injured persons reported at the A&E departments of 16 hospitals in the Netherlands. LIS provides information on roughly 120,000 recorded injury patients per year. It is a representative sample of 10-15% of all hospitals with an A&E department. Therefore, LIS data may be extrapolated to the national level. LIS provides information about the backgrounds and causes of the injury sustained. In addition to age, sex, date and time of admission and discharge, information is recorded on: - body region (like brain, elbow) - nature of injury (like open wound, burn, frostbite) - specialisms involved in the treatment (like surgery, cardiology) - referrals (like examination or follow-up with general practitioner, intensive care, operating theatre, death) - cause of the injury (like home and leisure accident, occupational accident, sports accident, traffic accident, violence)

- description of the cause (like injury sustained in construction, at home, fall from a stepladder, bitten by a dog) - objects associated with the injury (like chest of drawers, marble) The cost model makes primary use of the incidence data derived from the LIS. The classification of patients is done using the data established on the level of individual LIS records. To estimate the various forms of use of care, a number of continuous health care registrations in the Netherlands will be called upon, including those relating to hospital care, nursing home care, rehabilitation and physiotherapy. In order to acquire more information, an additional questionnaire must also be distributed among injury patients. This will be targeted at a stratified random sample of roughly 5,000 LIS patients. The possibility to get information about the use of care by injury patients (volume units) depends on the route they followed and the degree to which this route is covered by a surveillance system. In addition to volume data, cost price data are also required. This can be acquired from: the tariffs of the Central Health Care Tariffs Organ (Centraal Orgaan Tarieven Gezondheidszorg, or COTG), published cost data and cost studies, while remaining data will have to be collected via special cost studies.

5 Estimation of costs The software for the cost model is being developed. In the software, the classification into patient groupings (see Table 2) is stored in basic files, as are the cost elements that can be differentiated, together with the accompanying volume units (see Table 1). A diverse number of classification criteria for patient groupings can be used per cost element. These data, as shown in Table 3, are stored in the software. On the basis of the characteristics of an LIS record, patients are classified into patient groupings. In addition, the average costs of this patient grouping are added. Imagine that, in the case of a hip fracture, in addition to injury type, age is the only important criterion in determining the patient grouping (younger or older than 75). This means that, in the LIS file, a distinction is made between records concerning hip fractures among patients aged 75 and older (grouping 1), on the one hand, and hip fractures among those younger than 75 (grouping 2) on the other. Depending on the cost elements and volume units to be used, the software assigns a certain amount of costs to all LIS records belonging to grouping 1, and a different amount to all records belonging to grouping 2. For every random selection from the LIS file, costs can be calculated per record and can be provided as output per record. Particularly when aiming at trend comparisons and international comparisons, it is important not only to map the costs, but also to be able to chart the underlying

43

use of care continuously. The output of the model consist of: - the costs calculated; - the number of volume units (use of care). The cost model calculates the average costs for each individual LIS record, and adds this to the record. So, all output is provided per record and on an aggregated level. Classifications that are also available from the incidence data of LIS (including age per year, accident facts, products involved) can be used as a basis for cost calculations. We chose to develop the application with the same software as for LIS, namely, Lotus Notes. The basic files of the model are designed as such, so that they can be easily maintained and updated.

Table 3 Applied criteria per cost element. Cost element Criteria

General practitioner A&E care Outpatient care Day treatment Inpatient care Rehabilitation centre Nursing home care Physiotherapy Ambulance transport Resources Medication Home care

Initial Body type of region medical care x x x x x x x x x x x x x x x x x x x x x

Type of injury

Age

Sex

x x x x x x x x x x x x

x x x x

x x

6 Discussion Injury surveillance provides support for priority setting in prevention. The development of nation-wide hospitalbased registration systems is therefore very important for health policy making in this field. These systems should preferably be comprehensive, in the sense of producing figures on the incidence of injuries in the population for all external causes, all ages, both sexes and all types of injury. Comprehensive injury surveillance systems allow one to make comparisons between the societal burden of different accident categories, such as traffic accidents, occupational accidents, home and leisure accidents, sports accidents and intentional injuries. In the Netherlands, on January 1, 1997, a comprehensive registration system was launched: the Dutch Injury Surveillance System (LIS). This is a representative system including 10-15% of all injury patients seeking medical treatment at all A&E department of a hospital in the Netherlands. This can be seen as a major improvement with regard to the provision of policy information on injuries in the Netherlands. Adequate comparisons of accident subcategories can now be made on a continuous basis. Previously, data from several sources with quite different registration criteria and procedures had to be compared on an ad-hoc basis.10-13 44

It has been recognised, however, that incidence figures are not sufficient for setting priorities in public health. In order to assess the societal burden of injuries and their subcategories, information is needed on injury severity and the long-term consequences of injuries as well.8 An additional instrument is the assessment of the costs of injuries, which is increasingly appreciated by health policy makers. A major advantage of cost estimated is that they give an overall measure of the burden of injuries and their subcategories. cost estimates include information on the incidence, severity and consequences of injuries. They allow a straightforward comparison of the societal burden of different subcategories. Moreover, they give the potential of balancing the costs of preventive measures against the benefit of reducing risks.14 Therefore, in order to increase the value of LIS, a model is being developed for the continuous monitoring of direct medical costs of injuries in the Netherlands. It can be considered as a promising new direction in injury surveillance. Although previous studies have already produced valuable information for health policy makers,3 15-17 these were all performed on an ad-hoc basis. The novelty and strength of our new model is that it is directly embedded in injury surveillance, allowing the monitoring of costs on a continuous basis. Apart from the ability to monitor continuously, the model has additional advantages. The model uses the incidencebased approach6 which leads to estimates of the ‘lifetime costs’ of all new injuries in the base-year of the study. The cost estimates include both present and future costs due to the injury, until the moment of full recovery or death. These costs should be prevented by policy measures. For purposes of priority setting the incidence-based approach seems preferable to the prevalence-based approach, which is applied more often internationally.17 The prevalencebased approach measures the value of resources used or lost during a specific period of time. It deals with injuries with onset in the base-year of the study or at any time prior to the study. Therefore, the method includes the costs of injuries that happened in the past. Another advantage of the cost model is the ability to produce estimates for detailed accident subcategories. This opens the way for cost-effectiveness analyses of preventive measures aiming at specific categories. The output of the model allows inter alia for the estimation of the incidence and costs of intracranial injuries as a result of cycling accidents among children. This is important basic information for an analysis of the costs and effects of the use of bicycle helmets among Dutch children. This type of information cannot be produced with the aid of a ‘top-down approach’ as used in previous studies.3 A final possible advantage of the new model stems from the activities aiming at international standardisation by the ECOSA Working Group. In order to allow for international comparisons of the results of cost assessment studies, a common methodological framework must be

used. The ECOSA Working Group tries to define this methodological framework. It includes decisions on the basic method, the cost elements included, and the output generated. The Dutch model acts as a point of reference for the discussions in the Working Group and can offer the basic structure for similar tools to be developed in other countries. Just as LIS is the basis for the cost model in the Netherlands, the European Home and Leisure Accident Surveillance System (EHLASS) can be used for the incidence figures in countries of the European Union. Although the model certainly has several advantages, this does not mean that it has no limitations. First, it must be recognised that in spite of methodological standardisation, the international comparability of cost-of-injury studies will always be limited. There are important international differences in the structure and financing of health care. Countries have, sometimes considerable, differences in price and wage levels. Also, the type of treatment and the quality of care may differ per country. It seems worthwhile, however, to avoid international variation based on incomparable methods. If this condition is met, it becomes possible to study international variation in health care utilisation and costs of injuries in relation to differences in health care practices. Another limitation concerns the availability and quality of injury surveillance data. The selected approach requires detailed information on the incidence of injuries and resulting health care utilisation. It requires the existence of a representative injury surveillance system and the availability of high quality health care registrations. This means that structural support from health policy makers is needed, including the finances for public health surveillance activities in this field. This limitation, however, is not specific for our new cost model but pertains to all cost assessment studies. A specific limitation of our approach refers to the fact that not all injury patients in the population are included. The model starts with all patients treated at the A&E department of a Dutch hospital. It misses those patients only treated by general practitioners and non-medical professionals. Although these patients account for almost twothirds of the incidence of injuries in the population,18 they only cause a small part of the direct medical costs.2 Therefore, in the continuous monitoring of direct medical costs, this is not a major omission. Moreover, including A&E-treated patients is already an important extension compared with many previous studies which only included patients admitted to hospital. Finally, it must be recognised that the model reported in this article focuses on the monitoring of direct medical costs. It does not include indirect costs or economic production losses, nor human costs or losses of quality of life because of injuries. Previous studies have shown that indirect costs3 and human costs19 in general account for much higher amounts of lost resources than direct medical costs. In our approach, however, we have chosen a stepwise procedure. First, we want to produce valid

estimates for the direct medical costs. Subsequently, other societal costs will be dealt with. The model structure readily permits future extensions. First, however, methodological progress will have to be made. For estimating indirect costs, there is still a debate among health economists about the appropriate methodology. Within the framework of the ECOSA Working Group, a state-of-the-art-report on this issue has been published.19 The same strategy is applied with respect to the human costs of injuries. These ‘costs’ are completely different from the economic costs resulting from health care utilisation and lost productivity. In fact, this represents a different tool to assess the burden of injuries to society. In order to produce valid estimates, a lot of research is needed on the prevalence of disabilities and handicaps resulting from injuries and on the valuation of life and non-fatal injury. It seems worthwhile to investigate whether the application of general public health indicators, such as the Disability-Adjusted Life-Years,1 would be feasible in this field. This would certainly facilitate the comparison of injuries with other public health problems. In conclusion, we can report that a new direction in injury surveillance is being explored: the development of a model for the continuous monitoring of the costs of injuries. This article reported the first step in this comprehensive activity, which will be continued in the years to come. A model has been built for the continuous monitoring of direct medical costs of injuries in the Netherlands. During the next year the incidence and health care utilisation data needed for the cost calculations will be acquired. In the meantime, the ECOSA Working Group will try to reach consensus on international standardisation of methods, including the estimation of indirect and human costs. Therefore, the model reported in this article can be considered as an important first step in the development of a tool for priority setting in injury prevention, which is additional to data on the incidence and severity of injuries.

References 1 Murray CJL, Lopez LD. Alternative projections of mortality and disability by cause 1990-2020: Global Burden of Disease Study. Lancet 1997;349;1498-504. 2 Polder JJ, Meerding WJ, Koopmanschap MA, et al. Kosten van ziekten in Nederland 1994. Rotterdam: Instituut Maatschappelijke Gezondheidszorg; 1997. 3 Beeck EF van, Roijen L van, Mackenbach JP. Medical costs and economic production losses due to injuries in the Netherlands. J Trauma 1997;42:1116-23. 4 Ministerie van Volksgezondheid, Welzijn en Sport. Gezond en wel : Het kader van het volksgezondheidsbeleid 1995 –1998. The Hague: SDU; 1995. 5 Vejdirektoratet. Undersøgelse af større hovedlandevejsarbejder. Metode for effektberegning og økonomisk vurdering. København: Vejdirektoratet; 1992. 6 Rice DP, Mackenzie EJ, eds. Cost of injury in the 45

United States : A report to congress. San Francisco: Institute for Health & Ageing, University of California; 1989. 7 Rogmans WHJ, Mulder S, eds. Priority-Setting in Accident Prevention : Proceedings of a European conference on Priority-Setting in Accident Prevention, held in Vienna on the 29th and 30th of September, 1994. Amsterdam: European Consumer Safety Association; 1995. 8 Mulder S, Rogmans, WHJ. eds. Measuring the severity and costs of accidental injuries : Proceedings of a European conference on Measuring the severity and costs of accidental injuries, held in Oslo on October 10-11, 1996. Amsterdam : European Consumer Safety Association; 1998. 9 Koopmanschap, MA, Roijen L van, Boneux L. Kosten van ziekten in Nederland. Rotterdam: Erasmus Universiteit; 1991. 10 Beeck EF van, Mackenbach JP. Ongevallen signaleringsrapport. Rijswijk: Stuurgroep Toekomstscenario’s Gezondheidszorg; 1989. 11 Beeck EF van, Mackenbach JP. Ongevallen signaleringsrapport 2, 1990 : trends in enkele geïndustrialiseerde landen, 1970-1987. Rijswijk: Stuurgroep Toekomstscenario’s Gezondheidszorg; 1990. 12 Beeck EF van, Mackenbach JP. Ongevallen signaleringsrapport 3, 1992 : ontwikkelingen sinds 1985. Rijswijk: Stuurgroep Toekomstscenario’s Gezondheidszorg; 1992. 13 Beeck EF van, Mackenbach JP. Ongevallen signaleringsrapport 1995. Zoetermeer: Stuurgroep Toekomstscenario’s Gezondheidszorg; 1996. 14 Robertson LS. Injury Epidemiology. New York: Oxford University Press; 1992. 15 Max WD, Rice P, MacKenzie E. The lifetime cost of injury. J Health Care Org Prov Financing 1990;27:332-43. 16 Miller TR, Pindus NM, Douglass JB. Medically related motor vehicle injury costs by body region and severity. J Trauma 1993;34:270-5. 17 Miller TR, Lestina DC. Patterns in US medical expenditures and utilization for injury 1987. Am J Public Health 1996;86:89. 18 Mulder S, Bloemhoff A, Harris S, et al. Ongevallen in Nederland : Opnieuw gemeten 1992/1993. Amsterdam, Stichting Consument en Veiligheid; 1995. 19 Beeck EF van, Mulder S. Costs of injuries in Europe : a review of the state of the art. Amsterdam: European Consumer Safety Association; 1998.

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COMPUTING AND PRESENTING INJURY COSTS Ted R. Miller, PhD Principal Research Scientist Pacific Institute for Research and Evaluation 11710 Beltsville Drive, Suite 300 Calverton, MD 20705 USA

This paper discusses why we use injury costs and give some pointers on effective use. It then provides a primer on injury costing that defines terms and outlines affordable costing approaches. A closing section discusses how to present costs. The Appendix answers eight frequent questions about injury costs. Why should we consider costs? Because they make the burden of injury understandable. Injury costs offer a major advantage over incidence; they reduce disparate outcomes — traumatic deaths, broken noses, frostbite, rapes, poisonings, even damaged bicycles — to a single familiar metric. They describe how injuries affect society and drive analyses of the potential to reduce injuries least expensively. Costs have seven primary uses. 1. Problem size and risk assessment. Costs let you draw that picture worth a thousand words. Figure 1, for example, is a stunner. Violent victimization of kids aged 10-14 accounts for almost 30% of their costs. Sexual violence dominates those costs. Rape is America’s silent shame! (Miller et al., 1999). 2. Health and safety advocacy. Costs are readily grasped by legislators, media, and the public. They communicate problem size clearly and illuminate policy relevance. For example, the average beer consumed by an underage drinker in the U.S. results in $1.15 in outof-pocket costs and work losses (Levy et al. 2000). Yet that beer costs only $.75, including $.35 of gross profit (Miller Brewing, 2000). $1.15 of misery for a $.35 profit! Can this possibly be worth it? 3. Broad priority-setting. Costs let you compare across sectors. For example, Figure 2 compares US research funding on injuries, cardiovascular diseases and cancers with two importance measures: medical spending and years of potential life lost. Injuries seem to deserve more research funding. Notably, years of potential life lost are computed from the age distribution of people killed. They ignore disabled survivors. Thus medical costs may be the cleaner comparison. 4. Resource allocation modelling. Setting the injury prevention budget is the start of a process. Costs also can guide priorities within that budget. Figure 3, for example, shows stairways and furniture pose greater risks than poisons for US infants and toddlers. At ages 5-9, bicycles and playground equipment become the largest risks. As Weimer and Vining (1989) point out, however, cost differentials alone do not tell us what intervention investments make the most sense. Since resources are always scarce, the priorities for invest-

ment are the interventions that will yield the greatest problem reduction within the funds available, even if they only address narrow parts of the overall problem. To aid resource allocation, Miller and Levy (2000), Zaloshnja et al. (2000), and Miller (in press) collectively compare the benefits and costs of 93 U.S. injury interventions. 5. Prospective legislative and regulatory analysis. When passing a law or regulation, government needs to make a case for intervening. Consider this case for taxation. In New Zealand, the average drink carries a drunk driving crash price tag of $.35 for people other than the drinker. Add that to the other public costs of a drink, at least $.50 in violence, medical, and social welfare costs. The average drink—drinks in bars, drinks in cars, drinks stolen from Mum’s hidden bottle—the average drink costs people other than the drinker $.85 (Miller and Blewden 2001). That charge belongs on our booze bills. As a second example, in the US, a dollar spent passing and administering a driver blood alcohol limit of 0.08% will save society $14. It will save government more than it costs. (Miller and Levy 2000, Miller in press). These analyses build the political case. 6. Program evaluation. From an investor’s viewpoint, the key question often is whether safety will pay for itself. Finding that a $28 poison control center call saves $174 in medical spending (Miller and Lestina 1997) justifies continued center funding. Similarly, learning that a $10 bicycle helmet saves auto and health insurers $40 encourages those insurers to continue helmet giveaways (Miller and Levy 1998, 2000). 7. Performance comparison. Costs effectively contrast problems. That is especially true when divided by sensible exposure measures. For example, Canada has much tighter gun control than the U.S. The costs of gunshot wounds are $490 per resident in the US but only $180 per resident in Canada (Miller and Cohen 1997). This difference is suggestive but in a political forum, it’s bait in a trap. The immediate pro-gun response is to claim that Canadians are less violent people. That’s the moment to announce the cost per gun is higher in Canada than the US ($840 vs. $630, according to Miller and Cohen). The difference is that Canadians have less guns. The two exposure measures, used in concert, teach a policy lesson. Figure 4 offers another powerful performance comparison. It maps the relative injury costs per worker among US states. Such maps grab the attention of policymakers in high-cost states. 47

An Injury Costing Primer This paper provides an overview of costing terms, concepts, and approaches. It discusses issues of perspective, costing on a prevalence versus incidence basis, discounting, burden categorization and measurement approaches, and cost-outcome analysis. It starts with a warning. Benefit-cost analysis terminology can be confusing: the costs of injuries averted represent the benefits in the analysis.

Perspective The first decision one makes in costing is to choose a perspective. The US Panel on Cost-Effectiveness in Health and Medicine (PCEHM) (Gold et al. 1996) recommends always including a cost estimate from society’s perspective. That perspective embraces all costs associated with a social problem—costs to victims, families, government, insurers, and taxpayers. Costs to government, to insurers, or to employers also frequently are computed separately. When evaluating minimum drinking age laws, helmet use laws, gun control, and other laws that interfere with personal freedom, economists often focus on external costs—the costs to people other than the person whose behavior is constrained. High external costs justify public intervention. The substance abuse and highway safety literatures define external costs quite differently. In the substance abuse literature, external costs of drunk driving crashes are the costs the drinker implicitly or explicitly chooses not to consider when deciding whether to drink and drive (Easton, 1997; Single et al., 1995). These costs, for example, would include personal costs that the drinker did not consider because of risk misperception. They are germane for analyzing policies designed to affect individual decision-making. In contrast, the highway safety literature defines external crash costs as costs that one group of road users involved in crashes impose on another group of crash-involved road users or on people who were not crash-involved (Elvik 1994; Jansson 1994; Jones-Lee 1990; Lave 1987; Miller & Levy 1998; Newbery 1988; Persson & Odegaard 1995). Elvik (1994) refines this definition, suggesting treating all costs borne by the family due to injuries of a drinking driver or non-occupant as internal and all other costs including costs of injuries to other family members as external. The drinker’s own unforeseen costs would not count. With this definition, external costs are paid by people other than the drinking driver. It is irrelevant whether drinking drivers correctly perceive their own crash risk or consider the crash risks they impose on others. This external cost definition is the relevant one for most public policy decisions. Another perspective problem, and a third definition of external costs, arises in costing illegal acts. From a societal perspective, many economists believe stolen money is an involuntary transfer payment, not a cost. The total money in circulation remains constant, so society does not 48

experience a loss. Taking this kind of reasoning to its extreme, some economists would argue that the sadist gained pleasure from an assault, a gain that offset some of the suffering costs to the victim. I am certain society disagrees with these views. William Trumbull (1990) suggests an alternative, stating that wrong-doers lack standing in societal costing. He recommends not counting gains criminals get illegally as societal benefits, nor viewing prevention of those gains as a loss. In proscribing these actions, legislatures implicitly state that the gains are ill-got and do not benefit society. Trumbull’s rule underpins a definition of external costs used by both Michael French and Mark Cohen in analyzing substance abuse and related crime costs. At least in Cohen’s (1998) work, the definitional line becomes blurry, with the money stolen by the criminal not counted as a cost but the wages that the criminal lost while in jail counted. Again on the blurry edge, Cohen (1998) counts the money spent on illicit drugs as a cost of substance abuse.

Costing Basis Costs can be prevalence- or incidence-based. Prevalencebased costs measure all problem-related expenses during one year, regardless of when the problem occurred. For example, the prevalence-based cost of spinal cord injuries (SCI) in 1996 measures the total health care spending on SCI during 1996, including spending on victims injured many years earlier. Prevalence-based costs for a community are computed by summing all costs incurred in the community during the year. They are used to project health care spending and evaluate cost controls. Incidence-based costs sum the lifetime costs that are expected to result from problems that arose during a single year. For example, the incidence-based cost of SCI in 1996 estimates present and future medical spending associated with all SCI that occurred in 1996. Incidencebased costs for a community are computed by multiplying the number of new victims times lifetime cost per victim. They measure the savings that prevention can yield.

Discounting Investments earn interest. In incidence-based costing and cost-outcome analysis, therefore, future costs and benefits must be discounted to present value. This procedure shows the amount that would be invested today to pay future costs as they arise. The PCEHM (Gold et al. 1996) recommends that all cost savings analyses include an estimate at a 3% discount rate to accommodate crossstudy comparisons. Real rates of return on investment and discount rates that individuals apply when making health decisions suggest this discount rate is a conservative upper bound in the US (US Supreme Court 1983, US Office of Management and Budget 1994, Viscusi 1995) and elsewhere (Murray and Lopez 1994). Worldwide, governments often require analyses of proposed government investments at discount rates of 7%-10%. These high rates offset optimistic impact estimates, lowering total expected benefits. For example, a $1 million cost saving 20 years hence has a present value of $625,000 at a

2.5% discount rate but only $275,000 at a 7% discount rate. Mechanically, how do you discount? The formula is simple. At a 3% discount rate, the present value of $500 in savings or maintenance costs that will occur next year is $500/1.03. If those costs occurred two years from now, the present value would be $500/1.032; three years from now, $500/1.033; and so on.

Burden Categories and Measurement Methods The burden from injury can be classified in many ways. I recommend using four categories. Medical Costs include emergency transport, medical, hospital, rehabilitation, mental health, pharmaceutical, ancillary, and related treatment costs, as well as funeral/ coroner expenses for fatalities and administrative costs of processing medical payments to providers. Other Resource Costs include police, fire, legal/court, and victim services (e.g., foster care, child protective services), plus the costs of property damage or loss in injury incidents. A difficult question here is whether to include intervention costs — e.g. the spending on security guards and alarm systems, on police patrol and ambulance stations, or on government safety agencies — in problem costs. A reasonable guideline is to include these costs only when evaluating a problem or intervention impact that is so large that eliminating it would substantially reduce the need for these prevention services. For example, eliminating alcohol-attributable violence would reduce total violence by perhaps 15%, with an even smaller effect on violence by strangers (Harwood et al. 1998). That might marginally reduce security spending but it would not greatly reduce it. Work Loss Costs value productivity losses. They include victims’ lost wages and the replacement cost of lost household work, as well as fringe benefits and the administrative costs of processing compensation for lost earnings through litigation, insurance, or public welfare programs like food stamps and Supplemental Security Income. As well as victim work losses from death or permanent disability and from short-term disability, this category includes work losses by family and friends who care for sick children, travel delay for uninjured travellers that results from transportation crashes and the injuries they cause, and employer productivity losses caused by temporary or permanent worker absence (e.g. the cost of hiring and training replacement workers), and possibly wages lost while incarcerated. Quality of Life includes the value of intangibles—pain, suffering, and quality of life loss—to victims and their families. Victim work loss costs often are called indirect costs, with medical care and other resource costs called direct costs.

The resource costs represent out-of-pocket spending. The indirect costs are gains foregone, money and other benefits that the injury incident caused someone not to receive. Some aspects of injury burden are readily measured in monetary terms. These include medical costs, other direct or resource costs, and work losses. Together, they are called human capital costs or economic costs. Placing a monetary value on pain, suffering, and lost quality of life, however, is challenging and controversial. The best approach may be to present both non-monetary and monetized estimates. Quality-adjusted life years (QALYs) and disability-adjusted life years (DALYs), defined below, are popular non-monetary measures. Costs that include the value of pain and lost quality of life are called willingness-to-pay costs or comprehensive costs. Medical Costs. Medical cost estimates are computed best bottom-up, by multiplying estimated medical spending per case or visit by diagnosis times corresponding estimated case or visit counts. Two coarser but less expensive approaches are possible. • Top-down. One can obtain total national medical spending, then apportion it according to hospital days by diagnosis group. This prevalence-based approach often is taken when comparing spending on injury and illness (Rice et al. 1985, Moore et al. 1997). In countries where national health systems do not track costs by patient, it is the only practical approach. We applied it to cost gunshot wounds in Canada (Miller 1995) and occupational injuries in the U.S. (Miller and Galbraith 1995). • Factoring. One can adjust a national cost per case to local prices (and preferably local length of hospital stay), then multiply times a local case count to get local costs. We often use this method to make state or provincial cost estimates. It is inexpensive, yet yields reasonably credible numbers. My Databook on Nonfatal Injury (1995) and unpublished updates, for example, contain U.S. costs per injury by diagnosis and whether hospital-admitted. By merging the costs onto local injury incidence data and adjusting to local prices and lengths of stay, we very inexpensively estimated injury costs in 22 states and selected local areas. Work Loss Costs. Victim work or productivity loss has two components: short-term losses during acute injury recovery and lifetime losses due to death or permanent work-related disability. The value of lost paid work includes both wages and fringe benefits. Employers or employees may bear these costs. On average, US workers lose housework on 90% of the work days that they lose wage work. Thus household work days lost can be estimated from the days of paid work lost (Miller 1993). These days typically are valued at the wages paid for comparable tasks (e.g., cooking, cleaning, child care). 49

Lifetime work loss costs value work losses in the current year plus the present value of probable work losses in future years if the individual dies or is permanently disabled. Children under age 15 will not lose work in the short-term. Thus, the lower bound on the cost of shortterm work loss due to a child’s injury is none. When injured children are impaired sufficiently that they would not have been able to work if they had been employed, someone else generally will lose work while serving as a caregiver. As an upper bound, then, it is reasonable to assume parental work loss equals the loss that normally occurs when an adult suffers a comparable injury. For other age groups, the value of lost work depends on the work that someone of the victim’s age and sex normally would do and the amount they would earn. Some administrative data sets record injury diagnoses and days of short-term work lost. We tabulated that information by diagnosis for motor vehicle and occupational injuries in the U.S. Our Workers’ Compensation data also provided diagnosis-specific probabilities of permanent disability and percentages of earning capacity lost if permanently disabled. Unfortunately, neither data system coded diagnoses with the International Classification of Diseases (ICD) used in medical coding. We translated them to ICD and used their estimates in our injury cost models. It is unclear if these work loss estimates would apply in other countries. Friction costs (Koopmanschap et al. 1995) are a subset of work loss costs. They were designed specifically to measure the productivity cost to people other than the victim. They are the only productivity loss to value when using a QALY measure that incorporates victim work loss. Unfortunately, they are hard to value empirically. Quality of Life. A quality-adjusted life year or QALY is a health outcome measure that assigns a value of 1 to a year of perfect health and 0 to death (Gold et al. 1996). QALY loss is determined by the duration and severity of the health problem. To compute it, one estimates the fraction of perfect health lost during each year that a victim is recovering from a health problem or living with a residual disability, then sums these fractions. People killed lose a full QALY per life-year; this value may be adjusted for pre-existing conditions and the general decline in health as people age. In cumulating future years saved, like with any benefit, one needs to discount. Numerous studies find that discount rates for longevity are not dissimilar to discount rates for monetary decisions. Consequently, the PCEHM and World Health Organization (WHO) recommend discounting QALYs at the same rate as monetary losses (Gold et al. 1996, Murray and Lopez 1994). The most practical way to assess health-related quality of life losses from a community viewpoint is a two-step process. In the first step, one creates a set of scales for rating health states, i.e., physical and emotional health 50

status. The general public then is polled to determine how they value the different health states relative to optimal health and to death. A good measure should allow people to rate some fates as worse than death. In the second step, either patient survey/observation or expert physician judgement is used to estimate the temporal pattern of health status changes over time that result from a medical problem. The rating scale then is used to estimate lost utility (an economist’s measure of the relative value people place on different goods). What results is an estimate of the QALYs lost to the medical problem. Over time, refinements to this method have led to the recognition that death does not result in a full QALY of loss per year of life lost. Because no one is perfectly healthy every day, estimated QALY losses normally should be adjusted for major pre-existing health problems. US data now are available to support adjustment (Krueger and Ward 1998). A good QALY scale is segmented by dimensions of functioning. The range of functional dimensions varies in scope and detail. For example, the Health Utility Index (Torrance 1982) considers four dimensions: socialemotional function, role function, physical function, and health/sensory problems. Other popular scales include the EuroQol, Short-Form 36 (SF-36), and Quality of WellBeing Scale. Patrick and Erickson (1993) and Miller (2000a) summarize the scale dimensions used in a wide range of QALY rating studies. My group’s work uses the Injury Impairment Index. We published average QALY losses by diagnosis derived from this index (Miller et al., 1995), then updated them with better disability data (Lawrence et al. 2000). The Functional Capacity Index (MacKenzie et al. 1996) should provide better estimates by diagnosis when its ongoing calibration is completed. Each scale, however, has strengths and drawbacks. Another popular measure, WHO’s DALYs (Murray and Lopez 1994), are essentially QALYs where the importance of different aspects of functioning is based on analytic judgment rather than a survey of public preferences. Furthermore, impact is rated on a single 6-point disability scale with little supporting evidence for the ratings. DALY estimates are little grounded in data. They have not been validated. The Dutch have a better approach, measuring QALY losses with the EuroQol scale and labeling them DALY losses.

Should QALYs Be Monetized? QALYs can simply be reported as a complementary measure to economic costs. Alternatively, they can be monetized. The strongest argument for monetizing is to permit comparisons between health sector investments and investments in other sectors. Such comparisons are especially important in guns and butter decisions. They assure interventions with large health impacts are fairly weighed against ones with primarily fiscal impacts. For example, the benefits of intercepting contraband, including some drugs, can largely be valued in dollars, but

QALY savings are a major part of the value of preventing or treating drug abuse and the injuries it causes. Monetizing QALYs assures the interventions that emphasize health improvement are fairly and fully valued. Consistent QALY valuation encourages sound decision-making. A related reason for monetizing is that analyses are simpler to conduct and understand when they use just one burden measure. Most QALY scales incorporate work-related impacts. A third reason for monetizing QALYs is to facilitate separating work losses from QALY losses. The alternative is to restrict work loss costs to friction costs and incorporate victim work losses in the QALY losses. One downside of this approach is that the QALY-based costs no longer include economic costs—costs many decisionmakers and the media are comfortable with—as a subset. Also, work losses, which typically are the largest component of economic costs, are not quantified even though they easily could be. The arguments against monetizing QALYs are three-fold. First, many people find it distasteful, even offensive to place a dollar value on human life. Second, efforts to value life and related health effects are plagued with validity threats. Third, the valuations obtained vary greatly between studies and lack much validation.

How to Monetize QALYs Four methods, described in Miller (1998, 2000b), can be used to place a dollar value on quality of life losses: (1) valuing a QALY, (2) analysis of jury awards for noneconomic damages resulting from non-fatal injury, which works well in the U.S. but not in less generous legal systems, (3) a survey probing how much people are willing to pay to reduce their risk from social problems, or (4) multiplication of work losses by the average ratio of QALY costs to work losses for other problems, which yields a low-cost order-of-magnitude estimate. For deaths, pain, suffering, and lost quality of life are best valued in dollars using an approach economists call willingness to pay. This approach derives the value of pain and suffering by asking people what they are willing to pay for or by studying what people actually pay for small changes in their chance of dying. The value of fatal risk reduction, aggregated over many people, yields the value of a statistical life. For example, suppose a study estimated that the average person spends $300 on optional auto safety features that reduce the chance of dying prematurely by 1 in 10,000. Dividing $300 by the 1 in 10,000 probability yields a $3 million value per statistical life. That value has two components: (1) the value of the future work that will be foregone and (2) the value of the pain, suffering, grief, lost companionship, and lost quality of life. The value of lost future work is known. Subtracting it leaves the value of the intangibles (Arthur 1981, Miller, Calhoun, and Arthur 1989), the cost of the QALYs lost. Importantly, when this subtraction-based method is used to value lost quality of life, the

total cost of an injury or illness becomes insensitive to the work loss estimate and is determined by the risk reduction value. The value of statistical life can be drawn from meta-analyses and literature reviews (Viscusi 1993, Miller 1990, 2000c; and two solid meta-analyses circulating in manuscript). It appears to lie in the $3-5 million range. The value of a statistical life times the percentage of lifetime QALYs lost to a nonfatal injury equals the estimated willingness to pay to avoid that injury.

Cost-Outcome Analysis Prevention and intervention often involve enforcement or other public action. Cost analysis can justify spending public dollars. Analyses that compare intervention costs with the benefits, i.e., the cost savings, from resulting problem reductions are critical to assess whether prevention efforts are good investments and to choose among investments that fix different problems. Such costoutcome analyses use cost-benefit or cost-effectiveness methods. In a resource-constrained world, decisionmakers need to consider if a program produces desired results less expensively than alternative approaches. They want to know not only that intensive probation supervision of juvenile offenders saves four times what it costs, but that diversion and intensive therapy is a better investment, with an expected return of at least 30 to 1 (Miller and Levy, 2000). Weighing benefits against costs becomes especially relevant for programs interfering with individual behavior (for example, mandating trigger locks for guns, forcing drivers to take sobriety tests or wear safety belts). In these cases, external cost savings—savings to people other than those whose behavior is directly affected—make the case for public intervention. Three types of cost-outcome analyses are available. CostEffectiveness Analysis may express some outcomes in dollars (e.g., reduced property damage, juvenile justice, foster care, and victim medical costs), but it expresses one outcome in a convenient and useful non-monetary measure. The findings are expressed as ratios, such as the cost per suicide act prevented. Generally we subtract any outcomes that are readily valued in dollar terms from the intervention cost when computing a cost-effectiveness measure. Cost-Utility Analysis extends cost-effectiveness analysis by allowing several different non-monetary outcomes, weighted by a common non-monetary unit. For healthrelated interventions, the common unit is usually a QALY. QALYs measure years of life saved and health preserved. They do not reliably measure out-of-pocket cost savings from intervention. Those savings are subtracted from intervention cost (which may mean the net intervention cost per QALY saved is less than zero, i.e., the intervention offers net cost savings). Cost-Benefit Analysis places dollar values on all significant outcomes, including death, pain and suffering, and 51

property loss, so that benefits are directly compared to costs in monetary terms. Reporting costs and outcomes in a common metric facilitates comparison over diverse programs, and allows the benefits to be clearly distinguished from the costs. As well as reporting the ratio of benefits to costs, a cost-benefit analysis should include a net cost savings estimate, computed by subtracting the cost of intervention from the benefits of the intervention. In allocating resources, analysts often trade off the most efficient investments (i.e., those with the highest benefitcost ratios) against investments with a broader reach that can produce a larger total benefit. For example, zero alcohol tolerance for drivers under age 21 has a higher benefit-cost ratio than an intensive sobriety checkpoint program (Miller and Levy 2000), but the checkpoints reach far more drivers and have a greater impact on alcohol-attributable deaths. Cost-outcome analyses count reductions in the costs and consequences of societal problems as benefits. Net societal costs can decline, however, if wrong-doers die or are severely disabled, even after we account for the income and quality of life lost by the wrong-doers and their families. This is especially true of predators and repeat drunk driving offenders who have high probabilities of recidivating and harming others even with the best available interventions. Protecting the public is a key rationale for incarcerating and even executing offenders. Analyses that value harm reduction strategies which save a troubled person’s life need to account for the increased likelihood that others will be harmed. Ideally they also should tailor cost savings estimates based on the lowerthan-average life span and resulting reduction in expected Social Security costs of people with risky lifestyles, although this virtually never occurs. Another difficult issue arises when interventions have the desired impact on the problem population but impose costs on others. For example, raising alcohol taxes reduces underage drinking and the associated harm, but it also forces responsible drinkers to drink less or pay more for the alcohol they consume (Pogue and Sgontz 1989, Kenkel 1996). Cost-outcome analyses require good estimates of intervention impacts. Except in cost-effectiveness analysis, those estimates need to measure changes in final outcomes like crimes averted or alcohol consumption reduced. We lack the tools to reliably translate effectiveness in changing attitudes or life skills into cost savings. Even the best program descriptions and effectiveness evaluations rarely report intervention costs. To learn the cost-effectiveness of programs, we need to change that. Peer reviewers and journal editors need to push for program cost data, perhaps by making program cost a category in structured abstracts describing interventions.

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Pointers on Presentation This closing section discusses how to use costs effectively. Research tells us that people rarely grasp the difference between $100 million and $10 billion. Legislators have learned to knock off the zeroes. For other people, both numbers are simply mind-numbingly big. Dividing a country or county cost estimate by a logical exposure measure like miles driven or drinks consumed can supplement or replace billion-dollar totals and help put problems in more concrete and comprehensible terms. For example, every gun in Canada—guns fired at targets, guns fired at animals, guns fired at people, guns merely gathering dust in the attic—every gun causes an average of $840 in injury costs annually (Miller and Cohen 1997). Sound bites should be planned. Enclose the costs in rhetoric or poetry that makes your point. Earlier, I used a New Zealand sound bite to sell an alcohol tax. It made you think of children drinking. To use the same costs to sell alcohol treatment, a better choice might be: the average drink—drinks at parties, drinks with buddies, drinks with breakfast—the average drink costs people other than the drinker $.85. Another strategy is to give a policy-relevant yardstick. For example, underage drinking cost $53 billion in the US in 1996. To sell prevention, one can compare this to the $1 billion in Federal spending on alcohol prevention services. To sell enforcement, instead compare it to the $9 billion in retail sales to underage drinkers. In presenting benefit-cost analyses, I strongly recommend giving the cost of the intervention, then its savings. Thus, “aggression replacement training for violent juvenile offenders costs $400 per youth assisted and saves $36,000 including $850 in medical spending, $19,000 in other monetary costs, and $16,000 in quality of life” (Miller and Levy 2000). A common error in using cost data is to describe what one could buy if the comprehensive costs of impaired driving or violence were avoided. Comprehensive costs include the value of lost quality of life. Preventing alcohol-related crashes will preserve that quality of life, not put money back in our pockets. It is only appropriate to look at what we could buy if we prevented the monetary costs. For example, preventing all impaired driving crashes would save $42 billion annually. That is enough to buy a $400 television for every American home. Caution your political allies not to describe these savings as money the legislature could reprogram since most of the savings will not go to the government. You should carefully select the types of costs and cost categories that are appropriate to the audience. In some cases, total costs of impaired driving, which more completely reflect the costs to society by including the value of pain, suffering, and lost quality of life, may be most useful. In other cases, specific categories of monetary costs may be more relevant. When you step beyond the academic audience, collapse the costs into just the broad categories that make your point and will interest your audience.

• Property and health insurers may be focused on their payments for injury to third parties, property damage, and medical care claims associated with impaired driving crashes. When talking to a managed care provider about the need for alcohol abuse screening, you might focus on the medical costs. • Businesses may be particularly interested in the productivity and revenue losses they incur when employees are injured or killed in crashes, including the costs when supervisors spend time juggling schedules or recruiting and training replacements for injured workers. • State and community leaders may be particularly concerned about the costs of violence to state and local governments (Medicaid costs and costs of public services such as EMS, police, victim assistance, and perpetrator sanctioning). When presenting these costs, you might only quantify the monetary costs and mention that there are additional losses associated with pain, suffering, and lost quality of life.

If you do not feel comfortable answering questions about how the intangibles were costed, it is okay to omit them. Alternatively, you can tell the press that they were costed with methods recommended in the academic literature. Give them the name of an academic expert to call for details. Journalists appreciate having multiple sources.

Figure 1. Injuries to US children 10-14 cost $113 billion in 1998

Figure 3. Eight leading products by age group, ranked by percent of nonfatal injury cost, United States, 1995-1996 *

Motor vehicle 8% Rape 25%

Fall 18%

Assault 4%

Struck by/vs 10% Poison 3%

Other known 12%

Other cycle 3% Unknown 15%

Although costs are an important prevention tool, they rarely should stand alone. Putting a face with the costs is advisable. Some people are swayed by statistics but others relate better to stories. Data on the cost savings from bicycle helmets are more persuasive when accompanied by the picture of a child bicyclist who walked away unscathed after a car ran over his head.

ACKNOWLEDGEMENT This paper was supported in part by NHTSA contract DTNH22-98-D-35079, Task Order 7 and Children’s Safety Network contract MCJ-240-98-0006 from the US Health Resources and Services Administration. All content is solely the author’s.

Rank 1 2 3 4 5 6 7 8

Age 7 days (3) Death at hospital (2)

Production loss 1 day (17) 2-7 days (5) > 7 days (3) Death at the sceen (2)

Results Pilot study Direct medical costs in moderate and severe injuries are payed by the public financied health care. The major part (90%) of the costs for indirect medical care, production loss, police, and postmortem were payed by the victim or relatives. Severe but non-hospitalised injuries have the highest average cost (US$ 29) compared to hospitalised severe injuries (US$ 18). The total average costs for hospitalised injuries were 24 028 US$ and 8 259 US$ for non-hospitalised injuries. The major part of the costs was due to production loss.

The population study The total costs for the Sherpur area based on injury surveillance during a one year period were 1 267 932 US$ (Rahman, 1998). The total costs are distributed on direct medical costs (54%), production loss (35%) and indirect medical costs (11%). Among minor injuries the costs among non-hospitalised victims are twice as high compared to hospitalised (195 538 US$ compared to 102 097 US$).

Commentary Compared to western industrialised countries the patients, not the social insurance system, pays the main part of the medical costs. Another difference is how to calculate the production loss of the relatives. In low-income countries it would be important to add such costs. Uncertainties due to irregularities in hospital management cause extra costs. Another bias is pro-longed inpatient care because of legal not medical aspects, which tend to overestimate some part of the total costs. Also, injuries which should be treated in hospitals but are taken care outside the medical care system could in the future cause extra costs due to disability problems. In a long-term perspective a better financing of the health care providers by the state could reduce costs for avoidable disabilities. Because of the lack of national data on injury incidence and average costs, individual data had to be collected. This is very time-consuming and increase the costs for calculations. Some cost elements are not available for farmers and low-income groups, e.g. sickness benefit, disability pension. The manual should to a greater extent be divided into public and private costs. One reason is that an increased awareness of the large private costs in the area could increase the motivation of implementing safety measures. Bangladesh II Rahman (2001) conclude that cost calculation of road traffic accidents include several limitations in low-income countries. Examples are the lack of injury data, costs of property damage, estimation of human costs, and production loss. Low-income countries therefore need robust methods for cost calculation. Sweden An external review of the manual was performed in an intervention programme against fall injuries in a suburb area of Stockholm. The societal perspective was stressed featuring costs for the time spent by the participants in the programme, e.g. old-age pensioners, and personnel from voluntary organisations. Their contribution was significant, appr 2 million SEK, including 18 000 hours of work among the pensioners, and 11 000 hours among the voluntary personnel, appr. 1.8 million SEK. In a costeffectiveness analysis such costs should be considered. The total societal costs for the intervention was appr. 7.5 million SEK (1 US$ = 7SEK, 1996) during a 5-year period, including research funding of 2.5 million SEK. The matrix in the manual should be complemented with 65

these costs, and it should be divided on the expenses for the specific project, the collaborators, and the target groups in the intervention area.

Concluding remarks The results from the field tests give only limited experiences to be used for a revised version of the manual. For example the manual should to a greater extent consider the limitations in basic surveillance data, especially in low-income countries, and the need for extra resources when achieving a representative sample of different cost elements. Societal costs featuring intervention costs from the target groups and voluntary organisations are a major part of the intervention costs seldom calculated in costeffectiveness studies. The matrix on intervention costs should therefore be expanded.

How to launch cost calculations in community planning? It would be better to involve the calculations on cost impact of injuries and interventions in the overall community planning process. This means that „all“ community responsibilities should be discussed from a cost-effective perspective. To implement such changes the political decision-making process have to be challenged. A general cost calculation instrument could be one way of question expenditures in the community due to health and safety. In a promotion perspective health and safety issues could be discussed in the ordinary political and administrative contexts, e.g. schools, elderly care and road network planning. However, not always priority will be given to safety, especially if the intervention plans are poor, which will hopefully increase the implementation of evidense-based measures and programs. There are a situation of competing interests dealing with scarce resources and increasing demands in almost all communities. Safety planners therefore to a much greater extent have to be more skilled in how to influence the policy making process. We also argue that increased co-operation and coordination is saving money and increase the interest of overall safety practice. There is no precise methods available to analyse such rationalisation gains yet. We therefore need to develop methods for calculating savings from succesful co-ordinated planning between significant authorities, agencies and voluntary organisations. Even if someone contribute to a program on a non-expenditure basis resources are consumed. A much discussed problem is the in-balance between expenditures and savings among different participants in safety promotion. As concern health care costs the municipalities have to invest in safety but the county councils would gain the preventive outcomes. On the other hand production loss will have an impact on all bransches in the society, but mostly those with a high impact of injuries. 66

References Bender S. Partial application of a Swedish cocting model: calculation of the projected costs of a South African home visitation programme. Khan J, Rashid HO, Jansson B. Costs of injury in Sherpur, Bangladesh in 1996. Johansson P. Societal perspective and cost effectiveness in safetypromotion interventions. Rahman F. Cost calcualtion of traffic accidents in lowincome countries: some methodological issues.

The Cost Calkulation Manual - Test-future (idea, contents,demonstration, test, future) Kent Lindqvist, Associate Professor, Department of Health and Environment, and Department of Computer and Information Science, Linköping University, SE-581 85 Linköping, Sweden. E-mail: [email protected]. Phone: +46 13 222087. Fax: +46 13 221865

This lecture will be designed on the background of the pre-conference at Viborg 28-29 September 2001. Ongoing field tests with the cost manual in different coutries will be presented, discussed and summarized at the pre-conference. These experiences will be introduced at session B3 of the main-conference. Recommended changes or complementary additions in the manual will be presented as well as how the manual can be distributed to the remaining Safe Communities and other interested communities over the world.

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1st Safe Community-Conference Viborg County, Denmark 30 September - 3 October 2001

Plenary Session C2 Wednesday, October 3rd 2001

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Valuing Road Traffic Safety - A comparison of methods for estimating costs for fatal casualty in different countries Ulf Persson, With considerable contributions from Anna Trawén and Pia Maraste, Department of Technology and Society, Lund Institute of Technology, Lund University, Box 118, SE – 221 00 Lund, Sweden. Telephone +46 46 222 97 48 or +46 46 32 91 16. Fax +46 46 12 32 72 or +46 46 12 16 04. [email protected] Please do not quote without authors’ permission.

Introduction In many countries national authorities are responsible for road maintenance and road construction and for the execution of cost-effective road-construction projects. For example in Sweden, the Swedish National Road Administration (NRA) has applied more or less conventional social cost-benefit analysis in their framework for investment appraisal since the second half of the 1960’s. Within this investment framework, prospective safety improvements are given explicit monetary values. These values are then considered together with other costs and benefits, such as the value of travelling time and changes in vehicle operating costs. Thereby, monetary values are fixed on prospective safety improvements and casualties are given an average cost or value. These estimations should reflect the social utility of decreasing the number of fatal road traffic accidents. Similar methods for investment appraisal are developed in many countries. However, estimating the value of resources lost, due to traffic accidents and the value of risk reduction per see is not easy. In several countries, for example Sweden and the United Kingdom, the NRA and the Department of Transport have consulted economists on several occasions, which have led to several major revisions of the way of valuing safety. In the early 90’s, the Commission of the European Communities requested a review (COST 313, 1994) of socio-economic costs of road traffic accidents in 14 countries. From all countries data were collected on the cost for a fatal casualty. That study showed disparities in a) the cost for a fatal casualty between the countries, with a range from 0.1 to 2.2 million ECU, b) the level of the cost-elements included in the cost per fatality, c) methods adopted to estimate the costs. Since a methodological discussion of estimations of risk reductions can be seen in the literature, (for example, Schwab Christe and Sougel, 1995, Viscusi, 1993, Beattie et al., 1998, Carthy et al., 1999) we found it interesting to investigate the approaches adopted in different countries for estimating cost per fatality and if the levels of the costs are revised. The purpose of this study is thereby, to assemble information of costs per fatal casualty in traffic accidents in different countries. We analyse and compare the values adopted by authorities in different countries, as well as the methods used for estimating these values, both between countries and over time, 1990-1999. The basis 70

for this time comparison is information from the COST 313 (1994) study.

Cost Per Fatality When estimating the costs of a fatal injury a number of cost-elements have to be considered. The costs per fatality are commonly defined as direct and indirect costs, plus a value of safety per se. The direct cost contains the costelements medical costs (health care due to the accident, such as first aid, ambulance transport etc) and other costs (for example property damage on vehicles and buildings, administration for insurance companies, police and court due to the traffic accident). The indirect costs comprise lost productive capacity that represents the value of lost production due to the accident. Gross lost production is often determined by social security contribution and income loss for the dead person. Net lost production refers to the value of gross lost production minus the value of the individuals’ consumption lost. The value of safety per se means human cost and a value of statistical life. Human cost often refers to the pain, grief and suffering components that follow from a fatal injury and reflects a value of risk aversion in general. The value of a statistical life (VOSL) is for example estimated in studies where hypothetical markets are created. Individuals are then asked about their willingness to pay for a marginal risk reduction of a fatal injury. The VOSL is estimated by dividing the respondents’ average willingness to pay by the individual risk reduction. For example, if the respondents on average are willing to pay USD15 for a 1/100,000 reduction in the probability of death, the VOSL is US$1.5 million and would reflect the populations’ value of a safety improvement involving the avoidance of one statistical death. The VOSL is often taken to include lost consumption. Therefore, when considering total costs it is important to distinguish between human cost and VOSL and how to add them to the lost productive capacity to avoid double counting.

Method and data At the end of 1999, we sent a questionnaire to individuals involved in the COST 313 survey and to other contact persons outside Europe. We received information from 14 countries, i.e. Australia (AU), Austria (AT), Belgium (B), Canada(C), Finland (FI), Germany (GE), Great Britain (GB), Italy (I), the Netherlands (NL), New Zealand (NZ), Norway (NO), Sweden (SE), Switzerland (CH) and the US. Canada is excluded from the study, since their answers consisted of costs of the total number of

traffic accidents and were not given per fatality. Belgium and Italy answered that no official values exist for road safety policy purposes, but some research projects are ongoing. For the remaining 11 countries we collected both values accepted by the national road transport authorities and data estimated in research projects from which results were not accepted for use in project appraisals. We compared the estimated costs per fatality over time by converting the national cost figures by purchase power parities (PPP) into US$ 1999. In some cases, country-specific consumer price indices were used to attain 1999 price level, since the cost figures were only available for some earlier year. This was done both for the official values used by national authorities and for estimates not accepted for planning purposes.

Results In Figure 1, the cost per fatality in 1990 and 1999, divided into cost-elements, is shown for the 11 countries from which we received completed questionnaires.

The largest parts of the cost per fatality are the cost for lost productive capacity and the VOSL/human cost. However, all countries do not include the human cost, and when included the estimation methods varied quite widely. Other costs and medical costs are based on market prices or administrative unit prices, in all countries and only represent a small part of the total cost per fatality. In 1990 and 1999, all countries include a value of lost productive capacity, with the Netherlands as an exception in 1990. The lost productive capacity refers to gross cost in all countries with Norway in 1990 as an exception where it refers to net cost.

Lost Productive Capacity The lost productive capacity is estimated by the human capital approach, which is based on future productive potential of the victim and measures the loss to society due to a fatal accident. The estimate of lost productive

Figure 1. Cost per Fatality in 1990 and 1999, official values for use in Cost-Benefit analysis on road safety improvements, converted by PPP, US$ 1999 USD

The US, Norway and the Netherlands showed the highest increase in cost per fatality while Switzerland and Finland reduced the cost per fatality during the period.

other costs human costs/ lost productive medical cost

4 000 000 3 500 000 3 000 000 2 500 000 2 000 000 1 500 000 1 000 000 500 000

AT

CH

NL

AU

DE

Source: Trawén et al, Forthcoming in Accident Analysis & Prevention 2001 Between 1990 and 1999, the cost per fatality increased in almost every country. The mean cost was for the countries included in 1990 is about US$0.9 million (1999 prices) and for the countries included in 1999 the mean costs has increased by 70% to about US$1.5 million (1999 prices).

FI

90

99

90

99

90

99

90

0 S

capacity varies by method used. Important methodological differences are: a) if the estimates include only the workforce and exclude children, unemployed and housewives, b) if the costs include lost consumption or not, c) if future loss of earnings are discounted and the level of the discount rate, d) if an assumed growth rate for income or output is made explicit and the level of this growth rate.

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Table 1. Discount Rates and Growth Rates in 1999 AT CH NL AU DE FI SE GB NZ NO US

Discount rate % 0 0 3 4 0 4 5 6 7 4

Growth rate % 0 1 0 2 0 2.4 1 2 2 1.5 wage work 0 household work

The lost productive capacity in 1999 was in all countries estimated by average gross earnings, gross income or gross national product. New Zealand however, has not explicitly estimated lost productive capacity but lost consumption is taken to be included in the VOSL. All estimates include future loss of earnings of those not currently in the workforce (children, unemployed, housewives etc). The future loss of earnings is discounted by a rate that varies from 0% in Austria, Switzerland and Germany to 7% in Norway. Also the growth rates for income or output vary, though not that strongly, from 0% to 2,4%, see Table 1. Consequently, these disparities in growth rates and discount rates account for the variation in lost productive capacity.

Value of Statistical Life / Human Cost Several methods for estimating VOSL/human costs were identified. Estimates could be obtained from implicit valuations in public decisions making. Human cost can for example, be estimated by the use of insurance payments or court compensation payments for pain and disfigurement for injured persons or for loss of life of fatalities. The value of statistical life may for example, be estimated by the willingness to pay (WTP) approach, which is based on preferences stated or implicitly revealed by individuals or society. In the contingent valuation method, the individual willingness to pay is estimated with questionnaires, where the respondents give their maximum willingness to pay for a risk reduction. In the conjoint analysis the trade off between several attributes, i.e. safety, travel time and income are investigated simultaneously. The revealed preference method investigates behaviour in situations where reduced risk must be traded off against other commodities. A meta-analysis is a systematic review of several other estimates.

In 1990, Australia, Finland, Switzerland, Sweden, Great Britain included a value of a statistical life / human cost in the cost per fatality. In Australia, the human cost was settled by court compensation payments and political standards. The human cost in Finland corresponded to the cost of a 100% institutionalised disabled person and in Switzerland the human cost was based on the evaluation of the loss of leisure time (COST 313, 1994). Great Britain and Sweden conducted contingent valuation studies, where a representative part of the population stated their willingness to pay for risk reduction in road traffic. In 1999, all countries estimated VOSL / human cost. Austria and Germany included human cost in the cost per fatality and estimated it by insurance payments and court compensation payments respectively. Australia based the human cost on court compensation payments and political standards as in 1990. Switzerland however, changed the estimation method and human cost was in 1999 based on court compensation payments. The human cost in Finland was in 1999 based on the same approach as in 1990 and corresponded to the cost of a 100% institutionalised disabled person. New Zealand based the VOSL on both a contingent valuation study and a stated preference study, which was a survey of speed choice behaviour where a value of statistical life was stated as a function of the value of travel time. Sweden conducted a contingent valuation study, where a representative part of the population stated their willingness to pay for risk reduction in road traffic. Great Britain conducted a multi-stage approach, which involves ”chaining together” responses to contingent valuation and standard gamble answers. The Netherlands, Norway, and the US based the value on reviews of previous studies, meta-analysis. The metaanalysis in Norway was based on 80 willingness to pay studies conducted in other countries, of seven types: wage-risk trade off on labour market, income-risk trade off on consumer market, traffic users behaviour, compensation payments to victims, authorities implicit assessments, interviews, authorities explicit assessments. The meta-analysis in the US was based on 47 willingness to pay studies, conducted in the US and other countries, of four types: wage-risk trade off on labour market, incomerisk trade off on consumer market, behavioural and

Table 2. Methods for Estimating VOSL / Human Cost Method Court/insurance payments Expenditures of a disabled person Leisure time based Contingent valuation Conjoint analysis Revealed preferences Meta-analysis

1990 AU FI CH SE, UK -

1999 AT, AU, CH, DE FI NZ, SE, UK1) NZ NL, NO, US

Note: 1) ”chaining together” responses to contingent valuation and standard gamble answers.

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Values not accepted AT, SE NZ, SE AT, US FI

contingent valuation surveys. In the Netherlands, the estimation was based on a review from European Transport Safety Council (1997), where the VOSL for various countries are calculated by multiplying the gross lost productivity in each country by 1.54. This ratio is a mean value based on the relationship between the willingness to pay value and gross lost production in Finland, Great Britain and Sweden. Values not accepted have been estimated in several countries. In Austria studies have been conducted with the contingent valuation approach and the revealed preferences approach. Sweden has new estimates from a large contingent valuation study and from a small pilot study using conjoint analysis. New Zealand has also recently conducted a conjoint analysis, but data have not been available for our analysis. In Finland a new metaanalysis are under review by the transport authorities. Figure 2. Accepted and not accepted VOSL/human costs, PPP adjusted, 1999 US$

meta-analysis yielded the highest values followed by estimations based on leisure time and contingent valuation. First, one interesting conclusion is that we found an increased use of the contingent valuation approach and the court compensation / insurance payments approach. The contingent valuation approach aims at reflect what people would be willing to pay (or sacrifice) of his/her income or wealth in order to obtain a reduction of the probability of death or injury. The court compensation/ insurance payment approach will rather answer the question of how much relatives to the victims of traffic accidents will be compensated. Second, another interesting conclusion is that methods not used in 1990 such as revealed preferences, metaanalysis and conjoint analysis were adopted, sometimes to complement or validate the contingent valuation approach. Third, it is interesting to see that countries using 0% discount rate for human capital estimation also tend to use court compensation/insurance payments for estimating VOSL/human costs. The use of 0% discount rate will produce the highest estimate of the lost productive capacity and this could be one attempt to compensate for the choice of an approach producing low values of VOSL/ human costs.

USD 3 000 000 2 500 000 2 000 000 1 500 000 1 000 000 500 000

) (5

) s

ce

(2

) (8

ns

nd

ur

itu

an

re

V C

More profound information about the studies conducted in the countries and new studies not yet accepted by the countries’ authorities can be found in Trawén et al. (2001).

C

ou

rt

/i

pe Ex

R P M (2 et ) aan al ys is Le (4 is ) ur e tim e (1 )

-

Comparing VOSL/human costs estimated by different approaches shows that the two revealed preference studies from New Zealand and Austria produced the highest values. Averages from four meta-analyses, eight contingent valuation studies and one leisure time study are all around US$1.5 million in 1999 prices. The average value from the two Finnish estimates of expenditures of a disabled person is about US$0.8 million. The valuation approach producing lowest figures is the court/insurance payment method, for which an average figure from five studies is only about US$86,000.

Discussion In most countries the total cost per fatality, adopted by official authorities, increased between 1990 and 1999. The mean cost was for the countries included in 1990 US$ 0.9 million and for the countries included in 1999 US$ 1.2 million (fixed prices). This increase is larger than the mean increase in GDP in these countries. One explanation for this increase is that more countries, in 1999, included the cost-element VOSL / human cost in the cost per fatality, which was one of the recommendations in COST 313 (1994). Moreover, the methods of evaluation have changed in some countries and thereby influenced the values. In average, revealed preference and

References Beattie, J., Covey, J., Dolan, P., Hopkins, L., Jones-Lee, M., Loomes, G., Pidgeon, N., Robinson, A., Spencer, A., 1998. On the Contingent Valuation of Safety and the Safety of Contingent Valuation: Part 1 – Caveat Investigator. Journal of Risk and Uncertainty 17:5-25 Carthy, T., Chilton, S., Covey, J., Hopkins, L., Jones-Lee, M., Loomes, G., Pidgeon, N., Spencer, A., 1999. On the Contingent Valuation of Safety and the Safety of Contingent Valuation: Part 2The CV/SG “Chained” Approach. Journal of Risk and Uncertainty 17:3 pp.187-213. COST 313, 1994. Socio-economic cost of road accidents. Commission of the European Communities, Brussels, Belgium Elvik, R., 1995. An analysis of official economic valuations of traffic accident fatalities in 20 motorized countries. Accident Analysis and Prevention, Vol. 27, No. 2, pp. 237-247 European Transport Safety Council, 1997. Transport Accident Costs and the Value of Safety. Brussels, Belgium Schwab Christe, N. G., Sougel, N., 1995. Contingent Valuation, Transport Safety and the Value of Life. Kluwer Academic Publishers, Massachusetts, US Trawén, A., Maraste, P., Persson, U., 2001. International Comparison of Costs of a Fatal Casualty of Road Accidents in 1990 and 1999. Accident Analysis and Prevention (forthcoming) Viscusi, K., 1993. The Value of Risks to Life and Health. Journal of Economic Literature, Vol. XXXI, December, pp.1912-1946

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Questionnaires answered by: Amoako J., The Bureau of transport economics, Canberra, Australia Elvik R., The Institute of Transport Economics, Etterstad, Norway Guria J., The Land Transport Safety Authority, Wellington, New Zealand Krupp R., Bundesanstalt für Strassenwesen, Bergisch Gladbach, Germany Lung E., Bundesministerium für Wissenschaft und Verkehr, Wien, Austria, McMahon K., The Department of the Environment, Transport and the Regions, London, Great Britain Miller T., The Pacific Institute for Research & Evaluation, Landover, the US Persson U., The Department of Technology and Society, Lund Institute of Technology, Lund University and The Swedish Institute for Health Economics, Lund, Sweden, Riebesmeier B., Institut für Tranaportwirtchaft, Wien, Austria Rossel R., Office fédéral de la statistique, Neuchâtel, Switzerland Tervonen J., VTT, Technical Research Centre of Finland, Communities and Infrastructure, Espoo, Finland Wesemann P., SWOV Institute for Road Safety Research, Leidschendam, The Netherlands

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Cost-effectiveness analyses to set priorities and financial decisions in safety promotions Jes Søgaard, Director and Professor. Director of DSI Danish Institute for Health Services Research.

The lecture is not received due to long term disease. The lecture will be issued during the Conference

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Cost calculation and injury prevention Issues of science, rationality and ethics David J. Ball, Middlesex University, School of Health, Biological and Environmental Sciences, London N19 5ND, UK. [email protected]

Introduction The motivation of this conference on the calculation of injury costs is primarily the idea that such information can provide an incentive for decision makers and citizens to increase safety at work and during leisure. Certainly, such information can be used to convey an apparently powerful argument to those decision makers who are driven by economic arguments rather than by less tangible, beyond-the-corporate-balance-sheet, or just downgraded, considerations such as human welfare or environmental quality. In Britain, for example, calculations have been made of the cost of workplace injuries as a means of demonstrating to employers that, although stopping accidents in the workplace undoubtedly costs them money, the benefits accruing to society from the reduction of the ‘external’ costs of ill-health and injuries justifies the expenditure. 1 Likewise, studies have also been made of consumers’ willingness-to-pay for environmental quality, for example, clean bathing waters at the seaside, in order to see if it could be ‘proved’ that while the discharge of untreated sewage to sea is a low cost option for waste disposal authorities and, in due course, tax payers, it is overall ‘illogical’ because, when all costs are considered, the balance sheet is in the red. Thinking back in history, however, to the days before company or state balance sheets were invented, one can imagine that there might have been a period when decisions about what to do were made in some other way. It is conceivable that during such times, when decisions about future activities were not framed in the form of balance sheets, the problem of the so-called ‘externalities’ did not exist, or if it did, showed itself in some other way. Vikings ‘visiting’ Britain would not have needed to calculate injury costs with economic tools to know that being wounded in battle was a serious matter for the individual and also diminished their collective chance of survival. The implication that might be drawn from this is that the sophistication of modern day society, which has resulted in a proliferation and fragmentation of disciplines and a consequent narrowing of horizons of individual decision makers, has in fact created the problem of externalities. Furthermore, it can be speculated that the invention of tools such as balance sheets has actually contributed to this ‘dumbing down’ process. But, having realised (after, it has to be said, some considerable time) what was going on, those professionals (now in the guise of yet more 76

niche specialisms such as health economics and environmental economics) seek to improve the ‘balance sheet’ approach so that life may progress in a way more in tune with our desires. The following important question still remains, however: ‘By how much does the addition of injury costing improve decision making? To this should be added, are there any new or outstanding drawbacks, and, if so, what are they and how may they be dealt with?’

An Illustration Someone (a cricket enthusiast) once said to me that the whole of life can be seen in a game of cricket. I am not going to use this as a model here because hardly anyone, including most English people, fully understands the rules. However, there is some truth in the concept itself and I would, personally, also apply it to the environment of children’s playgrounds. Many of you here will be familiar with this topic, if not cricket, as it has been a priority for the injury prevention community for at least two decades. During the past year I have been re-evaluating the safety of children’s playgrounds in the UK.2 Although not high on my own list of play priorities, the particular issue which has had a strangle-hold so far as public interest in playgrounds is concerned is equipment under-surfacing. This is because there has been a widely held belief for many years that soft undersurfacing is the most important risk reduction measure on offer, and many legal cases have been brought (and won) against play providers who have failed to bow to this popular wisdom. Because of this strong interest in under-surfacing, I have felt obliged to evaluate its utility at the national level, and I have resorted to using basic cost-benefit analysis. This evaluation illustrates many of the strengths and weaknesses of injury costing methodologies and associated techniques like cost-benefit analysis. In order to complete a cost-benefit evaluation of compliant under-surfacing one needs to know a number of things. These include: • the cost of the intervention • the effectiveness of the intervention in terms of reduced incidence of injury (equivalent to the epidemiologists ‘dose-response function’) • a technique for converting the avoided injuries into a monetary value (i.e. injury costing) • a decision rule

As it turns out, not one of these items is free of politics, value judgements or significant uncertainty. Furthermore, and perhaps of most importance, although these four steps might appear all-embracing, two further crucial items are missing. However, first let us consider the four steps, starting with the cost of the intervention. Surprisingly, nobody admits to knowing how many playgrounds there are in Britain, let alone how much surfacing would be required and at what cost. Complicating the issue is the fact that some types of surfacing are high on capital cost whereas others are expensive in terms of maintenance. My current best estimate is that for the UK the annualised capital and revenue cost implication of maintaining impact absorbing surfaces in all playgrounds is in the region of 30 to 100 m euros. However, the problems of costing the above pale almost into insignificance compared with those of estimating the effectiveness of the measure in terms of injury reduction. Despite the passionately-held views on the desirability of IAS (impact absorbing surfacing), evidence in support of this vision is rare, contradictory, and leaves many questions unanswered. Probably the best evidence is that reported by Chalmers et al.,3 who conducted a casecontrol study of childhood falls and consequent injuries in some New Zealand playgrounds. This study found that the most important risk factor on playgrounds was fall height with an odds ratio of 8.6 for equipment over 2 metres high compared with equipment of less than 1 metre, whereas for non-IAS versus IAS the odds ratio was 1.79 (examination of the data shows that from a statistical perspective the most important risk factor is actually body orientation on impact, but the authors mention this only en passant because they did not see it as amenable to intervention). Now, risk factors of less than two, three or even four are generally regarded as signifying only a weak correlation, so one would normally search for other studies which might replicate the finding to increase confidence. Probably the best study for this purpose is one reported by Macarthur et al.4 in Canada. However, although this study confirmed height as a risk factor, it did not so find for IAS. Although several reasons may be advanced for this, one is left with the results from just one study in New Zealand on which to base a dose-response function. Application of the Chalmer’s odds ratio of 1.79 has, therefore, been the vehicle used to progress this calculation. Unfortunately, another problem soon emerges. If the factor is applied to UK playgrounds, and using a number of unavoidable and heroic assumptions, it appears that the annual number of childhood attendances at hospital A & E departments due to falls from equipment in playgrounds would be reduce from ~30,000 in the hypothetical total absence of IAS, to ~17,000 if all playgrounds were fitted with IAS. Over the last fifteen years, about 80% of UK playgrounds have been fitted with IAS, but no significant change has been observed in

the number of A & E attendances arising from playground accidents (this disturbing finding is replicated in the USA where no trends have been observed despite numerous interventions5 ). If it is assumed that the Chalmers factor is intrinsically correct and transferable to the UK, one is left to explain the discrepancy. A possibility is that some kind of ‘negative feedback’ mechanism is at work,6 in which the intervention somehow perturbs the way in which the playground and the children interact, so wiping out or diminishing any hoped for advantage e.g. children, perceiving greater safety, behave more carelessly; guardians likewise are less attentive; and so on. However, to get a feel for the numbers Table 1 (figures in red only at this stage) sets out what we have so far, and assuming for the moment that the Chalmers factor is valid. To compute the monetised benefits, some additional data and assumptions have been used. In terms of playground fatalities, there is one every three or four years in the UK. However, only a fraction of these would be prevented by IAS (because many are not due to falls, and because IAS are not totally effective) and a crude estimate, which is all that is possible, suggests that 0.04 to 0.2 fatalities per annum might potentially be prevented were IAS installed everywhere. Coupling this with a monetary valuation of life (currently ~ Euro 1.67m in the UK based on willingness-to-pay), leads to the range of 0.07 to 0.3 million Euros saved per annum. For non-fatal injuries, the assumption of 13,000 less A & E attendances has been taken as a straw man upper estimate. Direct (hospital) costs have been estimated using UK Department of Health figures, that is, 87 Euros per A & E attendance and 325 Euros per overnight stay in hospital. To allow, crudely, for those injured children seeking some other health outlet, the resulting estimate of 2.15 million Euros has been doubled to 4.3 million Euros. More problematical is the so-called ‘welfare’ component used to account for pain and suffering associated with injuries. Not everyone applies this factor, and in the case of playground injuries certain philosophical issues arise because there is a belief that playground injuries are a more gentle and necessary introduction to the real dangers of the world, in other words, a learning resource. However, if this welfare component is included, itself a political judgement, it can be seen to be by far the largest so far encountered in the benefits column and also the source of the most uncertainty (the uncertainty arises from lack of information on the severity of injuries in the UK injury database. Not included is any uncertainty over the value of pain and suffering, though such uncertainty is also considerable7 ). The next step is the decision rule. Should costs simply be compared with benefits or should some weighting factor be applied? How should uncertainty be treated? The answer to these questions cannot be found in the domain of science (though some decision analysts might give that impression). It is political. 77

Costs of IAS Capital and maintenance Risk transfer mechanism

Play value

Million Euros per annum 30 to 80

Reliability and validity of estimate Moderate

???

???

Benefits of IAS Fatality avoidance

Million Euros per annuma 0.07 to 0.3

Reliability and validity of estimate Moderate to speculative

No estimate is currently feasible

Injury reduction - avoided direct costs

4.3b

Unknown. Could be positive or negative

- avoided welfare costs (? to) 13 to 40b, c Play value ??? Could be positive or negative

- Moderately speculative - Highly speculative Unknown.

Table 1: Summary of costs and benefits associated with impact absorbing surfaces (IAS). a b c

Values of safety in this column are based on DETR and DoH figures. These figures include an allowance of x2 for non A & E attendances. Although a range of 13m euro to 40m euro is estimated, this does not mean that values outside of this range are inconceivable. In particular, this range is anchored in the ‘Chalmer’s factor’ which would project a rather large benefit from IAS in terms of reduced injuries, but which has yet to be observed in practice.

However, this is far from all. As mentioned above, there are two other key factors which have so far not figured in the analysis. One is the possibility of risk transfer.1 There is considerable anecdotal evidence in the UK that the cost of IAS, and some other playground safety interventions, have resulted in a reduction of playground and play equipment provision. Potentially, this could place children at greater risk because they may be displaced to play in less suitable environments, such as near roads or on waste ground. Consider the fact that, for every child who dies in an accident on a UK playground, roughly 2,000 die in accidents elsewhere. There is minimal research on this threat, probably because it is difficult and requires a less reductionist approach, yet the existence of various forms of risk transfer mechanisms in society is believed to seriously undermine many attempts at injury prevention.8 And finally, and probably most important of all, the discussion so far has been solely about the costs and benefits of IAS. Nothing has been said about play value which is, after all, the purpose of the activity. In the language of John Adams, failure to consider benefits of activities or products in risk decisions is, with reference to Figure 1, “bottom loopism.” This interaction could be either beneficial, say, if sand were used which has its own intrinsic play value, or detrimental if it meant replacing, say, grass, which has the important attribute of naturalness,2 with some synthetic material. Another important dimension of play value to consider is the benefit of exposing children to modest risk so that they can learn how to handle it, before being thrust in the far higher risk situations of the older teenage and adult world. This again is entirely a question of beliefs and preferences and not of science in any form. Figure 1: The Adams model of risk compensation. Risks are accepted in exchange for benefits. Failure to consider the ‘benefits loop’ leads to a culture overly preoccupied with risk reduction.1

Where Are We? The illustration of playground and surfacing issues, summarised in Table 1, shows that whereas the costing of injuries is a useful process through which to go, because it clarifies some matters, one needs to remain extremely vigilant from a number of respects. • Many imponderables and uncertainties remain. Costs of safety interventions can be refined, but the value of injuries avoided is far more difficult to assess because the effectiveness of safety measures is seldom known with any reliability. • The benefits of activities and the effect on them of safety measures must be considered, yet this is seldom costed in the same way. Benefits continue to be an ‘externality.’ • The results of injury costing may conflict with strongly held pre-existing opinions. In the case of playground surfacing, CBA does not appear to support the view that IAS is sine qua non as some people appear to believe. • The potential for risk transfer mechanisms should also to be routinely considered but is generally just another externality. The nature of the fundamental problem, as exhibited by playgrounds, is summarised in Figure 2. All of the

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disbenefits of play provision, injuries, costs of provision, law suits and bad publicity are painfully tangible and amenable to calculation and enumeration. Injury costing techniques will assist this process. In contrast, the benefits of play for children, although widely recognised, remain elusive, intangible and outside the reach of scientific assessment and cost benefit. The final risk management decision, therefore, remains essentially political despite the advent of injury costing and related techniques. To use words of Seedhouse, techniques such as cost benefit and injury costing, are characteristic of a phenomenon

referred to as ‘enclosed rationality.’2 That is, the technique is, within its own selected boundaries, rational according to its own criteria. The real world, however, may be affected by forces beyond those boundaries. Furthermore, there is no doubt that the choice of criteria for deciding what is rational and what is irrational is not a matter of science or for science. Indeed, rationality is defined differently by different people according to their personal world view. Figure 3, also from Seedhouse, shows how different approaches to health provision may be linked to different ideologies

Figure 2: A summary of the play dilemma.2 79

Figure 3: An elementary illustration of possible political bases of health promotion.1 To sum up, therefore, while injury costing takes us one step forward in enumerating decision factors, there are still many other factors which remain outside of that process which should not be overlooked. These remaining externalities may be of paramount importance. In many cases they will not be amenable to quantification or scientific analysis. Perhaps this is why Moller has warned that:

decisions are made locally, to change the perception of the problem and the availability of appropriate solutions among key decision makers and the population in general, so that countermeasures may be put in place. It is their effectiveness in doing this which should (be) the major emphasis for evaluation.”2

“Community based injury prevention programs are often incorrectly evaluated as though they were specific countermeasures. The major role of community based programs in many settings is to shift the ways in which

Although Moller’s position is clearly based on his own values, and is not going to be shared by everyone, it once more illustrates how those working in the field of injury prevention need to remain constantly wary of the essential and unavoidable role of politics, and the utility and limitations of expert decision supporting tools.

1

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2

3

4

5

6

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Heath & Safety Executive, ‘The costs to Britain of workplace accidents and work-related ill health in 1995/96,’ HSE Books, 1999. ISBN 0 7176 1709 2. D. J. Ball, ‘Playgrounds – risks, benefits and choices,’ Report to UK Health & Safety Executive, in preparation. D. J. Chalmers, S. W. Marshall, J. D. Langley et al., ‘Height and surfacing as risk factors for injury in falls from playground equipment: a case-control study,’ Injury Prevention, 2, 98-104, 1996. C. Macarthur, X. Hu, D. E. Wesson and P. C. Parkin, ‘Risk factors for severe injuries associated with falls from playground equipment,’ Accident Analysis and Prevention, 32, 377-382, 2000. D. K. Tinsworth, ‘Playground injuries – 1990 versus today,’ Proceedings of ‘Playground safety,’ Penn State University, 1999. Edited by M. L. Christiansen, ISBN 0 960342 1 6. Negative feedback is engineering jargon. Others talk of ‘risk compensation’ (J. Adams, ‘Risk,’ UCL Press, 1995) or ‘reflexivity’ (U. Beck, ‘Die Risikogescellschaft,’ 1986).

8

9

10 11

12

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D. J. Ball, ‘Consumer affairs and the valuation of safety,’ Accident Analysis and Prevention,’ 32, 3, 337-344, 2000. J. D. Graham and J. B. Wiener, ‘Risk vs. risk: tradeoffs in protecting health and the environment,’ Harvard University Press, 1995. ISBN 0 674 77304 7. P. Slovic, ‘Perception of risk,’ in: ‘Social theories of risk,’ S. Krimsky and D. Golding (eds.), 1992. ISBN 0 275 94317 8. J. Adams, ‘Risk,’ UCL Press 1995. ISBN 1 85728 068 7. D. Seedhouse, ‘The ethical limits of rationality,’ personal communication. D. Seedhouse, ‘ Health promotion – philosophy, prejudice and practice,’ Wiley, 1997. ISBN 0 471 93910 2. J. Moller, ‘The culture of safety: a foundation for environmental and behavioural change,’ Plenary Address, World Injury Prevention Congress, Melbourne, 1996.

1st Safe Community-Conference Viborg County, Denmark 30 September - 3 October 2001

Abstracts Session B1 Thuesday, October 2nd 2001

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B1 – 1-1: Traffic Evaluation of Social Cost of Road Traffic Accident in Bangladesh M.J.B. Alam, Associate Professor, Dept. of CivilEngineering, BUET, Dhaka-1000, Bangladesh

Summary Evaluation of benefits and costs of various items related with an investment project is important for the purpose of optimizing social benefit. It assists in making equitable allocation of limited resources among competing sectors as well as among competin projects within a particular sector. Traffic accident is one of the most important items in transportation and safety related projects. Usually, the benefits of transportation projects are evaluated in terms of savings in time and accident. These benefits need to be evaluated in monetary terms so that it can be directly compared with other items. Although a lot of research has been performed on the evaluation of costs of road traffic accident, a comprehensive methodology in this regard is yet to evolve. This is particularly true for developing countries like Bangladesh. It can be attributed to fact that such an evaluation is extremely difficult considering theoretical and practical complexities. The rate of occurrence of road traffic accident in Bangladesh is very high. Its characteristics are also different from the same of the developed countries. Most of the casualties of road traffic accident in Bangladesh involve the working group of the population. In a country of scarce financial and technical resources, the role of this group is

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highly significant. In many families, the futures of a lot of individuals depend on the fate of a single person. In country devoid of any social security system, the cost of any accident should include the value of the economic disaster borne by the dependents of the victim over and above the traditional cost items of accident. Now a days in the developed countries contingent evaluation and willingness to pay methods are widely used for economic and social evaluation of costs of accident. Considering the problems associated with these methods it can be concluded that such approaches are well suited for countries like Bangladesh. Rather than behavioral approach, it is required to develop an approach to estimate the resource cost of traffic accident. The research reported in this paper aims at developing such an approach. The procedure developed in this research includes the factors stated above other than the conventional items. It is observed that the cost of road traffic accident is much higher than the costs estimated by using the conventional methodology. The results of the research suggest that the road traffic accident costs the country more that 3 percent of its GNP which is much higher than the earlier estimates. If the effect of under-reporting of accident, which is prevalent in countries like Bangladesh, is considered the estimation may exceed 5 percent of nation income.

B1 – 1-2: Traffic Cost of road accidents in Kerala State of India Mahesh Chand, Dr. Chief Project Coordinator, India

Introduction:

Results:

Transportation system in South India in general and in Kerala in particular has become one of the most accidentprone systems with high levels of accidents and fatality rates. The present study in this context aims at estimating scientifically cost of accident and examining the policy implications in terms of planning; developing and operating a safer transportation system.

The cost of a fatality has been estimated as Rs.510; 000/(USS11333) at 1998 prices. Similarly the cost of one serious injury was computed as Rs-40; 500/- (USS 900) and cost of minor injury as Rs-5200/- (USS 115) at 1998 prices. The cost of damage was highest for truck (Rs.42; 000 or US $ 933) followed by bus (RS. 30.500 or US $ 678) and car (Rs.10800 or US $240). The cost of damage to three wheelers and two-wheelers were estimated as Rs.5; 200/- (US S 115) and Rs.2; 800(US S 62) respectively. The total estimated economic loss due to accident came to Rs.3148.71 million (US $ 70 million) at 1998 prices.

Methods: Data for this purpose pertaining to accidents and accident cost factors has been obtained from multiple sources including State Police Computer Center; Motor Accident Claim Tribunal (MACT); General Insurance Corporation (GIC); Thiruvananthapuram Medical College (TMC); Automobile dealers survey and personal interviews of accident victims. The cost of fatalities and injuries has been estimated by adopting gross output approach. Five components of costs viz.; (i) loss of output (ii) medical expenses; (ui) court related expenses; (iv) administrative expenses including Police; Insurance; and visits by the relatives and friends; and (v) notional value for pain; grief and suffering have been estimated. The estimated cost of accidents thus obtained has been compared with „willingness to pay“ approach as shown by the survey of accident victims.

Conclusions: Thus total economic loss due to accidents in Kerala has mounted to almost one percent of State Domestic product. It is suggested that the State should spend more resources in improving the quality of roads and safety of public road transport system in order to reduce accidents. References: 1. Srinivasan N.S and Mahesh Chand‚ Accident Risk Index of Indian Staes‘ IRC Highway Research Bulletin No.25 1984

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B1 – 1-3: Traffic Road Traffic Injuries. A major public Health problem in Egypt Hesham El-Sayed, Professor, Egypt

Introduction: There is increasing recognition in Egypt that injuries is an important health problem ; that affects devlopment and cause enormous burden on the limited emergency health facilities in the country. However; we did not have accurate figures of specific causes of injury mortality and morbidity.

Methods: A cross sectional descriptive study was conducted on 239 deceased persons who were diagnosed as injuries or suspected injury-related deaths. Close relative of the deceased person was interviewed (verbal Autopsy). We compared our data with the vital records of the Ministry of Health; and with the Traffic Police Records. The Capture-Recapture method was used to estimate the proportion of motor vehicle fatalities that were not recognized by the other two methods.

Results: Injuries were under-reported by more than 26%. Extrpolating from our data; injury death rate in Ismailia Governorate is 43/100; 000. Motor vehicle injuries were the most common cause of injury deaths (55%); and estimated to be 27/100; 000. More than two thirds of motor vehicle injuries were among pedastrians; and only 14% were among motor vehicle occupants.

Conclusions: There if need to establish a regorous system for injury registration in Egypt. A National Safety Council in needed to organize all efforts for Injury control in Egypt.

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B1 – 1-4: Traffic Increased bicycle-helmet wearing reduce injuries and save costs. Experiences from Sweden. Robert Ekman, Ph.D., Sweden

Introduction:

Conclusions:

Is it possible to substantially reduce the incidence of injuries and costs related to bicycling through the provision of information on helmet wearing? This issue has been investigated in Skaraborg County; Sweden; where 90% of all pre-school children use bicycle helmets (Ekman et al. 1997)

Only 10-20% among the elderly wears helmets. They show a significant increase in injury rate over time (4.7% annually). Comparisons with Australia and some parts of the USA indicate that; despite the significant decrease of bicycle-related injuries among children and costs in Skaraborg; greater effects might be achievable if information is supplemented by compulsory-helmet-wearing legislation.

Methods: The experimental area was the county of Skaraborg in western Sweden; with a population of 275; 000. 20% of the population of Skaraborg was under 15 (also the experimental group). We also compared injury incidence with the elderly. Outcome-evaluation was based on hospital-discharge data from Sweden’s National Board of Health and Welfare. Such registry information; however; is not available for l984. Bicycle injuries were grouped; by their external cause; according to the injury-classification system; ICD-9; as follows: Vehicle Accident E819; 6 (up to 1986); E819; G (from 1987); and E826.; Cost calculation methods according to Persson (1983)were used.

References: Ekman R, Schelp L, Welander G, Svanström L. (1997) Can a combination of local regional and national information substantially increase bicycle-helmet wearing and reduce injuries? Experiences from Sweden. Accid Anal Prev 29:321-8. Persson U. Cykelolyckorna och deras kostnader. Läkartidningen 1983 49: 4771-3.

Results: In Skaraborg; children have been the target of helmetwearing programs at local and regional levels since 1982; and at national level since 1987. For children under 15 there was an average annual decrease in all bicycle-related injuries of 3.1%; equivalent to a decrease of 48% over the study period; 1978-93 (for head injuries; 59%). Approximately 200 fewer injuries (hospital cases) were found over the period 1985-1995. Saving for the society for all bicycle-related injuries were calculated to 1.8 million USD. The costs for the Bicycle Helmet program were estimated to 0.6 million USD. Net balance was at least + 1.2 million USD; e.g. costs for avoided injuries. The incidence rate over time increased for the elderly.

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B1 – 2-1: Traffic Computerisation of road traffic accident cost – pilot study in Bangalore City Nagaraja Krishnamurthy, Manager, India

Aim: Bangalore is called Silicon Valley,fast developing city in South East Asia. The city is having 14 Lakhs vehicles with a peculiar traffic Mix and inadequate infrastrcture. Police.statistics reveals that in the past three years an average ‚of 700 people are killed and more than 8.500 are grievously injured in road traffic accidents. Little attention has been directed towards the economic cost. The aim of this pilot -study is for better understanding and awarenes on cost.aspects of road traffic accidents.

Method: The data are collected from Traffic accident investigation squad, trauma care centre, victints nd their family members and legal experts, insurance cost also: added to) the total cost.

Findings: 150 cases were taken for the study and following inference of the accident victims were noticed: Average Injured Fatal Age group: 32,5 years . 28.9.6 years. Monthy income Rs 6126.00 Rs 4180 Medical Expences Rs 1,08, 600.00 Rs 86,742.00 Legal Fee Rs 3,726 00 Rs 3196.00 Feature loss Rs 21,00 Lakhs Rs 49,08 Laks

Conclussion: This study reveals the tip of the economic cost of road accident, and.its serious impact on victims and their family who cannot afford from their limited source of income. Also this can be used a launching pad for further studies on systematic approach for budget provision, prevension and controlt measures. of .accidents at the black spots, which are already identified in the city.

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B1 – 2-2: Traffic The economic impact of Road Accidents in the United Arab Emirates Mohammed Elsadig Haj Ahmed, Dr., United Arab Emirates

Introduction: The aim of the study is to quantify the economic impact of RTAs in the United Arab Emirates (UAE) during 1998.; Objectives:; 1. To quantify the present value of the direct economic costs of RTAs; per AIS; in the UAE including: workplace and household productivity losses; material damages; emergency; medical and ancillary care costs and insurance; fire; police; legal and insurance administration costs. 2. To assess and quantify the present value of the indirect economic costs of RTAs; in terms of traffic delay; pain; grief and suffering to casualties; their families and to society.

Methods: To assess the true impact of RTAs in the UAE; the study took a societal viewpoint. To achieve that the study used CBA based approaches; the HC and the WTP approaches; to quantify the material and human losses caused by RTAs. The data sources ranged from deterministic non-sampled sources; including Ministry of Health annual reports; UAE police annual reports; UAE Annual Statistical Abstracts; etc. Sampled and qualitative data (informed specialists’ opinion) were also used to infer the necessary parameters for injury severity; incapacitation; medication costs; legal and police costs; etc. The essential elements of RTA costs were workplace and home productivity losses; medical and ancillary services costs; police administration costs; court and legal costs; traffic delay; property damage; in addition to estimated WTP values; derived from the international literature; to compensate for pain grief and suffering.; The study used prevailing market prices and wage rates to estimate the resource use associated with RTA outcomes; in addition to shadow prices for non-marketed elements. The results were discounted to the present; using the adjusted market rate of interest in the UAE. Sensitivity analysis was used to test parameters for uncertainty.

Results:

injury and death per RTA) was concurrently rising. During the period 1985-1998 the risk of injury and death in RTAs in the UAE more than tripled. ; The quantification of RTA losses revealed that a single fatal injury cost was UAD 1; 221; 000 (US$331; 793). The total cost of RTA fatalities in the UAE exceeded UAD 1.5 billion (US$408 million). For non-fatal injuries: a critical injury; AIS-5; was UAD 1; 058; 000 (US$287; 500); a severe injury AIS-4 was UAD 965; 000 (US$262; 228); a serious injury UAD 341; 600 ($92; 826). For the total number of non-fatal RTA injuries the cost exceeded UAD 2.1 billion (US$571 millions). Property damage costs were UAD 362; 430; 000 (US$98; 486 millions). Overall; the total direct costs of RTAs in the UAE exceeded UAD 3.6 billion (US$ 1 billion) during 1998. Indirect costs of RTAs including; pain grief and suffering (PGS) and traffic delay were estimated by combining willingness to pay values (WTP) derived internationally by other researchers.

Conclusions: UAE’s rates were high compared to other countries. The cause for the increasing severity of RTAs is not clear but it could lie in speeding; careless driving; the changing vehicle mix and the standard of immediate care for victims. Further investigation is essential. Many human lives and large resources could be saved if the underlying factors of RTAs in the UAE were investigated and controlled.

References: Elvik R. Analysis of Official Economic Valuations of Traffic Accidents Fatalities in 20 Motorised Countries. Accid Anal and Prev 1995 27:237-247. Lawrence J., Blincoe J. Barbara MF. The Economic Cost of Motor Vehicle Crashes. 1992 DOT HS 807 876:I.1-I.14.

In the UAE road traffic accidents (RTA) rates were found high when compared with the equivalent rates in other developed and developing countries. Based on population the UAE’s rate was twice the mean rate in developed countries. Based on motor vehicles the UAE’s rate was five times higher than the equivalent rate in the comparison group of countries. Although the trends of RTAs per population and motor vehicles in the UAE were declining; the risk of injury and death in RTAs (the ratio of 87

B1 – 2-3: Traffic The development in injuries following severe road traffic accident with motor vehicles Lars Binderup Larsen, MD, Denmark

Introduction: The Danish Road Safety Commission set up an action programme in 1988 with the aim of reducing the number of road traftic fatalities as well as non fatal injuries by minimum 40% during a period of twelve years. The aim of the study was to examine the epidemiology of moderate or severe injuries sustained in road traftic accidents with motor vehicles in the period 1988 to 2000 to see if safety measures implemented had had signiticant effect.

Material and methods: All persons treated in the emergency room at Odense University Hospital folIowing road traftic accidents are included in the Accident Statistics Register. For this study all persons sustaining lesions with AIS>=3 following accidents with motor vehicles were included. Only registered inhabitants of the Odense Municipality were included since this is a well detined geographical area with only one hospital.

Results: The study included 312 persons. The male/female rate ratio was 3.4 (95%CI 2.6-4.5) while for road traftic accident victims as a whole it was 1.4 (95% Cl 1.3-1.5). Men aged 20 to 39 years accounted for 41% of all the injured persons. We found no statistical signiticant fall in the number offatalities or more severe injuries in the period. The lesions were most frequently localised to the thorax or the legs (28% and 27% of the total number oflesions). The use ofsafety belts in victims with injuries with AIS>=3 was 53% while for all injured it was 72%.

Conclusion: We found that the number ofmoderate and severely injured persons in Odense, Denmark had not decreased signiticantly in the period. During the latest three years a signiticant increase was recorded. Younger men have a signiticantly higher risk. The low percentage use of safety belts indicate that the use of safety measures should be further promoted.

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B1 – 2-4: Traffic Road traffic accidents in Republic of Macedonia Fimka Tozija, Macedonia

Introduction The studies done so far in the area of road traffic accidents (RTA) indicate the seriousness of this problem in Macedonia, with high priority for prevention, especially among children and adolescents. The number of injured children and adolescents, victims from RTA is continuously growing. The percentage of those who died after the RTA injury is still high, the disability rate caused by these accidents is high and the economic consequences tremendous (costs for diagnostics, therapy and rehabilitation, costs due to early death and lost active work years).

Methods This imposes the need for safety promotion research to identify the risks for RTA, dynamics and structure of the injuries, and prevention measures. The main objective of this paper is to present the seriousness of the road traffic traumatism in Macedonia, emphasizing the need for specific prevention. This objective can be achieved by: analysis of the epidemiological features: social-medical aspects (mortality, out-patient and in-patient morbidity, disability), economic aspects of the RTA); assessment of the severity of the road traffic accident traumas, and their impact to the outcome of the injury; analysis of the risk factors and causes for the RTA (human, vehicle, road, environment). This is retrospective research based on the social-medical, epidemiological and statistical methods and is envisioned to cover the period 1983-1999, providing epidemiological description and analyses of the RTA traumatism in Macedonia. The frequency, distribution and dynamics of the RTA, incidence and mortality rates caused by road traffic accidents, demographic analysis of the victims (injured, dead) in RTA (distribution by gender and age and category of participation in the road traffic), chronological analysis (cyclical, seasonal, weekly and circadian variations) and topographic analysis (in and out of the inhabited area, per municipality) will be presented Official statistical data were provided by: National Statistical Office; Republic Institute for Health Protection - Skopje; Ministry of Health, Ministry of Internal Affairs; Health Insurance Fund, WHO.

Results The RTA traumatism in Macedonia has a cyclic oscillation with five-year variations, seasonal epidemic wave lasts from April to October, critical days in and out of the inhabited area are Friday and Saturday, and „rush hours“ from 4 p.m. to 6 p.m. The rates of RTA per 1000 vehicles are as follows: incidence of accidents varies from 6.1 to

7.9, rate of injured oscillates from 8.3 to 10.9 and mortality rate from 0.4 to 0,6. The level of the severity of the injuries oscillates from 46%o to 75%o. The largest number of accidents happened due to the driver’s mistakes 82.6%, then mistakes of the pedestrians 15%, due to a vehicle 2.2%, and due to the road 0,2%. The leading mistake among drivers is the unadjusted speed, after alcohol consumption, disrespect of the priority for passing another moving automobile etc. Around 35% of the victims are drivers, 34% travelers, and 31% pedestrians. Age distribution of RTA shows that children and adolescents are the most exposed group participating with 38% in 1983 and 41% in 1999 in the total number of TRA. Children suffer mostly as pedestrians, around 80% at age 0-4, and 70% at age 5-14. Adolescents at age 15-24 in 35-40% of the cases suffer as drivers (10% of the adolescents younger than 18 suffered as drivers without license); 35-40% as passengers and 20% as pedestrians. Injuries are the main cause of death among children aged 7-19 in Macedonia. Around 30-50% of the fatal injuries happen with age groups 5-14 and 15-24 and are result of RTA, or 25-30% of the age group 0-4. The mortality rate is increased from 3,9/100 000 in 1994 to 7.4/100 000 in 1999 for the age group 5-14, while for the age group 1524 from 7,0/100 000 to 12.4/100 000 in 1999. The majority of the injured are cases with light injuries with a rate of 85.8/100 000 in 1983 and 117,5/100 000 in 1994, cases with serious injuries with rate of 38.3/100 000 (1983) and 42,8/100 000 (19940, whereas the lowest is the mortality rate which is 9.3 in 1983 and 8,1 per 100 000 in 1994. Total mortality rate from RTA in 1999 is increased to 10.7/100 000, and the rate of all injured is 143.4/100 000. Sex distribution demonstrates three times higher rates among males. Mortality rate is highest in cases with intractranial injuries, internal injuries and burns.The highest hospitalization rates from intracranial and internal injuries are with the children of the age groups 0-4 and 5-6. 115/100 000, fractures are with a rate 219/100 000 in the age group 5-9, and the burns with a rate of 92/100 000 in the age group 04.DALY calculations done by RAND on the “best available data” show that in 1995 10,646 DALY’s were lost due to injuries.

Conclusions Based on these results assuming that the same factors will persist in future, further increasing trend of the RTA and its consequences can be foreseen. This underlines the necessity of urgent multisectoral injury prevention action. Particular stress should be put on the education and 89

community safety especially for children, respect of the traffic-related legislation, strict technical control of the vehicles and a comprehensive examination of the health status of the drivers.

References 1. Foltin E. Pediatric and adolescent victim (ICD -E 800 to 829) in Austria 1980 to 1989. Unfallchirrurgie. 22(3): 99-109, 1996 Laflamme L, Svanstrom L, Schelp L. Safety Promotion Research. A public Health approach to Accident and Injury Prevention. Stockholm: Karolinska Institute: 1998 2. Schelp L. Epidemiology as a basis for evaluation of a community intervention programme on acpcidents. Stockholm: Karolinska Institute, 1987: 7-15 3. Peabody WJ, Ponce N, Molyneaux WJ. Disease burden and Costs of treatment: Establishing Policy Priorities for Health Care Reform in Macedonia. RAND. DRU-1633-WB. 1997 4. Tozija F, Stikova E. Medical Gegraphy of Accidents and Injuries in Macedonia. Vth National Congress in Medical Geography with International Participation. Sofia: 10-12 October 1996: Book of papers: 156-159 5. Tozija GF. Mortality from injuries in Macedonia Macedoniani Medical Journal 1994;48(3-4): 114-118 6. WHO. Accidents in childhood and adolescence. The role of research. Geneva: 1991 8. WHO. Health for All 2000. HFAWIN. 1999

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B1 – 3-1: Models/Programme Costs of injury in a Safe Community region in Austria – a pragmatic approach to injury costing Robert Bauer, Dr., Austria

Introduction When the first Safe Community project in Austria started in the Province of Vorarlberg in 1993 the allegedly high costbenefit ratio of injury prevention was a key argument. However, to demonstrate benefits a cost of injury (COI) model that could be applied on regional and community levels had yet to be developed. The multiple payer health care system in Austria which is similar to other countries as well, required a model that would allow for customisation to particular payer.

Method Reimbursements of direct costs and compensation payments to health care providers, companies, and individuals were traced back to the sources of payment (payers) by account analysis. Payers considered were: federal, state and community governments, social and private insurance, employers, and the patients themselves. State and community government expenditures were attributed to the nine provinces of Austria. Resources (cost elements) considered were: practitioners and hospital services, absenteeism salaries, and disability compensations. By attributing total costs of injury to the respective number of injuries (by type of accident) the average costs per injury could be determined by type of accident, by payer, by cost element, by region and per resident.

Results Streams of payments and compensations due to accidental injuries in Austria in 1998 amounted to EUR 2785 million per year, and to EUR 0,34 million per year in the province of Vorarlberg (Table 1): Area Residents (million) COI (million EUR) COI per resident (EUR) Austria 8,06 2.785 350 Province Vorarlberg 0,34 130 380 Table 1: Total and average Cost of Injury (COI) in Austria and the province of Vorarlberg

COI per injury (EUR) 3.430 3.300

Main cost elements were found to be hospital treatment, sick leave salaries, and disability compensation payments. Hospital treatment and sick leaves are predominantly funded by regional institutions and employers, whereas disability compensation comes exclusively form the Federal Workers‘ Compensation Board and the federal Disability Pension Fund (Table 2). Cost elements COI per Injury (EUR) % Main funding Hospital in-patients 840 26% Regional governments and health insurance Sick leaves 730 22% employers, regional health insurance Disability compensation 590 18% Federal social insurance Private insurance 480 15% Consumers Hospital out-patients 310 9% Federal social insurance, regional health insurance Table 2: Average Cost of Injury (COI) in the province of Vorarlberg by main cost elements

In Vorarlberg about 70 % of total expenditures on injuries are due to home, leisure and sport accidents, and approx. 60 % of this money is spent by regional institutions („regional share“; Table 3). Workplace Traffic Sports Home and Leisure Total Total COI (million EUR) 38 14 13 64 130 Regional share * 37% 61% 57% 62% 53% Federal share ** 63% 39% 43% 38% 47% Table 3: Total cost of injury (COI) in Vorarlberg by accident category and regional share (* State government, Community governments, Regional social health insurance, Employers; ** Workers Compensation Board, Disability pensions, Private insurance, Federal Government)

Conclusions Information on the magnitude of payments due to certain categories of injuries is often not readily available to participants in a multiple payer system of health care funding. Therefore, the concept of both „customising“ (attributing cost to responsible payers) as well as „regionalising“ (to community level) gives an added value to the „cost only“ orientated concepts. The resulting COI model demonstrates the potential benefits of injury prevention programmes to particular stake holders in particular regions. It also enables COI and Cost-Benefit calculation for programme managers on the regional level. An example will be given of how this COI model is used as part of the evaluation of the Safe Communities in Vorarlberg from 1993 to 2000. 91

B1 – 3-2: Models/Programme Partiat Apptication of a Swedish Costing Model: Calculation of the projected costs of a South African Home Visitation Programme Susanne Bender, South Africa

Introduction:

Conclusion:

In order to develop a context-adapted costing manual for South African low-income settings, a planned home visitation programme for injury prevention was costed projectively. The costing was based on information from previous studies in the same communities. Cost calculations are needed in South Africa (SA), to highlight costbenefit ratios, thereby illustrating the severity of the injury problem, its cost to the state, and how interventions can save money as well as lives. The Swedish Costing Manual was applied to calculate the costs of the planned intervention, with the aim of testing and evaluating this model in a SA context. Recommendations for improvement and adaptation of the Swedish Manual are the outcomes.

The application is valuable, in that a number of recommendations are listed. For purposes of refining the manual, the feedback given can be useful for the manual developers, as well as to South African researchers involved in the evolution of the manual for South Africa.

Methods: The paper is a description of the actual costing of the planned home visitation programme for injury prevention in low-income contexts. This description is preceded by a rationale for costing and for cost-benefit anatysis in particutar. Secondty, a community profile and its injury profile is given for the two tow-income informal settlements, followed by a summary of home visitation practices, drawn from national as wett as international studies. The design of the home visitation intervention is included to contextualise the costing details that follow. The Swedish Costing Manual is also outlined, to identify the dimensions that were costed, and in w hat way the process to ok place. The main costing dimensions are: personnet (hours and fee per hour), operating costs, and procurement. Evaluation is an added dimension, which was reported in a separate matrix. With the help of the ISHS human resources and financial managers, intervention costs could be calculated using expenditures from the injury epidemiology studies done in 1998 in the two targeted communities, using the same groups of community volunteer workers, and ISHS staff in a similar research capacity.

Results: The paper provides detailed tables of how the final figures were arrived at. The application is therefore useful for demonstration of the costing process, and of use of the manual. Purthermore, two sets of recommendations are given. The first set relates to the accessibility of the manual in general, and is guided by the manual’s evaluation questionnaire. The second set of recommendations pertains to ideas for adaptation of the manual to South African society. 92

References: Bowman, B. (2001). Towards the development of a comprehensive costing program for the South African injury context. UNISA Institute for Social and Health Sciences. Johannesburg. Draft. Jansson, B., Laur, A., Khan, J, Springfeldt, B, Lindquvist, K. & Lindholm, L. (March 2001). Manual for cost calculations and costeffectiveness in safe community practice. Final test version, Karolinska Institutet, Sweden.

B1 – 3-3: Models/Programme Cost effective injury control programme Alagu Muhtu Ramalingam, Dr., India

Introduction: Experience gained from 30 years of Orthopedic Service in Government and Private Institution. My Orthopedic Service in East Africa - Rotary Volunteer 3 times in 10 years. My teaching of First Aid preparedness to college Students past 6 years. The results of Intersectoral Seminars conducted by me in many Towns in my State.

Methods: Collected all data from participants in various Seminars. Top-Down method of Government has not helped to prevent Home and Vocational Accidents involving the Vulnerable Group of Women-children and Old People. Huge sums of money is spent for treatment and Re-hab. of these Injured persons. India is an Agricultural Country-70% work in forests and fields and Construction Works. Hence Home and Vocational accidents are scrutinised more.

Results: Potential years of Life Lost due to these Accidents cause a big drain to Government Exchequer and Loss of Man Power affect country‘s economic Progress. My Bottom-Up method of Intersectoral Seminars created awareness and Caution among the Public for Home and work place Safety. Fire accidents and Burns in children at home and old People fall due to want of support and presence water the floor. First-Aid taught to college Students equ1pped them facts to carry to Illiterate Villagers with great Benefit for them.

Conclusion: India is developing County No modern sophisticated machines to carry the daily work - and population is enormous and Literacy rate is 30% and Poverty is 70% and needs tireless efforts from all quarters to spread the message of saving Money and avoid Disability through Preparedness to meet increasing incidences of Natural Disasters“ and Home ard work place injuries.

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B1 – 3-4: Models/Programme Medical Care Cost of non-fatal injuries in Taiwan Lu Pai, Associate Professor, Taiwan

Introduction:

References:

Injury is the third leading cause of death; after cancer and stroke; in Taiwan. It kills more than 10000 persons each year. Estimation of the costs of fatal injuries; in terms of YPLL or WYPLL; can be found elsewhere. The costs of nonfatal injuries were not yet evaluated. National Health Insurance (NHI) program; established in 1995 and covered 96.1% of the total populaton; provides a nationwide database for looking into various health related issues. This study analyzed NHI data to evaluate the magnitude of direct medical costs for nonfatal unintentional injuries.

Department of Health Taiwan. Health and Vital Statistics 2000. Tsai MC Hemenway D. Effect of the mandatory helmet law in Taiwan Injury Prevention 1999 5: 290-291

Methods: Nonfatal unintentional injury data were extracted from NHI 1999 data base. Since injuries were coded with E codes only; cases with external causes codes of E800 to E949 were included. Total medical costs and subtotal costs for hospital stay; medical diagnosis; surgical care; anesthesia; medication; rehabilitation; etc. were calculated.

Results: A total of 8; 148; 830 injury outpatient visits and 381; 901 hospitalized injury cases were found in 1999. The total medical care cost was about 2.1 billions in US dollars. Ten percent of this amount was paid by out-ofpocket money for co-payment. Motor vehicle injuries which caused the most accidental deaths; were also the number one cause of injury hospitalization and injury outpatient visits. The total medical care cost for this single injury cause was over $101 millions.; The average length of hospital stay was 8 days. Hospital stay; surgical care and inpatient prescription drugs are leading costly items. Mental health care was seldom utilized and showed the least cost among all medical care items.

Conclusions: Direct medical care cost for injuries has risen up drastically for the last 4 years. Various law enforcement; such as motorcyclist helmet use law; seat belt use law; drivers BAC limits law; etc. ; should be continuously emphasized in order to reduce injuries caused by motor vehicle. To control the direct medical cost for injury; further studies could focus on reducing prescription drugs and encouraging mental health care utilization.

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B1 – 4-1: Violence/Work Cost Calculation of Violence (Incidence) Koustuv Dalal, India

Introduction:

Result:

Violence is one of the most emphasized problems in our world. So the cost calculation of it is highly important. As absolute measure of violence is lackadaisical in sociopolitico-economic analysis, the most effective, relative measure of violence is eccentrically relied upon cost calculation of both micro and macro violence, which can help policy makers in multifarious dimensions. Here cost calculations have to be considered on both individual or micro violence and mass or macro violence for its utmost effectiveness for fund allocation, decision making and pedagogical analysis.

„Political rivals hatched a person to death and his family was near to its end. The windows and front door were broken. The audio and television sets were deformed. Incidence spot was 3.6km from police station, where, one inspector and four constables were deputed“. As the violence was committed on an individual, it’s a micro violence. Here, nxPc =[32hrs.x42.45 for inspector + 84hrs.x28.60 for constable], Ps=O, Vc= @6x3.6km x 12times, Ac= (18600+13780), Lm=O, Llc= 100,000, Rc= 0, lp= 100,000-@10% for 1.5 months delay; i.e. cost =Rs.37649.90. „In an organized way, at the time of seeding, eleven wage-labours were brutally murdered in the paddy field by some paid miscreants with deep-rooted motivation and zeal to politically occupy the new areas. Timely police information saves the lives of miscreants from lynching. Local police station, 8.7km from the incidence, was failed to tackle the situation and curfew was deployed for two consecutive days to decline public resent“. Here, nxPc = [456hrs.x43.02 for inspector + 2160hrs. x 28.86 for constable]; 80000=paramilitary cost for two days including transport and other costs against them; 3800= cost of publicity against such incidence divided by the no. ofit under the state; Vc=@6x (8x2)x34 times; Mc= (800 informer cost +4500 telephone cost); GP=O; PP=70000 for two burnt hut; Hc=O as all were spot dead; Llc=50000 x 11 as govt. declared one time help against each dead body ( as their life were not insured), Rl=[75000 business loss for three days + @ 60xl12 laboursx3days ]; lp= 550,000- @10% for 3months delayed ; B=150000; i.e. cost = Rs.203231.00.

Method: As micro violence is eventually revolved around individual , its cost should be calculated with different objectives. Cost = Preventive cost (Police & other private security cost) + Conveyance cost + Tangible cost (assets & other visible losses) + Intangible cost (life & other invisible losses) -Insurance payments. So, Cost =[ nxPc + Ps] + Vc + [ Ac+ Lm] + [ Llc + Rc] -lp, where, n= no.of hours, police employed in the micro incidence; Pc= rank wise average police costs per hour; Ps = private security cost; V c= per km travel cost x km traveled; Ac = loss of asset; Lm = monetary loss; Llc = life insurance amount made by the concemed person; Rc = recovery cost of the injured; lp = insurance payments by the company. The macro violence consists of large numbers of human beings and liabilities. Here, Cost = Preventive cost ( Police + Paramilitary + Publicity costs ) + Conveyance cost + Damages (loss of public & private properties) + Human cost (injury & life) + Arter effects (revenue losses for social security like curfew etc.) -E (positive economic effect and business from media and books), i.e. Cost = [ NxPc + PMc + Ic ] + [Vc + Mc] + [GP + PP] + [ Hc + Llc ] + RI- [ lp + B], where, N= no. of hours, police employed in the macro incidence; PMc = paramilitary cost incurred in the incidence; Ic =publicity or information cost to the people; Mc = cost of massages with punctilious optimum information; GP = cost of public property; PP = cost of private property; Hc = injury cost including ambulance and trauma care costs; RI = revenue losses including business, job-hour and other public services; B = business of all media and books generated from the incidence.

Conclusion: In these ways we can easily calculate the costs of each violence incidence. Considering these costs under each police station we can determine the priority station not by the volume but by a true weightage. Using various forecasting methods from the past trend of cost, the authority can deploy their utmost attention in the relatively high cost zone, rather than in the violence zone, which not only economize fund allocation also improve social security .

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B1 – 4-2: Violence/Work Domestic violence against adolescents in Bangladesh M. Mizanur Rahman, Assistant Chief (Health), Bangladesh

Introduction:

Conclusions:

To assess the pattern of domestic violence against adolescent girls and also to identify the factors influencing violence against them

Conclusions: Married adolescent girls with rural background were more physically abused than their unmarried counterparts. The information provided a useful tool for action program against violence as well as further research. N.B. Data analysis is ongoing; final paper will be presented in the conference.

Methods: This was a cross sectional study conducted in rural and urban settings. Both married and unmarried adolescent girls aged 10-19 years constituted the study population. A multistage cluster sampling technique was adopted to select the sample.

Results: Data on 500 adolescent girls from rural and urban area were analyzed. The mean age of the respondents was 15.7 years with standard deviation of 2.0 years. Among the respondents; 35.2% had had history of violence in last 6 months. The average number of violence was 3.2. Married adolescent girls were more abused than unmarried; but the difference was not statistically significant (p>0.05). Among the married respondents; husbands were the main perpetrators of violence; whereas the parents were for the unmarried girls followed by other members of the household. Regarding the reasons of violence; 32.0% of the married girls were abused due to household matters followed by prevention of husband?s anti-social activities (15.1%); sexual disharmony (15.0%) and dowry related causes (15.0%); whereas among unmarried girls household matters (42.0%); poor academic performance (31.0%) were the main reasons for abuse. It was also found that married girls with rural background were significantly physically assaulted by their intimate partners than their unmarried counterparts (p0.05).

96

References: 1. Anonymous (1998). The intimate enemy: Gender violence and reproductive health. Panos Briefing 27. 2. Anonymous. (1992). Women?s Aid Organization. Draft report of the National study on domestic violence. Women AID Organization Kuala Lumpur.

B1 – 4-3: Violence/Work Cost of Occupational Accidents in companies: Activity Based Analysis and Information System Integration Pall Rikhardsson, Associate professor, Denmark

Introduction: Besides causing pain and suffering occupational accidents cost money. For a company the costs of occupational accidents are by definition non-value added ? i.e. they have an impact on corporate profitability. Everyone should thus agree that the prevention of occupational accidents; apart from being ethically right; makes good economic sense. There is however; less agreement in occupational safety research on exactly which costs are incurred by occupational accidents; the terminology of these costs; how high these costs are; how they should be measured and whether they could (or should) be integrated in the corporate accounting information system.

Methods: The method applied in the project; which is called the Systematic Accidents Cost Analysis (SACA); is primarily based on:; Activity mapping. Being a part of the methodological arsenal of Activity Based Costing; the activity mapping approach used in the SACA method focuses on identifying the activities carried out due to the specific occupational accident. This includes activities carried out on the day of the accident as well as activities carried out in the following time period. ; Valuation: After the activities have been identified a price tag is put on each activity based on direct expense or calculated cost from man hours involved.. These costs are e.g. sick-pay; nonproductive time of colleagues; administrative costs; production set-backs; replacement hiring costs; fines and investments in extra safety measures. ; Future cost impacts: Taking a more strategic view the future cost impact part of the SACA method aims at clarifying the interests of external stakeholders in occupational accidents and what impacts their interest might have for the future cost structure of the company. This is based on a rating system which rates the risk associated with each stakeholders based on an evaluation by the CEOs.

Results: Data is currently being analysed. Main conclusions will be ready by early september 2001

Conclusions: Data is currently being analysed. Main conclusions will be ready by early september 2001

References: To be included 97

98

1st Safe Community-Conference Viborg County, Denmark 30 September - 3 October 2001

Abstracts Session C1 Wednesday, October 3rd 2001

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C1 – 1-1: Traffic A Study on the Cost Effectiveness of Road Safety Measures in Preventing Socio-economic losses to the Indian society T. S. Reddy, Dr., India

India is a fast developing country with the motor vehicle population of about 40 millions. The composition of motor vehicles weighs heavily towards Two-wheelers (65%) followed by Cars, Trucks and Buses. The current trends indicate rapid growth of private vehicles and the traftic on roads is growing at about 7.5 percent per annum. The Govt. of India has embarked upon the developmental programme of National Highways by upgrading them to 4 lane divided carriageways to increase the output of these roads. Inspite of low per capita ownership of vehicles and low journey speeds the fatality rates on Indjan roads is considerably high. Estimatedly around 80,000 persons are dying on Indjan roads with majority of them constituting pedestrians followed by two wheeler riders (both cycles and scooters). With the changing trends in speeds and the impending accident situations Govt. of India has made safety audit mandatory for all newly constructed highways. For the existing highways the post audit (after construction) is also being taken up seriously with a view to evolve the counter measures to reduce the accidents. A number of measures like straightening the curves, posting appropriate communjcation devices (signs and markings), re-designing the geometrics are being contemplated to improve to safety on Indian roads. This paper attempts to describe the current situation of traftic safety in India and critically examines various possible counter measures and safety devices for their eftectiveness and economic viability. As a part of the analysis of the accident situations an attempt is also made to attribute the economic / financial values for the losses that are expected to result from the accidents.

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C1 – 1-2: Traffic Disaggregated Costing of Road Traffic Accident: Implication for Developing Countries. Mazharul Hoque, Ph.D., Professor, Bangladesh

Aims: Road safety in developing world is rapid1y deteriorating with increasing number of road deaths, largly as a direct consequences of rapid growth in population, motorisation and urbanisarion. Road traffic accidents have been shown to cost annually between 1 and 3 percent of GDP m developmet countries. Knowledge of disaggregated accident costs allows safety impacts to be economically justified This paper reviews the methodological issues of costing road accidents with particular regard to the evaluation of treatments/countermeasures intended to reduce the numbers of accidents in the contex of developing countries. The paper argues that the recently introduced new procedure of costing accidents based on standardised ‚accident type‘ costs should be used instead of the procedure of costing accidents based on accident severity in order to maximise road safety benefits and assess the cost-effectiveness of accident and injury prevention.

Method: Various methods exist for costing road accidents but the method currently recommended for use in the developing world is the gross output or human capital approach. This method takes into account the loss of current resources such as loss to society of killed/injured .person‘s output, property damage, medical treatment, police and administration costs- A sum is usually included to reflect pain.grief. and sufferings as well. Under the gross output method, accidents are costed by the degree of severity, viz. fatal., serious, slight and damage-orly accidents. The new procedure on the other hand bases accident costs on the type of accident (eg. head-on, rear-end, off carriageway. opposing vehicles turnmg etc.) and the costs have been derived from a distibution of the casualty classes persons involved- The power of using standardised costs for different accident types has been demonstrated showing significantly higher safety benefits for particular treatments.

Findings: The recently established Globa1 Road Safety Partnership has estimated that nearly 1 million deaths and 15 million injuries occur on roads worldwide each year- By far the majority - over 75 percent of these casualties occur in the so ca1led developing and emerging countries. even though these countries only account for 32 percent of the total motor vehicle fleet. Developing countries suffer staggering annual loss: exceeding US$ 100 billion. nearly equivalent to double all development assistance- Some

estimates have been made ofthe recurring economic wastage of scarce resources as a result of road accidents (as 1 % of GNP) for specitic developing countries. In current prices, road accidents in Indonesia for example max be costing about US$l000 million per annnum, in Pakistan $450 million., in Egypt $320 million, in Chile $250 rnillion and in .Bangladesh $260 .million. In large countries such as Mexico and India, road accidents may well be costing US$2.500 million to US$3.000 million per annum. Such figures are useful to help governments realise the heavy economic losses being incurred annually and for comparing road accidents to the total cost of illness and deaths due to particular disease and the arguing the increased share of the national budget to spent on road safety. To reduce such huge burden of accident losses most cost effective countermeasures should be direcled at the most prevalent accident types contributing to higher numbers of injuries involving higher costs. Understanding and applications of disaggregated accident types and their costing are clearly important for developing countries for improving safety at marginal costs-

Conclusions: Significant economic losses are incurred in developing societies due to road traffic accidents each year with lack of adequate investment in road safety .The systematic understanding and introduction of accident type method in examining road accident and injury problems and the production of costs for such accident types should be promoted with some urgency in assessing the costeffectiveness of treatments and thereby rnaximise safety benefits in developing countries. Indeed, it is argued that progresses in safety is achieved though an understanding of processes, not through descriptions of outcome and the disaggregated accident types give some understanding of the safety processes involved.

Reference: 1. Andreassen D.(1992) A guide to the use of road accident cost data in project evaluation and planning. ARR Research Report 226- ARRB Transport Research. Melbourn. 2. Hoque, MM (200 l) Road safety improvements in developing countries: priorily issues and options;. Proceeding 20th, ARRB Transport Research Conference, Melboumc. 3. Asia:n Deyelopment Bank (ADB,1996), Road accident costing, REATA 5620 Mani1a.

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C1 – 1-3: Traffic How would setting policy priorities according to cost-benefit analyses affect the provision of road safety? Rune Elvik, Chief Research Officer, Norway

Introduction:

Results:

The paper starts by observing that safety advocates often reject using cost-benefit analysis to set priorities for safety policies. The argument has been made that:; (1) There is no demand for safety; providing it only to the extent it is demaned will lead to small improvements in safety; and; (2) It is unethical to reject proposals for improving safety on the basis of an economic criterion.; Based on these arguments; the paper asks whether it is true that setting priorities for the provision of road safety according to cost-benefit analyses would in fact lead to the adoption of few safety measures; resulting in a small improvement in safety.

The analyses show that inefficient policy priorities and institutional factors constitute the clearly most important obstacles to improving road safety in Norway and Sweden. If all cost-effective road safety measures were adopted (i. e. measures whose benefits are greater than the costs); the number of fatalities could be reduced by about 50%. Measures that are too costly according to current cost-benefit analyses do exist; but the rejection of these measures according to cost-benefit analyses is far less important in explaining safety performance than the rejection of cost-effective measures in current policy priorities. The existence of social dilemmas is also likely to contribute to inefficiency in current road safety policy.

Methods: Based on recent analyses of road safety policies in Norway and Sweden; the paper develops a typology of obstacles to the introduction of effective road safety measures. The main categories of this typology are:; (1) Pure randomness; meaning that factors contributing to accidents or injuries cannot be identified statistically; (2) Lack of knowledge; meaning that factors producing systematic variation in the number of accidents or injuries are unknown; (3) Lack of technology ; meaning that risk factors known to contribute to accidents or injuries cannot be controlled by means of any known safety measure; (4) Too costly measures; that is measures that fail the cost-benefit test as currently applied; (5) Social dilemmas; which refer to situations in which a certain safety measure is desirable from a societal perspective; but not from an individual perspective; (6) Institutional factors; in particular a division of the authority to introduce road safety measures between different levels and sectors of government.; (7) Scarcity of resources; meaning that measures whose benefits are greater than the costs cannot be funded within current budgets.; (8) Inefficient policy priorities; meaning that policy makers give higher priority to other policy objectives than introducing costeffective safety measures.; The importance of the various limits to effective safety policies listed above is quantified on the basis of the recent analyses of road safety policies in Norway and Sweden.

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Conclusions: By rejecting the use of cost-benefit analyses to set priorities; safety advocates are in effect rejecting a road safety policy that would give far better results than current road safety policies. They are thereby defending policies that produce less safety than policies based on cost-benefit analyses would do.

References: The paper is based mainly on two reports issued by the Institute of Transport Economics (Report 446 and report 490).

C1 – 2-1: Models/programme Societal Perspective and Cost effectiveness of health and safety promotion Intervention Pia Johansson, Health economist, Sweden

Introduction:

Conclusions:

To prevent injuries; successful interventions are needed. One method of judging if interventions are successful is to perform cost-effectiveness analyses. Cost-effectiveness analyses relate the intervention costs to the effects; and compare the ratios between interventions; to facilitate decision-making on which interventions to implement.; The presentation will describe the methods for identifying; measuring and valuing the societal intervention costs of a safety promotion intervention. The importance of the analysis? perspective and its effect on cost-effectiveness is demonstrated.

The societal perspective is recommended for costeffectiveness analyses in the health-care sector; but it leads to elevated intervention costs for successful interventions with high levels of mobilisation of collaborators and participants. The societal perspective must also be taken on the intervention effects; otherwise health and safety promotion interventions will appear less cost-effective.

Methods: The societal intervention costs are compiled prospectively from a 5-year intervention programme against falls among elderly in Sundbyberg; in the Stockholm metropolitan area. Important collaborators have been the healthcare sector; different parts of the local authority; a housing company; an educational association; and a large number of local non-governmental organisations. The intervention cost has been computed as part of a future cost-effectiveness analysis.; Societal costs of an intervention include all resources used by the intervention; which are measured according to the opportunity costs. Apart from the costs incurred by the project; societal costs include working time and other resources contributed by the collaborators; and the time costs for volunteers and participants.

Results: The total societal cost for the intervention amounted to approx. 7.5 million SEK (1 USD 1996 ? 7 SEK) during the 5-year period; whereof 2.5 million SEK in project funds. Apart from the project funds; the largest contributor to the intervention was the participants; i.e. old-age pensioners. They contributed resources estimated at nearly 2 million SEK; mainly time costs for participating in activities during 18.000 hours; valued at 100 SEK per hour. Another important type of cost were working-time costs for personnel employed by other organisations; amounting to 11.000 hours and valued at 1.8 million SEK. The intervention cost will further be presented according to the perspective of the funder; the perspective of the health-care sector and the societal perspective.

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C1 – 2-2: Models/programme Cost Calculation of Traffic Accidents in low-income countries: Some methodological issues” Fazlur Rahman, Ph. D., Associate Professor, Bangladesh

Introduction:

Conclusions:

Road Traftic Accidents (RTA) cause subtantial economic loss interms of death, injury and property damage. Cost calculation ofRTA is an utmost need in low-income countries to persuade policy makers and politicians that expenditure on injury control is an appropriate and worthwhile investment, compared to other demands competing for scarce resources. But for a valid and reliable estimation of injuries particularly for traftic injuries is a challanging task in these countries. A pilot study was conducted in Bangladesh with an aim to estimate economical impact of RTA. It was also airned to explore the impact of RTA on the family interms ofpain griefand suffering.

There were severallimitations in the cost calculation of RTA in low-income countries like Bangladesh. The most striking features which need careful calculation are: i) Estimation of number of accident, fatal, severe and slight injury cases as there is no nation-wide injury surveillance system in these countries. ii) Estimation of cost for property damage as there is no comprehensive insurance coverage. iii)Estimation oflost output. iv) Estimation ofhuman cost: Pain, Grief and Suffering. In low-income countries, calculation ofRTA costing needs very robust methods.

Methods: Human Capital Method was used in the study. It included direct costs, such as vehicle damage, loss of output of those injured or killed; and human costs typically labelled ‚pain, grief and suffering‘. Face to face interview with head ofthe household was performed with a pretested questionnaires. Questionnaire 1 was used to record the occurance of fatalities, severe injuries and slight injuries. Questionnaire 2 was used to collect detail information on slight injuries, and questionnaire 3 for severe injuries and deaths.

Results: A total 11,655 population was covered in the survey. It has been estimated that there were 12 RTA fatalities per 100,000 population per year in Bangladesh. The rate of serious injury and slight injury per 100,000 population was estimated as 291 and 1192 respectively. The average monthly income of deceased, severely injured, and slightly injured persons were 88 US$, 76US$ and 52US$ respectively. Average lost working years was 27 years for fatal cases; mean recovery days for severe injury victim was 78 days. Household income, food production and food consumption were declined in 71.4% families with fatal RTA victim.

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C1 – 2-3: Models/programme Who gets the benefits from injury prevention in Tartu Lenno Uusküla, Estonia

Introduction:

References:

The first steps towards becoming a safe community were made in Tartu already a few years ago. Only cost-of-illness analysis has been carried so far. Taking into account total benefits from injury prevention in Tartu; the objective of this research is to find out who gains the most from it. In order to achieve the goal; costs are divided between institutions and people in the community. The more there are benefits; more there should be initiative for prevention.

Laflamme, L., Svanström, L., Schelp, L., (2000) Safety Promotion Research. Uusküla, L., (2001) The cost of injuries in Tartu (in Estonian). Viscusi, W. Kip, (1999) Rational Risk Policy.

Methods: Direct costs are combined from different data sources. Indirect costs are found by the method of human capital. For better resource allocation interpretation; both estimates; using GDP and salary; are used. The comparison of results is made with the willingness to pay analysis.

Results: The results show that the costs; although high; are distributed in a way; which does not lead to injury prevention if the members of the society act separately. The investments into injury prevention are at a low level; such; that neither cost-benefit; nor cost-effectiveness analysis can be used. The reason is the lack of possibility to test for statistical significance. It can be said that if the movement saves 1 life in 20 years (using the same amount of resources as today); the total economic effect is positive for the society as a whole. The results show that people?s willingness to pay is considerably higher than prevention in Tartu is carried out.

Conclusions: Cooperation between institutions and people is needed because there is no single beneficiary from injury prevention. People in Tartu are accepting higher and costs willing for more injury prevention than is the present state of the art. Therefore there are no economic reasons to reject further injury prevention and safety promotion projects in Tartu as far as transparency of the projects is guaranteed.

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C1 – 2-4: Models/programme Trauma Care is a costly affair at Bangalore City, India – Few tips to bring it down. Nagaraja Krishnamurthy, Manager (safety), India

The facts: 1. Middle class and lower class people cannot afford this costly treatment from their source of income. 2. Trauna care is a major.revenue centre in the hospital. 3. Most of vital equipments are imported and costly. 4. Super speciality Medical education cost adds to these figures. 5. Non-professionals manage health sector, as a profit oriented institute 6. Clinical Tests and Specialist service are costly at add Hours

Cost control: 1. Involve Insurance sector in trauma care cost 2. Better utilisation of Operation Teatre. 3. Common service centre for clinical and specialist services on shift duties 4, Better inventory system for Medicine and consumables 5. Bring. down Non oven product cost by recycling. 6. Adopt antibiotic drug policy. Attempt will be made to bring out each point in the presentation.

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C1 – 3-1: Models/programme Costing an Arm and a Leg: A Review of the South African Injury Costing Literature in Three Dimensions Brett Bowman, South Africa

The costs of injury are of obvious importance for the purposes of priority setting in prevention planning by policy makers and stakeholders in general. The economic costs of injury and death have been the focus of considerable international attention in recent years. Localization of these studies and their methods to the South African injury context however, remains largely underdeveloped. The costing of fatal and nonfatal injuries in South Africa consists in a number of initiatives undertaken by various segments of both the public and private sectors. Although these projects have successfully listed and evaluated the items falling within their domains of interest, a comprehensive study of the cumulative costs of injury appears to be lacking in the literature. This paper will reviews the existing literature devoted to the estimation of costs in various sectors of the South African morbidity and mortality contexts. The literature is examined across three primary dimensions; the precise object of the study, the method employed in the costing of that object and the sample coverage of the method. The findings of the review indicate a number of significant entry points for the development of a local South African costing model. A preponderance of direct medical costing, the presentation of an inaccessible and therefore opaque methodology for the calculation of the costs of injury and the prevalent blurring of distinct costing concepts are located as problematic themes throughout the review of the literature. It is through the identification of the problems and promises of these existing costing attempts that an informed contemporary costing model may be generated. It is hoped that this brief but critical review will provide a platform for, the development of a comprehensive and localized estimation of the economic costs of injury in South Africa.

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C1 – 3-2: Models/programme Cost Estimation of Injury among Community and at a major hospital of Delhi Pramod Kumar Verma, Dr. MD, Epidemiologist, India

Introduction: WHO has estimated that 5.8 million people died worldwide due to injury in 1998 which corresponds to incidence rate of 97.9/lac/year and rank 5th among leading causes of death. Cost will become a powerful persuader for policy makers if we calculate injury cost in terms of GNP loss and especially when Disability Adjusted Life Years (DALYs) is considered as an indicator of injury.

Methods: A sample size of 1095 individuals of all ages and sex were included from a population of 39,000 in primary health centre by systematic random sampling technique. Interviews were taken of all 102 victims for injuries occurring in past one year in the study area regarding expenses on injury management. Second data was obtained from case sheets of injured victims treated at major general government hospital of Delhi in the year 2000 regarding different type of treatment and investigation procedures of injured cases and cost of each procedure was calculated by considering government approved rates for each procedure.

Findings: A community-based survey was conducted in rural population of lower and lower middle socio-economic strata. As shown in Table No.1, average cost of the injury management was Rs. 639 per injury, but expenses were more when it required hospital treatment i.e. mainly in case of drowning, poisoning, snake-bite/animal bite, burn and traffic. Out of 102 injured, 15 injured victims had taken either home remedies or no treatment due to economic reasons. Table No. 1: Cost estimation of injury based on community data (In Indian Rupees , 1US$ = Rs. 44) Type of injury Total no. of injury Traffic Burn Fall Drowning Poisoning Snake/animal bite Misc. injury Total

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Total expenses (in Rs.) 22 15 29 2 2 6 11

12,650 9,250 8,900 2,000 2,000 5,000 1,550

87

41,350

Expenses per injured (in Rs.) 575 616 306 1,000 1,000 833 140 Avg. expenses/injury 639

Annual incidence rate of injury of this study was 93/1000 population so the possibility of expenditure of each individual on injury will be 639x0.093 = Rs. 59.4/year out of annual per capita income of Rs. 3120. Apart from this cost of injury, the total expenditure must include expenditure on legal, police as well as in terms of DALYs etc. As per this community based study, 12% of the injured victims had taken treatment from major hospitals. Keeping this in view, one government hospital was also selected for cost estimation of severe injuries so that the real cost of injuries could be calculated. Out of total patients treated in this government hospital, 5,500 were injury victims which correspond to 22% cases. As per records, male were 4 times more injured that female. Speciality wise, analysis of data shows that orthopedic department had more of young adult and old age group cases, nuerosurgery department had more of pediatric and young adult cases and general surgery department had maximum of young adults only. Table No. 2: Cost estimation of 5500 injured victims treated in one year by a major government hospital of Delhi. S. Type of treatment / No. investigation

No. of Govt. injured appoved treated / rate per invest. in treatment 1 year /invest (in Rs.) 3,839 550

Total expenditure (in Rs.)

678 1,400 8,000 4,000 80 80 80 200 1,500 70 200

1,35,13,896 21,14,000 45,44,000 6,00,000 72,000 32,000 32,000 60,000 15,00,000 15,40,000 1,60,000 2,62,79,346

1. OPD treatment 2. Admission in ward (Avg. 12 days stay) 1,661 3. Neurosurgery operation 151 4. Orthopedic operation 568 5. Genl. surgery operation 150 6. No. of X-ray 900 7. Bedside X-ray 400 8. OT X-ray 400 9. Ultrasonography 300 10. CT Scan 1,000 11. Laboratory test 22,000 12. Blood Transfusion 800 Total expenditure

21,11,450

Case sheets of the injured victims available in the medical records of hospital were studied and type of treatment and investigation undertaken by each victim was recorded and compiled as shown in Table 2 above. Cost of injury for each procedure (treatment/ investigation) was calculated by multiplying govt.-approved rates for each procedure by total number of procedures. Major cost of injury in hospital belonged to ward treatment (Rs. 1.35 lacs) and orthopedic operation (Rs. 45.40 lacs) followed by

neurosurgery operation (Rs. 21.14 lacs), OPD treatment (Rs. 21.11 lacs), laboratory investigation (Rs. 15.40 lacs) and CT scan (Rs. 15.00 lacs). Per injury cost of this hospital was Rs. 4,778 (Rs. 2,62,79,346 / 5,500). This cost does not include treatment at home, expenses on transport, police/legal expenses (majority of the injuries were medico-legal), rehabilitation cost, cost in terms of DALYs etc. In this hospital there were 150 deaths due to injuries in one year for which funeral cost and social loss for family/ nation must be calculated.

Conclusion: Cost estimation of injury in monetary terms is a very difficult task. However we can calculate the direst cost under various heads. The best way of cost estimation is prospective cohert study among population so that cost under various headings can be included like rehabilitation, non-medical expenses etc. There is wide difference in the cost of injury management in government and private hospital because private hospital charges are too high and include their profits. Only a govt. hospital gives true picture of the cost of injury treatment. The above used method is one of the best ways to calculate segregated injury cost in general government hospital where all type of patients are report

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C1 – 3-3: Models/programme Cost-effectiveness in childhood injury surveillance systems. A preliminary analysis Tomas Concepcion, Spain

Introduction: Collecting information about number of childhood injuries is the first step to know the incidence and prevalence of these events and risk factors. Although evaluation of injury prevention is not a priority in our health system less attention has been paid for the evaluation of injury surveillance systems. In this study we have compared three injury sources of information: primary care(PC), hospital emergency (HE) and population survey (PS). The aim of this study is to asses which of these sources are the most cost-effectiveness in the childhood injury surveillance.

Methods: Cost-effectiveness analysis has been applied as a methodology. Annual costs of collecting data are related to a period of one year, between may 1999 until september 2000. The costs have been calculated in euros (E). We have considered those resources directly requiered to data collection for each source of information in Zaragoza (Spain). Costs due to data collection included were: personal requiered to data collection, pediatricians for PC and nurses for PS and HE, and epidemiologists involved in the design of questionnaire and in the analysis; material and transport costs and telephone. Capital costs and family time spent are not included in our study, as in other studies. Effectiveness in this preliminary analysis is defined only by injury identified (II) in each source.

Results: The number of injuries identified were 169 in PC, 14393 in HE and 492 in PS. The whole number of questionnaires in the sample of population survey were 2.291. Table 1. Cost effectiveness analysis in the childhood injury surveillance systems Source of Cost analysis-Euros(C) Ratio information Personal Material C/E Primary Care 3369 Hospital Em. 83702 Population survey 68450

114 1357 1477

Effectivenes(E) Total

(II)

3483 85059 69927

169 14393 492

20,6 5,9 142

We have estimated the following ratios in each sources (Total costs/II): 5,9 E per injury identified in HE, 20,6 E in PC and 142 E in PS (Table 1). The number of injuries identified in population survey has been calculated in the 110

sample and they should be estimated for the whole population.The highest ratio in this source could be explained by this reason.

Conclusions: The lowest cost-effectiveness ratio is for hospital emergency, then primary care and the last population survey. These ratios have been calculated with the identified inujuries, and for population survey we should estimate the whole injuries in the population not only in the sample. Nevertheless, for the evaluation of these sources is necessary to analize the precision level of each source, the completeness, injury severity and other information related to risk factors asociated.These issues will be analised in a second step of our study.

References: - Wilt AS, Gabrel CS. A weapon-related injury surveillance system in New York City. Am J Prev med 1998; 15(3S): 75-82. - Robertson LS. Child Injury control: surveillance and research questions. Am J Med Sci 1994; 308(2):88-91. - Elliott DC, Rodríguez A. Cost-effectiveness in trauma care. Surgical Clinics of North America 1996; 76(1): 47-62. - Kortbeek JB. A review of trauma systems using Calgary model. Can J Surg 2000; 43-23: 23-8. - Miller TR, Levy DT.Cost-outcome analysis on injury prevention and control. Medical Care 2000; 38(6):562-568. Acknowledgement: This study has been supported by a grant FIS99/1179

C1 – 3-4: Models/programme Measurement Criteria for Evaluating Success? Safer City Program Calgary, Alberta, Canada Carol Eamer, Board Member, Canada

Introduction:

Results:

Safer City for Calgary is a long term initiative effecting a change in culture; attitudes and behaviours towards injury prevention and safety promotion. Measuring the number and severity of injuries can be accomplished with the cooperation of the local Regional Health Authority; but that is only part of the picture. To track long-term changes in attitudes; beliefs and behaviours; there are many other indicators that are required to be analyzed. The project steering committee with significant input from community representatives has invested time in determining what are the best measurement indicators for the Safer City for Calgary project.

The outcome of the work has been to establish ?Key Indicators? in four Theme Areas: ?Attitudes and Behaviours?; ?Crime Reduction and Violence?; ?Injury Data? and ?Clean Physical Environment?.; ?Attitudes and Behaviours?; More than 50% of the population of Calgary understand that:; • Most injuries and violent acts are predictable and preventable.; • They can limit personal risk of injury or injury / violence related death.; And:; • Be able to identify at least three new safety related behaviours that they have adopted ; ?Crime Reduction and Violence?; Statistical data for Calgary indicates a 25% reduction over Baseline Data in:; • Personal crime rate.; • Property crime rate.; • Indicators of Domestic Violence. ; • Indicators of Child abuse/violence against children. ; ?Injury Data?; Statistical data for Calgary (categorised by Traffic Related; Falls; Suicides; Workplace and Violence related) indicates a 20% reduction over Baseline Data for:; • Injury related emergency room visits per capita; • Injury related hospitalizations per capita.; • Injury related fatalities per capita.; • Potential Years of Life Lost (PYLL) due to injury.; ?Clean Physical Environment?; Reference ?The Sustainable Calgary Report? for the Measurement Indicators in this area.; A report has been developed that represents the current ?picture? in Calgary in the year 2000; using these indicators. This report will be presented to participants at the Viborg Conference.

Methods: Calgary is a modern; large; urban centre of approximately 850; 000 people; located in western Canada. Although Calgary can be considered to be a relatively safe city; rapid growth; traffic; social and other issues result in too many deaths and injuries each year.; Recently the City of Calgary has supported a Safer City initiative; to promote and coordinate work towards making Calgary a ?Safe; Caring City for all its Citizens?. This new initiative will bring together existing safety promotion and violence prevention programs into a collaborative approach towards safety promotion. ; From the start; measurement has been a key aspect of the initiative. Ensuring that key indicators for safety are in place to track change over time is one of the first steps in the Safer City program.; Initially the committee hosted a town hall meeting with over 70 people from the many groups in Calgary involved or interested in safety promotion and violence prevention. Participants were asked to identify key indicators that could provide short and long term measurement of whether Calgary was becoming ?Safer? as a community.; From this brain storming session; many ideas were compiled into a set of ?Key Measurement Indicators. The year 2000 was selected as the ?Baseline Data? year; to establish a ?Base line? for the beginning of the project; against which changes could be assessed over the next 10 20 years.

Conclusions: Using the Safe Community model in a large urban centre has different challenges. This is reflected in the measurement of success for a Safer City initiative. In Calgary we have confronted these issues and believe we have developed a model; including measurement indicators for tracking success on a broader scope than simply counting injuries; that can be of use to other communities of similar size.

References: Calgary Safer City Report. Measurement Indicators Report. Sustainable Calgary Report.

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C1 – 4-1: Work Prevention of Occupational Accidents and the economic Consequences Kirsten Jørgensen, Civ.Ing Ph.D., Denmark

Introduction: The Danish Working Environment Authority and the Labour Organisations for The Industrial sector has published 30 of the best Methods to make Accident prevention in Enterprises. Among this methods are two; with focus on the internal economic aspect of the consequences from occupational accidents. The methods describes how an enterprise can get the economic consequences of Occupational Accidents in the Enterprises to become visible; as a matter for Managers decisions and priorities.

Methods: Costs resulting from accidents are not recorded as an item in companies financial statements. The methods are an instruction for recording and mapping of financial costs of Occupational accidents as well as a guideline for concretising intangible derived effects of an accident; such as impaired reputation.; The methods are divided in three parts; First part describes methods for identification and mapping of the costs; that can be measured in money; Second part describes the calculation methods and the third part describes the evaluation of economic consequences for the enterprise that are difficult to measure directly in money.; The first and second part is based on the financial calculation model called A-B-C costing and is here applied for the costs from accidents. The third method is based on the model for balance scorecard. ; Beside the direct and the indirect costs from accidents in the enterprises ; the national and the social costs has to be supplemented. These cost has been discussed political in a long period. The amount of costs for the society has a certain level depending of the calculation of costs for hospitalisation; compensation for invalidity and early retirement; rehabilitation and medical care.

Results: The ABC costing model go through following direct costs: 1. The use of time to help the injured person; 2. The lost time in the production; 3. The lost production from the injured person; 4. The time used to investigated the accident; 5. Reparation of damages; 6. Purchasing and mounting of new equipment; 7. Fulfilling of papers for internal safety organisation; the authorities; the insurance; 8. The time used by the safety organisation for analysing the causes and to make preventive arrangements; 9. Payments for sick leave; 10 Payment for a substitute person and time for learning in the job; 11. The decline in the production from colleges who has seen or are influenced of the accidental event; 12. Loss of raw 112

materials.; The Balance Scorecard model go through following indirect costs: 13. Anxiety among the employees; 14. An arising in sick leave among the employees; 15. A decline in the productivity; 16. Internal problems with co-operations; 17. Difficulties in engagement of new employees; 18. A decline in the quality of the products; 19. Difficulties in delivering of the services; 20. Pressure from the investors and customers; 21. Loss of experiences; 22. Loss of competencies for decisions.; Some examples shows that the costs very easy can run up in 5.000 -10.000 USD or 40.000 - 80.000 DKr. and for very serious Accidents the costs can be much more. Some large companies tell about costs in millions.

Conclusions: The internal costs from occupational accidents in enterprises is to day a hidden cost that are not visible for the managers and the economical risk from accidents are not recognised. To make this costs more visible can hopefully give the safety management a higher priorities in more enterprises than to day.

References: Birgitte Mogensen et al PricewaterhouseCoopers „Økonomisk vurdering af arbejdsulykker“ En rapport ud af 28 hæfter om sikkerhedsarbejdet og 30 gode metoder publiceret af Arbejdstilsynet og Industriens Branchearbejdsmiljøråd København 2001.

C1 – 4-2: Work Cost of work-related injuries among injured workers in Lebanon 1998 Rim Fayad, M.Sc, Lebanon

Introduction: Work-related accidents continue to be a major contributor to ill health and economic losses. A recent study in Lebanon estimated around 22; 500 work-related accidents to had occurred in 1998 among workers covered by accident insurance with the majority (around 80%) occurring within the construction and manufacturing sectors (Fayad & Nuwayhid; 2000). ; This study assesses the burden of the problem of occupational injuries among insured workers in Lebanon.

Methods: This study aims at estimating the economic burden of occupational injuries in Lebanon among insured workers.; Compensation claims for work-related accidents filed in 1998 at five major insurance companies were used. A total of 3748 claims out of more than 7000 were reviewed; and the medical and non medical expenses were computed.

Results: Estimates showed that the overall cost; both human capital (direct and indirect) and human value cost; for the 22; 500 work-related injuries that were covered by insurance for the year 1998 ranged between 10 and 13 million US dollars. The average human capital cost per injury was around US $198.; Fractures and multiple injuries were the most expensive. ; Moreover; 3% of the injuries consumed almost 30% of the cost due to their high severity level.

Conclusions: The estimated cost can be considered an underestimate. Hence; prevention and control of work-related injuries must be stressed.

References: Kuusela, J., 1999. Miller, T.R., et al. 1999.

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C1 – 4-3: Work A Study of Variables Contributing to accidents among coal workers Alireza Dehdashti, Occupational hygienist, Iran

Introduction:

References:

This study was undertaken to detect and evaluate variables contributing to the occurence of occupational accidents among underground coal mine workers in Damghan district where working conditions are hazardous and various occupational stresses including psychlogical; chemical andphysical stresses combined.We tried to show that the collected accident data can be used as a commencement for the development of preventive measures to promote a safe working environment.

1 Accident facts Chicago 1992 national Safety Council. 2 Accident prevention manual for industrial operations chicago 1992. 3 Deloy DM:Toward a comprehensive human factors model of workplace accident causation Prof Saf 33(5):11 1990. 4 Denton DK:A strategy for improving safety problem solving Prof Saf 28(6):25 1983.

Methods: Thedata base of Damghan Provincial Health Centre concerning accident information in local mines were investigated by analysing individual variable including age; perodofemployment; material status; typeof occupations; work experience; awareness of appropriate work practices; level of accidents; type andcauses of accidents.

Results: We found a significant relationship between accident occurence and age; period of mployment and workers’ knowledge and awareness of safe work practices(p=0.05).The prevalence of accidents among younger miners had a high frequency rate.The highest rate of accidents occured at time interval between 10-12 am. during the workshift.Hand-arm injuries had the highest frequency rate and the common ; types of accidents were struck by moving objects; contact against sharp edges and fall at ground level.

Conclusions: The results suggest that occupational accidents may be more common among younger; inexperienced and miners with inadequate knowledge of safe work practices; therefore these important factors should be considered in a peridic training program to improve and maintain the effectiveness of accident prevention at work.

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C1 – 4-4: Work A Study on the Application of Industrial Ergonomics in the Workplace: Its Implication to Social Health Services Reuben Escorpizo, PTRP, Philippines

Ergonomics is the science of fitting the job to the worker. When there is a mismatch between the physical requirements of the job and the physical capacity of the worker, work-related musculoskeletal disorders (WMSDs) can result.

idea about it. Presumably because of this knowledge gap, 33% even refused that their working stations and piaces be modified by ergonomics once found ergonomically unsound.

Future plans: Purpose: The objectives of this study included: 1) to provide information about ergonomics; 2) evaluating the working conditions of the typical table-type workers in a workplace; 3) knowing the cause and effect of complaints brought about by the workers and the workplace; 4) citing the application of ergonomics to organizations and industries; and 5) signifying the role of ergonomics to Filipino social health system.

1) To conduct the second leg (medical techniques and work-related il Inesses) of this study series; 2) To detail information about the Occupational Safety & Health Center (Philippines) and its relations to the Philippine Health Social Science Associations goals and objectives; 3) To provide further grounds for the PHSSA-OSHC Joint Project on Industrial Ergonomics and Social Health (POJPIESH) for creating Filipino standard on ergonomics principles.

Methodology: Data were derived through a questionnaire distributed among all the secretaries, clerks, and other table-type workers in a university who share a common job. The results were treated by a simple percentage-type analysis and interpretation. They answered questions usually relevant to their job e.g. computer/workstations descriptions, work accessibility, etc.

Results: During work time, they have stated 6.5 sitting hours per day. Though 79% of them say they observe break time at least once in a day, have an average of 10.5 break time minutes for each outing, and a huge 96% observe frequent stretching, standing, or quick rest while working- 82% of the respondents complained of low back pain and 75% have had complained of pain in other parts of their body (e.g. hand, wrist, elbow, shoulder, hips, buttocks, etc.) observed at least once during or arter working hours. The pain complaints may have not been brought about by lack or insufficient rest and break time. The said complaints may be stemmed from the notably proionged sitting hours thereby constituting inactive and repetitive microinjury or yet other personal or environment factors, the specific details of which are beyond the scope ofthe study. It is interesting to know that 22% of the respondents are not comfortable sitting on their chairs when doing computer or paper works, 7% claim that not everything is within reach (e.g. pens, folders, staplers, puncher, clip, etc.) when working on papers, 7% claim that the height of their chair is too high, and another 7% say that the drawer or cabinet is too low when he/she reaches out for something inside it. Only 24% of the respondents heard of ergonomics and only 17% have an 115

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1st Safe Community-Conference Viborg County, Denmark 30 September - 3 October 2001

Posters Session A3 Monday, October 1st 2001

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The Economic Burden Of Injuries Robert Conn, Dr., President & CEO, Canada

Introduction: Injury prevention and control advocates and researchers in Canada have had access to little national information on the economic costs associated with injuries of different types. This lack of information has been identified as a critical gap at Canadian meetings on injury prevention. A partnership group including the SMARTRISK Foundation; the Kingston; Frontenac and Lennox & Addington Health Unit; the Ontario Ministry of Health and Health Canada jointly supported a project to estimate the economic costs associated unintentional injuries in Canada. The project was carried out by the Hygeia Group.

Methods: The direct and indirect costs of unintentional injuries were estimated through an incidence costing methodology where the lifetime costs of unintentional injuries in 1995 were discounted (3%) and assigned to the year of incidence. Costs are reported in Canadian dollars unless otherwise indicated. The study was conducted from a societal perspective. ; Indirect costs (productivity losses) were estimated using the human capital method where foregone income associated with mortality and morbidity were captured. Data constraints forced the development an Electronic Resource Allocation Tool (ERAT) in order to model a full episode (lifetime) of direct costs. Discharge abstract data were used to calculate the costs of hospitalized injuries which were integrated in the ERAT with coefficients from a major study conducted by the Urban Institute to generate estimates of the incidence and costs of unintentional injuries cared for in ambulatory settings as well as the post hospital costs of hospitalized injuries. Injury reduction scenarios were modelled through the ERAT and cost savings were demonstrated.; Beyond this study; the ERAT was also designed to be easily applied at the local/regional level through the adjustment select parameters in the model.

Results: The lifetime costs of unintentional injuries that occurred in Canada during 1995 are estimated at $8.7 billion (Cdn $) or $300 for every person. Falls account for 40% of the total cost and motor vehicle crashes account for another 20%. On average each of the estimated two million injuries generates $4; 000 in total costs. Direct medical costs; including hospital stays; services of health care professionals and costs of medical procedures and medications account for $4.2 billion. While only 6% of all injured persons are admitted to hospital; they accrue 118

23% of direct medical expenses. The 94% of nonadmitted (less severe) injuries account for 77% of direct medical costs. Injuries resulting in permanent disability account for the largest direct medical costs per person. The indirect costs associated with loss of productivity due to impairment; disability and premature death account for $4.5 billion. ; The ERAT was used to model the cost savings of investments in injury prevention. A 20% reduction in hospitalizations due to falls in seniors aged 65 or older would save $138 million annually. A reduction of 20% in falls among children less than 10 years of age would result in 7; 500 fewer hospital admissions; 13; 000 fewer non-hospitalized injuries and savings of $126 million each year. A combined intervention strategy involving buckling up; driving sober; marginal speed reductions and improved roadway design and maintenance could result in net savings of more than $500 million each year.

Conclusions: The cost of unintentional injuries in Canada during 1995 is estimated at $8.7 billion (Cdn $) This work highlights the large economic burden associated with injury and demonstrates the strong economic incentive to invest in program and policy development to prevent injuries. Furthermore; the ERAT continues to be used to estimate cost of injuries and to model the cost-effectiveness of injury prevention.

References: detailed references are included in the study details located at: www.smartrisk.ca/library.html#burden and click on „the appendices“ (pdf/116KB)

Aggredssiveness and Violence in Young People Teresa Garcia, Spain

Authors: García Jimenez MT, Gamonal, Pavon M, Marco S, Elder J, Munugarren R.

Purpose/Objectives: Due to the increase in violence and antisocial bahaviors among children and adolescents, we undertook this study with the following objectives: - To study the prevalence of violent behaviors among youth - To determine the nature of peer group and familiar relationships, and attitudes toward other religious, ethnic or cultural groups in terms of their correlation with violence - To indentify specific factors that induce violence in youth - To study the relationship between aggression and having been victimized by violence - To use the the results of the study to develop different strategies to prevent and reduce violent tendencies.

Methods: The methodology for the current study comprised the following elements: 1. - development of a survey instrument through the use of focus groups and expert consensus methods 2. Pilot testing of the instrument. 3. Administration of the questionnaire to 3000 youth (2000 in school and 1000 who had alredy dropped out) 4. Computer anlysis (SPSS) of the data 5. Determination of overall and subgroup result

Results: Data are currently being analyzed. Early trends indicate strong gender relationships (with males being far more violent) and substantial levels of aggression against disadvantaged groups. Results will assist in developing action plans to be implemented in conjunction with the Agencia Antidroga (Comunidad Autónoma de Madrid) for several actions with and secondary school teachers

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Test of the Manual for Cost Calculations and Cost-Effectiveness in Safe Community in Bangladesh Jahangir Khan, Bangladesh

Background Main cost components of the Manual for Cost Calculations and Cost-Effectiveness in Safe Community.

MAIN COST COMPONENTS Epidemiology of the injury

Costs of injury

Information about injured person - Age - Sex - Occupation (ISCO or NYK)

Medical costs - Transport to and from hospital - Costs for inpatient and outpatient care - Medicine - Medical investigation

Information about injury - Injury type (ICD and N-codes) - External causes (E-codes) - Injured part of the body - Severity of injury - Days of hospitalization - Lost working days

Other investigations - Police investigation - Postmortem Production loss - Production loss of the patient because of injury Production loss of the relatives because of injury

Information about injury events - Timing of injury - Place of injury (NOMESCO)

Purpose of the project To calculate the total costs of injury in Sherpur sub-district in Bangladesh by using the Manual for Cost Calculations and Cost-Effectiveness in Safe Community.

Material Individual data on injury and costs of injury through face-to-face interviews.

Method TC = å Iij ´(ADMCij + AIMCij +APLij) where, TC = total cost, I = number of incidences, ADMC = average direct medical cost, AIMC = average indirect medical cost, APL = average production loss, i = severity of the injury (i = 1, 2, 3), j = if the patient visited hospital or not (j = 1, 2). All costs are adjusted for 2001 year’s price level.

Results Average injury cost in Sherpur sub-district in 2001 (US$). Type of injury Minor Moderate Severe

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Location Hospital Community Hospital Community Hospital Community

Direct medical 7.88 0.92 30.84 2.30 53.44 12.93

Indirect medical 2.73 0.03 3.40 0.00 3.23 1.67

Production loss 0.06 1.96 0.20 0.72 1.51 17.41

Total 10.67 2.92 34.45 3.02 58.19 32.01

Estimated total costs of injury (US$) in Sherpur sub-district in 1996 (in 2001 year’s price level). Type of injury Location Number of injuries Minor Hospital 10528 Community 73693 Moderate Hospital 12811 Community 19216 Severe Hospital 2372 Community 0 Total 118620 Percentage

Direct medical 82961 67798 395091 44197 126760 0 716806 74.3

Indirect medical 28762 2303 43557 0 7669 0 82292 8.5

Production loss 632 144438 2562 13836 3582 0 165049 17.1

Total 112355 214539 441211 58032 138011 0 964148 100.0

Percentage 11.7 22.3 45.8 6.0 14.3 0.0 100.0

Total costs of injury (US$), divided into sources of expenditures in Sherpur, 1996 (2001 year’s price level).

Type of injury Location Minor Hospital Community Moderate Hospital Community Severe Hospital Community Total

Direct medical 82961 67798 201389 44197 37098 0 433442

Private costs Indirect medical 28762 2303 43557 0 7669 0 82292

Production loss 632 144438 2562 13836 3582 0 165049

Public costs Direct medical 193702 89662 283364

Conclusions and recommendations Applicability of the manual in Bangladesh is possible by collecting individual data through face-to-face interviews. Sources of expenditures on injuries should be specified, which can motivate the implementation of the prevention programs.

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Accident-analysis protocols at Viborg Hospital during the last decade Søren Kjeldsen, Dr., Denmark

1991: Explosion accidents during work with tires and wheel rims. Kalms SB, Mortensen JS. Seven illustrative cases are presented. A risk for accidental explosions is present in connection with pumping tyres and repairs of tyres and wheel rims. 1993: Accidental injuries from captive-bolt guns (slaugthterer’s gun). Tordrup PJ, Kjeldsen SR. Three cases of accidental injuries are reported. Security measures using CBG’s are required in Denmark. 1996-1997: Injuries from bicyclist-accidents. Kjeldsen SR. Report concerning details from 971 injured bicyclists with focus on the bicyclist, the scene and place of the accident and the bicycle. Two ”danger spots” for bicyclists in the Municipality of Viborg could be pointed out. Only 8% of the accidents were registered by the police in the national register of traffic accidents. Only 17% used bicyclist-helmets. 1997: Lightning injuries. Klebe T, Kjeldsen SR, Jepsen CF. Six cases of persons striked by a lightning – one with fatal outcome - illustrates, that simple security measures during thunders storms are often neglected. Precautions are emphasized. 1997: The true number of bicyclist-accidents in the municipality of Viborg. Kjeldsen SR, Grøn P. During one year 4108 randomly selected inhabitants in the municipality of Viborg were asked about bicyclistaccidents and habits related to bicyling. The true incidence of bicylist-accidents was estimated to 185 accidents/ 1000 inhabitants pr. year. Only 14 % of the injuries were treated at the hospital or at the General Practitioner. 1998: Injuries from roller skating accidents admitted toViborg Hospital 1995-1998 Kærlev HC, Klebe T, Kærlev L. Circumstances, pattern of injuries and use of protective gear from 399 injuries are reported. Roller-scate accidents accounted for 28% af all wrist-fractures among 11-15 year-old teenagers. 67% did not use protective gear. Education on non-risk behaviour and use of wrist-guards are recommended.

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1998: Hay Bale Accidents. Hummel S og Hvidt EP. Four severe accidetns related to handling large hay-bales in autumn 1998 are presented. All patients had such serious injuries, that they were transferred to a neurosurgical department, and one died subsequently. A registration protocol is advised to outline the trauma-mechanism and thereby propose safety rules.

Habits and accidents related to bicycling in the Municipality of Viborg Søren Kjeldsen, Dr., Denmark

Introduction:

Conclusions:

In Denmark are missing public statistics giving an estimate of habits and accidents related to bicyling in order to evolve injury-prevention programs. Most public statistics regarding bicyclist-accidents are based on policerecords, where only 8-19% of the accidents are registered, when compared to hospital-records (ref.1, 2).

In our municipal population the use of bicycle-helmets was very low among teen-agers and adults. Innovations regarding the helmet’s appearance and placing the helmets, when not in use seems desirable. Only 3% of the accidents were reported to the police. In only 9% of the accidents, the bicyclist was injured to such an extent, that a doctor had to take care of the injuries. The vast majority of bicyclist-accidents therefore are not registered by neither the police nor the hospitals.

Methods: During the year 1997 a total of 4108 randomly selected inhabitants of the Municipality of Viborg (41.000 inhabitants) were send a questionnaire regarding habits related to bicycling and bicyclist-accidents during the 3months-period prior to receiving the questionnaire. 71,9 per-cent answered the questionnaire.

Results: Habits related to bicycling: 65 per-cent were ”bicyclists”. 19% of these claimed, that they always used bicycle-helmets. However, this was clearly related to age, since 81% of children less than 10 years of age used helmets, while this was the case in 36% of teen-ageres and only 5% among bicyclist older than 20 years of age. 16% of teen-agers had a helmet at home, but not on their head when riding on the bicycle. Among reasons for not using helmets 24% were unhappy about their look when wearing helmets., while 16% felt the helmet were unhandy, when they were off the bicycle. Bicyclist-accidents: 136 accidents were reported, giving an estimate of the true incidence of bicyclist-accidents of 185 accidents pr. 1000 inhabitants per year. Two-third of the accidents took place either in the period June-August or DecemberFebruary. 60% of the accidents happened either in the time period from 6 to 8 o’clock in the morning or from 2 to 6 o’clock in the afternoon. 72% of the accidents were reported by children or teen-agers, and mostly to or from school or while playing. 70% of the accidents were soloaccidents. Only 3% of the accidents were reported to the police; all of these were counter-part-accidents. Surprisingly, among the accidents with a motorized vehicle as a counter-part, two-third were not reported to the police. In 63% of the accidents the bicylist were injured, but only 14% of the injured bicyclists went to see a doctor for treatment.

References: 1.)Olkkonen S et al. Incidence and characteristics of bicycle-injuries by source of information. Acta Chir Scand 1990; 156: 131-6 2.)Harris S. The real number of road traffic accident casualties in the Netherlands: A year-long survey. Accid Anal Prev 1990; 22: 371-8.

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Harstad 16 years experiences with injury prevention Yousif Rahim, Norway

Harstad: First Norwegian Safe Community, designated by WHO in 1994. From July 1985 started injury registration at Harstad hospital, and from 1986 we have started to analyse the injury panorama and plan for injury prevention programs.

Work methods: • Sustaining the injury registration unit to ensure a good injury data registration from the primary health care. • Co-ordinating the local injury prevention efforts, including areas of traffic, work, home, school and leisure. If desired as part focussing on total local society’s development. • Developing a new methods and techniques to establish and support multidisciplinary groups for injury prevention programs • Implementing the injury prevention work in municipalities plan and decision making organisations. • Post-evaluating of injury prevention programs. • Disseminating process tools in local society’s injury prevention activities generally and for prioritised areas in collaboration with National institute for public health. • Contribute in supporting a Safe Community Network through lectures, presentations, seminars and conferences Harstad hospital with Injury registration unit, Harstad municipality with public health nurse and other community safety partners, through multidisciplinary groups achieved very successful results. The total number of injuries in Harstad reduced significantly: • Baseline data showed that burn injuries in children under 5 years resident in Harstad reduced with 53% in the period 1985-94 and ZERO burn injuries for years 1995-1999. • Harstad adopted the zero vision for fatal traffic accidents. Traffic fatality rate was reduced 80% of last 7 years of an observations period of 14 years. • An injury prevention program for prevention Fall fracture in elders over 65 years started in 1988 and the results showing a significant reduction. • Violence cases are reduced with more than 50% in the period 1990-95.

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Harstad has a basic knowledge, experiences and good results from many years working with injury prevention. Harstad municipality has an important role in working for experience spreading to other municipalities which focuses on injury prevention within the framework of safe community. Harstad has a ”workshop-function” for developing a new and good contents to the injury prevention works. For more information visit www.harstad.kommune.no

Home Accidents and Occupational accidens Alagu Muthu Ramalingam, India

On Home Accidents

Pictures on Vocational Accidens

a) Coconut Plucking from 60 ft. high trees by climbing a) Lady cooking on Open Fire on the Floor

b) Slippery Bath Rooms

b9 Water needs of Homes are met through drawing water from unprotected wells - 30 ft. deep

c) Split Level pathways in residences

c) Work of Building Construction - workers use rickety wooden Scaffloding and suffe fall

d) Manual Cleaning of house-standing on the edge wooden stool and Fall thereof 125

Corporate Cost of Occupational Accidents: The SACA Project Pall Rikhardsson, associate professor, Denmark

The poster describes the Systematic Accident Cost Analysis (SACA) project, which aims at testing a method for analysing company costs in relation to occupational accidents as well as assessing these costs for selected accidents in selected companies. The SACA method, is developed by researchers from the Aarhus School of Business and consultants from PricewaterhouseCoopers.

accident, a less serious accident and a typical accident in the company.

The main elements of the poster include a project description, a description of the SACA method itself, what companies participated in the project and what main conclusions were reached during the project.

Due to the nature of the sample and the method chosen, it is neither possible generalising the results to other companies nor using the data to reach definitive conclusions about the full company costs of occupational accidents. However, it is possible to conclude on the applicability of the SACA method in companies as well as the experiences of the companies analysed regarding e.g. cost totals, distribution of costs, accounting system integration and stakeholders’ interests.

Project Description

Project Conclusions

The SACA Method has two broad aims. The first is to analyse the costs of occupational accidents by identifying the activities performed after the accident and assessing the costs of these activities. It thus borrows elements from the Activity Based Costing methodology. The second aim is to assess the possibility of current and future additional costs due to stakeholder interest in occupational accidents.

In general terms the SACA method can be used for accident cost analysis in all companies.

The SACA method process is composed of three main phases. In the first phase the activities following the accident are identified. This includes both those activities directly related to the accidents such as first aid as well as more indirectly related activities such as production disturbances in another department. In the second phase the costs of these activities are identified. The calculation of costs includes identifying man-hours and average wages as well as calculation of lost production capacity. In the third phase the feasibility of possible integration of accident cost calculations in the accounting information system is explored. Based on stakeholder analysis the current and future possibilities of increased corporate costs are assessed. Examples could be employees, customers and investors boycotting a company due to its bad occupational health reputation. This part of the SACA method is more strategic in nature than the accident cost analysis part and aims at the strategic management level. The project conclusions are based on case studies in nine Danish companies. These companies were selected to represent the service industry, the construction industry and the production industry. To further increase the scope of the empirical data, the companies were selected to represent small, medium-sized and large ones. The accidents analysed were selected to represent a serious 126

Cost behaviour varies significantly from company to company due to e.g.: - Accident type and duration of absence - Wage structures and policies - OHS management system scope - Production process vulnerability Total accident costs for serious accidents in the selected companies range from DKK 22,582 ($ 2,714) to 196,263 ($ 23,589). These costs often proved higher than managers initially expected. Total costs are composed of costs visible to company management as being related to the accident as well as costs, which at the moment are invisible to management, but driven by the accident. The ratio of these two costs ranges from 8 % visible and 92% invisible to 99 % visible and 1 % invisible. Visible costs in this survey are defined as health benefit to the victim during absence. A significant amount of the costs is often covered by the company insurance and social security, which minimises the amount the company actually pays. In some cases this might reduce the motivation to calculate accident costs. Very few companies use the accounting information system for registration and calculation of accident costs. Usually accident costs are not visible in the chart of accounts. The technological possibility of integrating accident cost registration and calculation in accounting information systems is present in most companies which have modern accounting information systems such as SAP R/3, Oracle,

BaaN, Navision etc. Setting up the procedures to do so is relatively straightforward. The managerial and practical feasibility of accident cost integration is often relatively small due to increased registration burden, system set up cost and system maintenance costs. Furthermore, managers tend to think that accident costs, seen in relation to the total costs of the company, are relatively small. However, these often prove to be higher than expected when applying the SACA method. Some managers also feel that the purpose of the registration and reporting of information in an accounting information system is to support decision-making and in some way change behaviour. But as zero accidents are the ultimate goal in any case, cost calculations would not change the aims of the occupational health system A more feasible way might be to periodically calculate average costs of accidents based on the SACA method and use these as a base for calculating the total accident cost of the company. The current possibility of stakeholder’s interest in company occupational accidents leading to additional costs is negligible. Customers only focus on occupational accidents if there is a risk of negative effects on themselves e.g. bad publicity due to construction site accidents and consequently loss of image for the customer. Accident prevention and occupational health are not factors for most customers, who are more likely to focus on price and quality. However, the absence of accident prevention and occupational health could have an effect on customers’ choices. In short: “You don’t sell more products due to accident prevention initiatives but you might sell fewer if you did nothing”. The case companies see accident prevention and occupational health as potentially more important in the future as a shortness of qualified labour is expected in the industrial countries rises and social awareness becomes more prominent.

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Economic evaluations in community-based injury prevention interventions: A compilation of original articles Hyun Jong Song, Research Prof., South Korea

Introduction:

Conclusions:

The evaluation of the cost and effectiveness of prevention program is crucial to public health activities. Most economic evaluation has been geared toward the medical treatment; while less has been focused on prevention of illness and injury (Elixhauser et al; 1993). However; the most recent estimates show that injuries are among the leading causes of death in the world (Krug et al; 2000); which suggests that injury prevention is a key to reduce overall medical and other societal spending. In order to identify the most cost-effective interventions for injury prevention; we have complied the data from the recent original articles.

This study reviewed 14 articles that evaluated the economic impact of the community-based injury prevention interventions on unintentional injuries. Results indicated that the analysis on cost and effectiveness of injury prevention program were limited to a few areas. Furthermore; most of these were CEA or CBA. The intervention with the highest benefit-coat ratio was children bicycle helmet use promotion program.

Methods: Studies from January 1991 to December 2000 were identified using Medline search through keywords. The search keywords used were ?safety and cost?; ?injury and cost?; ?safety and economics?; and ?injury economics?. In addition; bibliographies from prior review articles and published studies were used. ; Inclusion criteria used in this review was as follows: The articles must have (1) economic assessment such as cost-effectiveness; costbenefit; or cost-utility analysis; (2) proposals for interventions to correct the unintentional injuries; and (3) contents in English. This study focused community-based interventions; thus programs in the occupational setting were excluded. Only journal articles were considered for the complete studies. We examined the distribution of articles based on the type of analysis; injury category; and type of intervention. For some interventions we recomputed C/E ratio to improve the comparability among studies.

Results: A total of 14 completed community-based studies met the inclusion criteria (7 were US and 7 were foreign studies). Of these; 9 were cost-effectiveness; 4 were cost-benefit; and one was cost-utility analysis. 50.0% of sample targeted traffic accident; 14.3% poison; 28.6% fall. Among the articles; traffic accidents have been identified as the most studied subject; reflecting its greater prevalence over other injuries. Within the traffic accident studies; the most effective (cost-effectiveness and cost-benefit) intervention was promoting bicycle helmet use in children.

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References: Elixhauser A Luce BR Taylor WR Reblando J. Health care CBA/CEA: An update on the growth and composition of the literature. Medical Care 1993 31(suppl) JS1-JS11 Krug EG Sharma GK Lozano R. The global burden of injuries. American Journal of Public Health 2000 90(4) 523-526

The economic cost of mortality due to injury in Suwon 1998 Hyun Jong Song, Research Prof., South Korea

Introduction: Korea has a very high injury toll in comparison with other OECD countries; with an overall rate of 92 injury deaths per 100; 000 population in 1997. Although injury has been a leading cause of death in Korea; little attention has been focused on its associated costs; nor has there been a comprehensive study comparing economic costs of injury for different geographical regions. Such data is important for allocating resources and planning injury prevention work. In this study; we have estimated the cost in Suwon of lost productivity due to premature death associated with injury.

Methods: Census data on demographics were obtained from the Department of Information and Telecommunications of Suwon municipality government. Mortality data of Suwon were complied from the death record of the National Statistical Office; and the cause of death were coded according to the International Classification of Diseases; Tenth Revision(ICD-10). The economic cost of injury was calculated using the Years of Potential Life Lost(YPLL) measures using the methods of Haenszel et al (Haenszel; 1950); which has been useful in identifying the economic cost and risk factors for premature deaths and assisting public health decision making (McDonnell et al; 1998). We also calculated the productivity loss based on monthly mean wage (approximately 1; 000 U.S. dollars for male; approximately 670 U.S. dollars for female) from the survey of the Ministry of Labor.

450 million U.S. dollars) for 646 deaths; and cancer consisted of 6; 550; 056 million won (about 5; 458 million U.S. dollars) for 527deaths. Greater loss in productivity due to injury despite lower number of death can be explained by the greater YPLL due to injury.

Conclusions: This study estimated the economic cost using mortality data in Suwon; 1998. Mortality rate; YPLL; and lost productivity were employed for comparison among the three leading cause of death. Results suggest that injury resulted in more years of potential life lost before age 65 and lost productivity than either cardiovascular disease or cancer.

References: Haenszel W. A standardized rate for mortality defined in units of lost years of life. American Journal of Public Health 1950 40 17-26 McDonnell S Vossberg K Hopkins RS Mittan B. Using YPLL on health planning. Public Health Reports 1998 113 55-61

Results: Of 2; 775 Suwon citizen?s death with cause identified (23 cause of death was not identified); following trends were noted: male(56.2%); female(43.6%); the majority deaths(63.8%) occurred in person 60 years of age and older; with the highest proportion occurring in persons 70 to 79(23.0%). The leading causes of death in Suwon were cardiovascular disease; cancer; and injury; whose mortality rates per 100; 000 population were 88.9; 66.0; and 51.8; respectively. The total YPLL was 2; 582; 390 due to deaths in Suwon; 1998. The YPLLs of three causes of death were 400; 613 of cardiovascular disease; 519; 481 of cancer; and 805; 157 of injury. The 2; 752 deaths in Suwon resulted in total 33; 673; 068 million won (about 28; 069 million U.S.dollars) of lost productivity(discounted at four percent). Of these; injury consisted of 10; 811; 472 million won (about 9; 010 million U.S. dollars) for 414 deaths; while cardiovascular disease consisted of 5; 340; 168 million won (about 4; 129

A Swedish Model for Estimation of Injury Bengt Springfeldt, Sweden

Objective

Conclusions

In a research project it was tested if a program, called EV A, of economical estimations of road construction works and traffic accidents can be applied on accidents of different types, primarily occupational injuries.

The method can be used for estimation of the effects for society when people of different reasons are obliged to leave their work and be hospitalized by injuries: occupational accidents and diseases, as well as schooling, sports and home accidents.

Methods From the basic health cost calculations of the EV A program a new calculation program EVIS is built up. In the model studies accidents caused by vehicles and accidents occurred by fall of person were cost calculated. In a special study injmies by use of portable ladders were studied. The calculations were based on information on the accident cases from official statistics of occupational injuries as well as a labor market insmance statistics. Information from the two somces were matched together in a new data base. The injury cases were divided in severity groups. The average material costs for health care expenses and loss of production were calculated by use ofthe economical production method. To these costs were added a human value by use of the willingness-to-pay method, the same values that have been settled in the EVA-project.

Results In the method studies the material costs of occupational vehicle and fall accidents in the period 1991-93 have been estimated to on average about 38 and 33 thousand US dollars per case respectively. The total costs inclusive ofthe human values were 220 and 150 thousand US dollars per case Accidents with not more than 30 sick days cost about 3,3 thousand dollars materially, and totally 4,6 thousand dollars. By application ofthe EVIS method on all registered occupational accidents in 1995 the mean costs and sum costs have been calculated on different types of accidents. By special cross calculations the average costs have been estimated on accidents in different branches of industry , professions, main events and principal external agencies. Average material costs per case in the whole material are estimated to about 6 thousand US dollars and to 30 thousand dollars totally. The material mean costs in agriculture and forestry were lO and 8 thousand US dollars respectively, 60 and 54 thousand dollars totally.

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Keywords: Injury , cost, injury cost, accident, occupational accident, traffic accident, fall accident

The cost of traffic injuries in Klaipeda Birute Strukcinskiene, M.D., Lithuania

Introduction: More than half of the deaths in young people are due to injuries; and injuries represent the main cause of potential years of lost life. Injuries of all kinds cost the world community almost $500; 000 USD million a year in medical care and lost productivity (WHO; 1993). At this time there is no such calculation available in our country. More than 5; 000 people die because of injuries in Lithuania every year (142/100; 000 in 1999). More than 1; 000 children are injured in Klaipeda per year. ; Aim of the study ; To evaluate the cost of traffic injuries in the city of Klaipeda.

Methods: Data from traffic police and three Klaipeda hospitals were analyzed for the year 1999. ; We analyzed four groups of injured in traffic accidents; children; working people of working age; unemployed; and pensioners. The costs of injury were counted from number of hospital days; cost of one hospital day; cost of insurance; GDP and money spent for medicine.

Results: 290 people suffered from traffic accidents during the period of analysis. Total loss due to injuries was 4.5 million litas (4 Litas (LTL) = $1USD) in Klaipeda in 1999. Main losses were in the area of child (38%) and working people (59.7%) injuries. Costs of injuries in the unemployed and pensioners were 0.8% and 1.5% respectively.

Conclusions: Traffic injuries cause

References: van Beeck EF van Roijen L Mackenbach JP. Medical costs and economic production losses due to injuries in the Netherlands. J Trauma 1997 Jun 42(6):1116-23 (ISSN: 0022-5282). World Health Organization. Information material for 1993 World Health Day. Geneva Switzerland 1993

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WHO - Collaboration Centre on Community Safety Promotion Moa Sundström, Sweden

The Karolinska Institutet, Division of Social Medicine, Sweden, was designated as a WHO Collaborating Centre on Community Safety Promotion 1989, because of its long experiences with community oriented safety promotion programmes. The role of the WHO Collaborating Centre is to: - spread the WHO Safety Promotion Programme ASafe Community@ world-wide - review applications from communities related to 12 Criteria for Safe Communities - organizes together with Safe Communities annual International Safe Community Conferences - coordinates training courses sc „Travelling Seminars“ - publishes a newsletter: „Safe Community News“ - involves in other conferences like the biannual „World Conferences on Injury Prevention and Control“ - conducts methodological development and transfer of technology - organizes networks for community programs - participates in the World Health Organizations as well as the Swedish Bicycle Helmet Initiative - conducts research on: Community safety promotion; Injury surveillance; Injuries among children and adolescents; Injuries among the elderly; Bicycle helmets; Work-related injuries; Injuries caused by violence (Intentional injuries); Treats of violence and harassment; Macros-social determinants of intentional and unintentional injuries; Cost of injury and injury prevention savings; Design for safety.

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Road Safety in Viborg County Stine E. Andersen, Campaign coordinator, Viborg County, Denmark

In Viborg County there has been 3381 accidents with 2413 casualties on the roads in the period from 1996 to 2000, and 141 have been killed. Road accidents cause great human suffering, and the economic burden – the cost of road accidents – is in the region of 700 million DKr. (100 million Euro) a year. In Denmark accidents on the roads is the fourth largest factor to loss of life years. In e.g. Norway, Sweden and England 6 to 7 persons in 100.000 get killed in traffic accidents every, whereas in Denmark the rate is 9 persons in 100.000.

Road Safety Plan Viborg County has set the target to reduce the number of deaths and serious casualties on the county roads by 40% from 2000 to 2012 – despite the increase in traffic. This means that there can be a maximum of 8 deaths and 55 serious casualties in 2012. On the long term it is the aim of Viborg County to reduce the numbers of accidents with casualties to none.

Saved casualties per year Black spots 3 Grey spots 1 Technical initiatives on the roads 9 Campaigns 15 Road safety plans by local authorities 2 Road safety audit 2 Total 31

Total costs 2002-2005 19.400.000 DKr 8.500.000 DKr 8.200.000 DKr 7.700.000 DKr 200.000 DKr 400.000 DKr 44.400.000 DKr 6.300.000 Euro

The Road safety Plan covers 2002 to 2005. If the plan in fact can help prevent 31 casualties, the socio-economic cost saved will be approx. 45 mil. DKr/6 mil Euro, and it will be a reduction in the number of casualties of 15 %. After 2005 Viborg County will take new initiatives to reduce the number of casualties additional 25% from 2006 to 2012 reach the overall goal of a 40 % reduction in the number of deaths and serious Casualties

Viborg County is working on a detailed plan to reach this goal. This “Road safety Plan” describes the main problems concerning the traffic in the county, and the initiatives, which will be taken to solve them.

Initiatives The initiatives in the Road safety Plan can be categorised in 6 different categories: 1. Black Spots 2. Grey Spots 3. Technical initiatives on the roads 4. Campaigns 5. Road safety plans by local authorities 6. Road safety audit For each of the categories the cost of the initiatives and how many deaths and casualties they will prevent have been calculated.

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Water for Life Jeanette Lund, Projectworker, Viborg County, Denmark

In Denmark 99 percent of our drinking water origins from ground water. It is a demand that the drinking water supply is based on non-polluted ground water. Thousands of small and large private and municipal waterworks pump the water to the consumers. In most other countries surface water is the main source of drinking water. Surface water needs purification and desinfection before it can be utilized as drinking water - ground water needs no or only simple purification. Therefore the Danish drinking water supply is something rather unique. Drinking water in Denmark is of high quality, but because we get the water from the ground water, there is a great demand for ground water protection. So far the main quality problems have been pollution from nitrates and pesticides. In 2000 Viborg County launched the project ”Drinkingwater and health”. The aim of the project is to motivate and qualify the waterworks in the county to inform the consumers about the water quality and health and how the citizens themselves can take action to protect the groundwater. There are 48 waterworks engaged in the project, which will run for a period of two years. The project has arranged a ”Walk on the water-day”, where the local citizens were invited for a walk in the catchment area (where the groundwater comes from). We have focused on the general assembly – in an attemp to make it more interesting, and thereby, hopefully make more people interested in water management. We have also made a leaflet about the quality of the water, which the waterworks can hand out to the consumers. This autumn we try to inspire the waterworks to invite the local schools to visit the water work. There will be 4 posters telling more about Danish drinking water supply in an international perspective, more about the project ”Drinking water and health” and posters about water being healthy and water being cheap in Denmark. Contactperson is projectworker Jeanette Lund, Viborg County, telephone 87 27 14 19, e-mail: [email protected]

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The prehospital area in Viborg County Diana Sørensen, Head Clerk, Viborg County, Denmark

The posters shows hospitals, ambulance- and firestations in Viborg County, describes the County’s prehospital arrangements, and informs of the number rescues in 2000. By prehospital effort means all the activities initiated in caseof acute illness or accidents, for example firstaid performed by layman, alarm calling, communication, ambulancedriving to the scene, emergency treatment by ambulancepersonel and medical team, ambulancetransport to hospital, treatment and monitoring during transport and assignment to the hospital. The purpose with prehospital efforts is to save lives, improve healthconditions, reduce pain and other symptoms, reduce the illnessperiod, take care of patients and create safety.

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Author Index

Name

Position

Country

Session

Page

Alam, Dr. Jobair Bin Andersen, Stine E. David Ball Bauer, Robert Bender, Susanne Bowman, Brett Butchart, Alexander Chand, Mahesh Concepcion, Tomas Conn, Robert Dalal, Koustuv Dehdashti, Alireza Eamer, Carol

Dr. Campaign Coordinator Professor MD

Dr. Mr. Occupational Hygienist Chair, Measurement Indicators Committee Ekman, Robert Ph.D El-Sayed, Hesham Professor of Pediatrics Elvik, Rune Chief research offficer Escorpizo, Reuben Mr. Fayad, Rim Ms. Garcia, Teresa Head of service Grivna, Michal MD, MPH Haj Ahmed, Mohammed Elsadig Dr. Hoque, Mazharul Professor, Ph.D Jansson, Bjarne Ass. Professor Johansson, Pia Health Economist Jørgensen, Kirsten Civ.ing., Ph.D Khan, Jahangir Research Assistant Kjeldsen, Søren Dr. Specialist Orthopaediac Surg.

Bangladesh Viborg County, Denmark United Kingdom Austria South Africa South Africa Switzerland India Spain Canada India Iran Canada

B1 - 1-1 A3 C2 B1 - 3-1 B1 - 3-2 C1 - 3-1 A2 B1 - 1-2 C1 - 3-3 A3 B1 - 4-1 C1 - 4-3 C1 - 3-4

82 133 76 91 92 107 28 83 110 118 95 114 111

Sweden Egypt Norway Philippines Lebanon Spain Czech Republic United Arab Emirates Bangladesh Sweden Sweden Denmark Bangladesh Denmark

Krishnamurthy, Nagaraja

India

B1 - 1-4 B1 - 1-3 C1 - 1-3 C1 - 4-4 C1 - 4-2 A3 B2 B1 - 2-2 C1 - 1-2 B3 C1 - 2-1 C1 - 4-1 A3 A3 A3 B1 - 2-1 C1 - 2-4 B1 - 2-3 B2 B3 A3 A4 A2 A4 B1 - 3-4 A2 C2 A2 A3 C1 - 2-2 B1 - 4-2 B1 - 3-3 A3 C1 - 1-1

85 84 102 115 113 119 61 87 101 64 103 112 120 122 123 86 106 88 62 67 134 47 33 40 94 18 70 31 124 104 96 93 125 100

Research Psychology Intern Prof., MD Dr.

Larsen, Lars Binderup Lindquist, Kent

MD Ass. Professor

Denmark Sweden

Lund, Jeanette Miller, Ted R. Mohan, Dinesh Mulder, Saakje Pai, Lu Pedersen, Kjeld Møller Persson, Ulf Purtscher, Katharina Rahim, Yousif Rahman, Fazlur Rahman, M. Mizanur Ramalingam, Alagu Muthu

Projectworker Ph.D, Director Professor M.Sc.,Ph.D Ass. Professor Professor Ph.L MD Project leader Dr. Assistant Chief (Health) Dr.

Viborg County, Denmark USA India The Netherlands Taiwan Denmark Sweden Austria Norway Bangladesh Bangladesh India

Reddy, T. S.

Dr.

India

136

Rikhardsson, Pall

Ass. Professor

Song, Hyun Jong

Denmark South Korea

Springfeldt, Bengt Strukcinskiene, Birute Sundström, Moa Svanström, Leif

Ph.D MD Coordinator Professor

Sweden Lithuania Sweden Sweden

Søgaard, Jes Sørensen, Diana Tozija, Fimka Uusküla, Lenno Verma, Pramod Kumar

Director Head Clerk MD, Ass. Professor Mr. Epidemiologist

Denmark Viborg County, Denmark Macedonia Estonia India

B1 - 4-3 A3 A3 A3 A3 A3 A3 B2 B2 C2 A3 B1 - 2-4 C1 - 2-3 C1 - 3-2

97 126 128 129 130 131 132 58 60 75 135 89 105 108

137

138