Martinez et al.

Lat Am Econ Rev (2019) 28:17

https://doi.org/10.1186/s40503-019-0078-0 Latin American Economic Review

RESEARCH ARTICLE Open Access

Road safety: challenges and opportunities

in Latin America and the Caribbean
Sebastian Martinez1, Raul Sanchez2 and Patricia Yañez‑Pagans2*

*Correspondence:
[email protected] Abstract
2
IDB Invest, Washington An estimated 1.3 million people die in traffic accidents each year worldwide and mil‑
D.C., USA
Full list of author information lions more are injured, with developing countries disproportionately affected. It is pre‑
is available at the end of the dicted that the number of global traffic deaths will be around 1.8 million annually by
article 2030, making it the eight cause of death in the world. This paper provides an overview
of salient road safety issues in the Latin America and Caribbean (LAC) region. It also
reviews existing theoretical and causal empirical evidence of interventions to improve
road safety outcomes, concentrating on three core areas: safer roads and mobility, safer
vehicles, and safer road users. Despite the existence of potentially cost-effective and
life-saving interventions, there is surprisingly little rigorous evidence on the effective‑
ness of road safety programs in the LAC context. This paper discusses promising areas
for policy experimentation and future research.
Keywords: Road safety, Road traffic accidents, Road fatalities, Latin America and the
Caribbean
JEL Classification: R41, R42, L92, I15, K32

1 Introduction
Each year, 1.3 million people are killed on roads worldwide, and as many as 50 million
are injured (WHO 2015). Approximately, 90% of deaths and injuries from traffic acci-
dents occur in low- and middle-income countries, where direct and indirect costs are
close to US$65 billion a year, exceeding the total amount of developmental assistance
that these countries receive.1 WHO (2015) forecasts that there will be almost 1.8 mil-
lion traffic fatalities annually by 2030, and that traffic deaths will be the leading cause of
death among those 15–29 years old. According to the Economic Commission for Latin
America and the Caribbean (ECLAC 2015), the rate of fatalities from traffic accidents in
the region grew from 14.75 to 17.68 deaths per 100,000 population between 2000 and
2010, an increase of 20%. This fatality rate is almost twice the level observed in high-
income countries (10 per 100,000 population) (Diez-Roux et al. 2012).
Traffic deaths and injuries have become a major health and development concern.
Research by Wijnen and Stipdonk (2016) shows that social costs of road crashes in high-
income countries range from 0.5 to 6% of GDP, with an average of 2.7%. For low- and
1
According to the Association for Safe International Road Travel. http://asirt​.org/initi​ative​s/infor​ming-road-users​/road-
safet​y-facts​/road-crash​-stati​stics​ (Accessed in May 2018).

© The Author(s) 2019. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License
(http://creat​iveco​mmons​.org/licen​ses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium,
provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and
indicate if changes were made.
Martinez et al. Lat Am Econ Rev (2019) 28:17 Page 2 of 30

middle-income countries, these social costs range from 1.1 to 2.9%, and these values
might be underestimated as they do not include the internationally recommended will-
ingness-to-pay method for estimating human costs. A study by the World Bank (2017)
estimates both the potential economic benefits and aggregate social welfare gains of
reducing road traffic injuries in low- and middle-income countries. The main argument
of the authors is that those that are injured in road traffic accidents are disproportion-
ately in their economically productive years, plus there is a substantial burden on limited
health system resources. Findings show that, over time, sharply reducing the number
of road traffic injuries and deaths would enable these countries to attain substantial
increases in economic growth and national income, while leading simultaneously to
clear welfare gains.
In 2010, the United Nations (UN) General Assembly proclaimed 2011–2020 as the
Decade of Action for Road Safety. In addition, in 2016 the UN General Assembly and
its member states adopted a resolution entitled “Improving Global Road Safety” that
calls on governments to take a leading role in implementing road safety measures. These
measures include adopting comprehensive legislation on key risk factors such as speed-
ing, drinking and driving, and failing to use motorcycle helmets, the use of seatbelts and
child restraints, improving the safety of vehicles and roads, and strengthening emer-
gency trauma care for victims of traffic accidents (WHO 2015).
Surprisingly, there is limited causal evidence on the effectiveness of road safety inter-
ventions in Latin America and the Caribbean (LAC) or in middle-income and lower-
income countries more broadly. Moreover, the evaluation of road safety programs has
traditionally been based on comparisons of outcome variables, such as the number of
people injured or killed in traffic accidents before and after a given intervention. As sev-
eral authors have already highlighted in this literature, the main concern is that these
outcomes may be affected by multiple factors (such as drivers’ and pedestrians’ behavior,
road conditions, weather events, and local laws), making it difficult to attribute changes
observed over time to a single program or intervention (Elvik 2002; Hauer 1997). Two
notable exceptions of rigorous studies conducted in LAC are those by Rau and Otero
(2017), who evaluate the impact of drinking laws in Chile, and Blanco et al. (2017), who
measure the effects of motorcycle laws in Uruguay.
This paper reviews the challenges and opportunities for addressing road safety in
the region using evidence-based solutions. The paper starts by presenting a review of
the theoretical literature on the causes of traffic accidents, including perspectives from
diverse fields of study including psychology (Froggatt and Smiley 1964; Näätänen and
Summala 1974; Fuller and Santos 2002; Summala 1988), transport economics (Elvik
et al. 2009), and more recent theories from microeconomics based on utility-maximiz-
ing frameworks. This theoretical overview of road safety helps to broaden the under-
standing of available empirical results and guide the formulation of research questions in
future empirical work looking at the causal impacts of road safety interventions.
The paper then examines the available causal evidence on road safety interventions.
With a dearth of evidence for LAC, studies that are available for the region are reviewed
and a broader overview is provided of the work that has been done in this area world-
wide. The review considers interventions within three of the five pillars established by
the UN Decade of Action (WHO 2010): (1) safer roads and mobility, (2) safer vehicles,
Martinez et al. Lat Am Econ Rev (2019) 28:17 Page 3 of 30

and (3) safer road users. The review excludes the road safety management pillar, which
has to do with institutional capacity strengthening and data generation, and the post-
crash response pillar, which is related more closely to the health and insurance literature,
which is outside the scope of this paper.
Overall, the summary of the literature highlights the urgent need to generate evidence
for developing countries and especially for LAC. Moving forward, it will be important
to strengthen evaluation methods in road safety by giving more careful attention to the
definition of the counterfactual situation. The theoretical overview and empirical evi-
dence presented in this paper highlight the multiple trade-offs and complementarities
that characterize road safety interventions. This calls for a careful design of impact eval-
uations in this area, considering the timing of potential effects, crowding-out effects on
behavior, and the need to isolate the impact of multiple interventions that may simulta-
neously affect results.
To construct a solid research agenda with empirical evidence in LAC, first, there is
an urgent need to improve information systems in developing countries, as the lack of
data is one of the primary constraints to empirical work in this area. For example, in
most countries, data on traffic accidents are already being collected, but these data are
not yet systematized and can be difficult to access and use. Until more evidence from
LAC is generated, literature available from other contexts can be used to help guide road
safety intervention design, which may otherwise lack empirical underpinnings due to
the absence of context-specific evidence. However, as new road safety interventions are
designed, tested, and adapted to the LAC region, it is imperative that these include pro-
spective evaluations that help to strengthen the evidence base on cost-effective ways to
achieve safer roads.

2 Road safety in Latin America and the Caribbean

Traffic deaths claimed more than 1.4 million lives worldwide in 2013 (Table 1), making
them the ninth leading cause of death, just above hypertensive heart disease. Low- and
middle-income countries suffered the most, with fatality rates twice as high as those in
high-income countries. According to WHO (2015), 90% of these traffic deaths occurred
in low- and middle-income countries. Surprisingly, while these countries represent 82%
of the world’s total population, they bear a disproportionate number of deaths, consider-
ing that they only hold 54% of the total number of registered vehicles in the world. By
2030, it is projected that road injuries will be the seventh largest cause of death, above
HIV/AIDS, diarrheal diseases, and hypertensive heart disease (see Table 6 in Appendix),
and will be the leading cause of death for people aged 15–29 years old (see Table 7 in
Appendix).
The risk of death in a traffic accident fluctuates by region, and there has been little
change in the trends in national traffic mortality rates since 2010. The highest rates
worldwide are in Africa, while Europe is well below the world average (9.3 per 100,000
population), and the global rate is 17.4 per 100,000 population. There is also substan-
tial variation in rates within regions. For example, rates in some of the high-income
countries in the Western Pacific region (such as Australia) are among the lowest in the
world, while a portion of the region’s middle-income countries have rates well above
global averages, with 24 deaths per 100,000 population. While high-income countries
 Martinez et al. Lat Am Econ Rev

Table 1 Top ten causes of death: number of deaths reported by cause, 2013. Source: Authors’ calculations based on data from WHO (2015)
(2019) 28:17

World High-income Low- and middle-income countries

countries
East Asia Europe Latin America Middle East South Asia Sub-Saharan Africa
and Pacific and Central Asia and Caribbean and North Africa

Ischemic heart disease 7,593,875 1,292,609 2,023,162 1,455,823 468,580 370,278 1,629,386 354,037
Stroke 6,699,717 764,051 2,911,243 815,131 309,911 239,370 1,142,133 517,879
Lower respiratory infections 3,222,634 379,177 475,855 66,981 206,418 95,812 798,400 1,199,991
Chronic obstructive pulmonary disease 3,216,606 369,748 1,104,306 83,865 133,634 45,641 1,375,033 104,378
Diarrheal diseases 1,807,702 35,190 91,934 11,472 23,266 21,893 881,311 742,637
HIV/AIDS 1,666,646 20,483 158,465 93,978 57,518 21,100 167,512 1,147,589
Trachea, bronchus, lung cancers 1,636,037 583,707 694,081 126,183 76,665 22,520 112,952 19,929
Other circulatory diseases 1,583,574 758,799 348,258 74,157 136,304 65,897 119,299 80,859
Road injury 1,423,355 87,958 453,851 57,140 124,035 90,630 367,212 242,530
Hypertensive heart disease 1,136,930 222,327 341,390 88,985 122,834 59,513 207,975 93,906
Total of top ten causes of death 29,987,076 4,514,049 8,602,545 2,873,715 1,659,165 1,032,654 6,801,213 4,503,735
Page 4 of 30
Martinez et al. Lat Am Econ Rev (2019) 28:17 Page 5 of 30

have reduced death rates compared to low- and middle-income countries, high-income
nations in the Eastern Mediterranean region have higher rates than their less-affluent
neighbors in the region (22.4 compared to 19.7) and more than twofold the regular
rate of high-income countries globally (9.2). This evidence suggests that in some of the
more affluent Eastern Mediterranean countries, rapid economic development that has
resulted in increased motorization and the construction of road infrastructure has not
been accompanied by sufficient investment in institutional capacity or by the interven-
tions needed to cope with these changes and ensure that roads are safe.
Almost half of all deaths on the world’s roads are of people who have the least pro-
tection—motorcyclists, cyclists, and pedestrians. However, the likelihood of dying on
the road as a motorcyclist, cyclist, or pedestrian varies by region. Africa has the highest
proportion of pedestrian and cyclist deaths, at 43% of all traffic fatalities, while South-
east Asia presents the lowest rate in the world at 16%, according to estimates by WHO
(2013). The Americas, the Mediterranean, and Europe have moderate rates of 25, 30, and
30%, respectively.
Road traffic injuries place a massive burden on national economies and on households.
In low- and middle-income countries, they mainly affect the economically active age
group; that is, those persons set to contribute to family, society, and the workforce. Many
families are driven deeper into poverty by the loss of a household head, the expenses of
extended medical care, or the added burden of caring for a family member who is disabled
from a road traffic injury. The economic costs also strike hard at a national level, imposing
a significant impact on the health, insurance, and legal systems. This is an important issue
particularly for countries struggling with other development needs and where investment
in road safety is limited when compared to the scale of the problem. Data suggest that
traffic deaths and injuries in low- and middle-income countries cause economic losses of
up to 5% of Gross Domestic Product (GDP) among these countries (WHO 2015). Glob-
ally, an estimated 3% of GDP is lost to traffic deaths and injuries (WHO 2018).
It is estimated that there were 124,035 traffic deaths in LAC in 2103, with an average
death rate of 17.55 per 100,000 population. Similar to the patterns observed worldwide,
estimated mortality rates due to road traffic injuries also vary among sub-regions and
countries, with death rates ranging from 16.46 per 100,000 population in the Southern
Cone sub-region to 18.27 in the Mesoamerica sub-region (Fig. 1).2
Table 2 shows that deaths of drivers and/or passengers in four-wheel vehicles account
for most of the traffic deaths in many countries, with percentages that range from 2.5%
in Peru to 60.8% in Bolivia. The highest proportion of deaths among riders of two- and
three-wheel vehicles occurs in Colombia and the Dominican Republic, at 52.5 and
67.0%, respectively, of total traffic deaths. Finally, 30% of traffic deaths in LAC are pedes-
trians and cyclists, with the highest shares corresponding to Dominica (60.0%).
Wearing a seatbelt reduces the risk of a fatality among drivers and front-seat occu-
pants by 45–50% and the risk of minor and serious injuries by 20 and 45%, respectively

2
The sub-regions in Latin America and the Caribbean are the following: the Latin Caribbean (Cuba and Dominican
Republic), the non-Latin Caribbean (The Bahamas, Barbados, Dominica, Guyana, Jamaica, St. Kitts and Nevis, St. Lucia,
St. Vincent and the Grenadines, Suriname, and Trinidad and Tobago), the Southern Cone (Argentina, Brazil, Chile,
Paraguay, and Uruguay), Mesoamerica (Belize, Costa Rica, El Salvador, Guatemala, Honduras, Mexico, Nicaragua, and
Panama), and the Andean South region (Bolivia, Colombia, Ecuador, Peru, and Venezuela).
Martinez et al. Lat Am Econ Rev (2019) 28:17 Page 6 of 30

Fig. 1 Road traffic deaths per 100,000 population in Latin America and the Caribbean by sub-region, 2018
(Source: Prepared by the authors based on data from WHO (2018))

(Elvik et al. 2009). Table 3 presents estimates of the proportion of car occupants (i.e.,
drivers and passengers) who use seatbelts, highlighting high variability across countries.
For instance, only 39% of front-seat passengers wear a seatbelt in the Andean South sub-
region, compared to an 85% of passengers in the Latin Caribbean sub-region.
Several countries have achieved sustained reductions in traffic-related injuries
and fatalities through effective road safety programs that included legislative change
(Peden et al. 2004; WHO 2013). According to data collected by WHO (2018), all
LAC countries have national legislation requiring the use of helmets on motorcycles
and/or mopeds. Despite this, there is wide variation within sub-regions in the appli-
cation of this type of legislation. For example, while all countries in the Southern
Cone require helmets to meet certain (national or international) standards, only 14
and 60% of the countries in Mesoamerica and the Andean South, respectively, have
this requirement (see Table 8 in Appendix).
In terms of alcohol consumption and driving, while all countries in the region have
drunk driving laws, not all of them have a clear definition of what should be consid-
ered a violation based on blood alcohol content. The most recent data indicate that
most of the countries in LAC (except in Mesoamerica, with 78%) have a drunken
driving definition based on blood alcohol limits (Table 4).
Ensuring that vehicle manufacturers build in seatbelts and the necessary features
for child restraints are critical for reducing road traffic fatalities. Ten of thirty-three
LAC countries have standards for front and rear seatbelts on new cars manufactured
or assembled in the country, and twenty-three have standards for new imported cars.
Vehicle safety standards and regulations are uneven among LAC countries
(Table 5). Most of the countries in the Southern Cone and Andean regions have
Martinez et al. Lat Am Econ Rev (2019) 28:17 Page 7 of 30

Table 2 Distribution of traffic deaths by type of road user (percent). Source: Prepared by
the authors based on data from WHO (2018)
Country Drivers/passengers Drivers/passengers Cyclists Pedestrians Other/
in four-wheel in motorized two- unspecified
vehicles or three-wheel road users
vehicles

Argentina 47.2 22.2 2.4 8.2 20.0

Bahamasa 57.7 17.3 3.8 21.2 –
Barbados 33.3 33.3 0.0 22.2 11.1
Belize 18.8 19.8 11.9 24.8 24.8
Bolivia 60.8 19.7 2.5 17.1
Brazil 23.2 31.4 3.4 18.1 24.0
Chile 42.0 8.7 5.7 36.0 7.7
Colombia 8.4 52.5 5.3 26.0 7.8
Costa Rica 24.0 40.0 10.4 24.7 0.9
Cuba 10.1 15.6 9.9 33.2 31.2
Dominica 10.0 0.0 60.0 10.0 20.0
Dominican Republic 11.0 67.0 1.0 17.0 4.0
Ecuador 5.2 19.1 1.8 19.8 54.0
El Salvador 32.1 14.2 1.4 49.0 3.3
Guatemala 19.4 32.7 0.4 39.2 8.3
Guyana 24.2 21.9 12.5 29.7 11.7
Honduras 18.6 24.3 4.1 27.9 25.1
Jamaica 33.0 28.8 8.4 22.2 7.7
Mexico 18.4 9.6 1.1 28.5 42.4
Nicaraguaa 23.2 26.0 5.5 32.8 12.5
Panama 32.3 4.4 5.7 40.0 17.5
Paraguay 16.5 52.2 0.2 22.5 8.7
Peru 2.5 0.6 0.2 8.1 88.6
Saint Lucia 46.7 20.0 13.3 13.3 6.7
Suriname 33.8 45.9 4.1 14.9 1.4
Trinidad and Tobago 57.8 2.2 0.7 31.1 8.1
Uruguay 30.7 45.7 7.0 16.6 0.0
Region average 27.4 25.0 6.9 23.7 17.9
a
WHO (2015)

Table 3 Seatbelt wearing rate (percent). Source: Prepared by the authors based on
available data from WHO (2015)
Sub-regions Front seat Rear seat Drivers only All occupants

Andean South 38.60 3.40 79.85 55.60

Latin Caribbean 85.00 10.00 90.00 60.00
Mesoamerica 63.15 25.20 69.63 70.00
Non-Latin Caribbean 76.33 4.00 75.33 –
Southern Cone 61.88 34.76 64.10 47.15
Numbers reported are the average of rates observed in countries within each sub-region

national policies that promote investment in or use of public transportation. Simi-

larly, most countries have national policies that promote non-motorized modes of
transportation, such as walking and cycling. Furthermore, all countries in these two
Martinez et al. Lat Am Econ Rev (2019) 28:17 Page 8 of 30

Table 4 Definition of drunk driving by blood alcohol content, by region (percent). Source:
Prepared by the authors based on data from WHO (2018)
Sub-regions Definition of drunk driving by blood Existence
alcohol content of a national drunk
driving law

Andean South 100 100

Latin Caribbean 100 100
Mesoamerica 78 100
Non-Latin Caribbean 100 100
Southern Cone 100 100

Table 5 Percentage of countries with different types of vehicle safety standards

and regulations. Source: Prepared by the authors based on data WHO (2018)
Sub-regions National policy National policy Road safety National road
on public transport on walking lead agency safety strategy
and cycling

Andean South 100.00 75.00 100.00 100.00

Latin Caribbean 100.00 50.00 100.00 100.00
Mesoamerica 80.00 80.00 100.00 100.00
Non-Latin Caribbean 60.00 23.00 88.89 55.56
Southern Cone 100.00 100.00 100.00 100.00

sub-regions have a government agency responsible for coordinating road safety.

However, regionally, 50% of countries still need a national strategy on road safety
to set out the main principles, to define goals and objectives, to prioritize actions,
and to coordinate mechanisms for preventing road traffic injuries and reducing their
consequences.

3 Theoretical framework
Road safety policies have been analyzed using the tools of enforcement, education,
and engineering, and from the standpoint of traffic engineers, economists, psycholo-
gists, statisticians, public health professionals, and urban planners. Thus, establishing
a unique conceptual framework for road safety is not an easy task. For instance, while
economists tend to analyze optimal driving decisions, engineers examine the physi-
cal characteristics of roads and cars. This section reviews the main theoretical frame-
works that have guided studies in this field and that ultimately seek to understand and
explain the main causes of traffic accidents.

3.1 Theories based on human factor aspects and systems

The first theory that studied the causes of road accidents can be categorized as an
accident proneness theory, where the human factor is the main explanatory variable.
Developed by psychological researchers in 1926 (Froggatt and Smiley 1964), the the-
ory considers that certain individuals are more likely than others to be involved in
traffic accidents, even though there are no differences in risk exposure (Farmer and
Chambers 1940). Tillmann and Hobbs (1949) examined many lifestyle variables that
might affect driving and concluded that high-accident taxi drivers most frequently
Martinez et al. Lat Am Econ Rev (2019) 28:17 Page 9 of 30

come from a home marked by parental divorce and instability. The main critique to
this theory was the small statistical evidence to prove these arguments.
Other theoretical studies concentrated on the human factors contributing to traffic
accidents. Some studies attributed accidents to a chain of events ultimately caused
by human error (Reason 1990). These errors were broadly categorized as overload
(the task is beyond the capability of the driver, either by physical, psychological, or
by environmental factors), inappropriate driver response (either the driver’s or the
authority’s fault), and inappropriate activities (for instance, a lack of training).
More recent studies introduce a different theoretical approach by proposing a sys-
tem theory where traffic accidents occur because of a failure of the whole traffic sys-
tem (interaction between the driver, vehicle, and road infrastructure) rather than only
a failure of the driver as postulated by previous theories (Elvik et al. 2009). The main
argument behind this theory is that the demand for mobility puts the driver in a com-
plex system where he or she has limited capacity. Therefore, this theory contemplates
that the systems should be designed to reduce complexity, thereby helping to prevent
errors from occurring.

3.2 Cognitive/psychological theories
The system theory treats the driver as a passive responder in his or her environment.
However, the evidence shows that the driver is in fact an active participant and regu-
lates his or her level of preferred risk. For this reason, several psychological models were
developed to explain what determines the driver’s speed choice. Theories in this area
focus on the driver’s behavior and motivations for achieving a certain outcome given a
particular risk level (Fuller 2005).
Following work in psychology (Taylor 1964), Näätänen and Summala (1974) developed
the first psychological approach to road safety. The authors suggested the idea of zero-
risk theory, which states that the primary motive for using a specific means of trans-
port is the mobility provided by the vehicle. Then, the risk which the driver perceives
in a situation corresponds to the perceived likelihood of a hazardous event. As experi-
ence increases, self-confidence increases as well, and the perceived risk diminishes to the
point of zero perceived risk. Therefore, experienced drivers feel that there is no real risk
at all.
Wilde (1982) formulated the risk homeostasis theory,3 which states that for any activ-
ity, people accept a level of associated risk and safety, referred as the “target level of risk.”
If people perceive that the degree of risk is low and acceptable, then they modify their
behavior to increase their exposure to risk. Conversely, if they see a higher than accept-
able level of risk, they will compensate by exercising greater caution. Therefore, people
do not always respond as expected to traditional safety initiatives, but rather adjust their
response to more rules, administrative controls, new procedures, and engineering tech-
nologies according to their target level of risk. Fuller and Santos (2002) proposed the
idea of task difficulty homeostasis: drivers seek to maintain a given level of task difficulty.

3
Homeostasis refers to the tendency toward a relatively stable equilibrium between independent elements, especially
as maintained by physiological processes. For a discussion on the strengths and weaknesses of this theoretical approach,
see Wilde et al. (2002).
Martinez et al. Lat Am Econ Rev (2019) 28:17 Page 10 of 30

Speed is proposed to be the primary mechanism whereby drivers regulate the difficulty
of the task. However, speed choice is also determined by other motivations, such as time
constraints. A key component of this theory is that different drivers have different capa-
bilities, and that they balance the difficulty of a given task with their ability to safely com-
plete the task.
In some situations, people’s reaction to a policy might reduce the expected outcomes.
Suppose that engineers can demonstrate that, under certain circumstances, airbags
reduce the risk of injury in a car accident by 25%. Whether or not the application of
these devices reduces the fatality rate by 25% depends on the response of drivers to the
increased protection from dangerous accidents. If drivers increase their driving intensity
(speed, recklessness, and driving while intoxicated), because they feel like they are more
protected by the airbags, then actual fatalities avoided may be lower than the 25% pre-
dicted. Crandall and Graham (1984) describe this situation with the concept of offsetting
behavior. The authors explain that such behavior is not irrational; it merely represents a
substitution of the marginal benefits of driving intensity for the reduced marginal cost
of risk. This theory was extended by the risk-compensation theory, where users respond
to or compensate for perceived changes in the dangers to which they are exposed (Elvik
et al. 2009). Therefore, measures designed to improve traffic safety may provoke negative
consequences from increased riskiness of driving behavior, because individuals feel safer
(Dulisse 1997).
Elvik (2004) considers that the risk homeostasis and risk-compensation theories are
too vague in explaining the specific underlying behavioral mechanisms, which makes
empirical testing extremely difficult. According to the author, the behavioral adapta-
tion is a wider term referring to all behavioral changes triggered by a safety measure.
After changes in the road-vehicle system are implemented, road users sometimes adapt
their behavior in a manner inconsistent with the initial goals of the safety measures: for
instance, safer highways and safer cars often lead to more dangerous driving habits.

3.3 Economic theories of road safety

The psychology-based models presented above help to provide further understanding of
drivers’ mental processes and behavior, while the economic-based models of individual
driver behavior presented in this subsection assume rational behavior (which is usually
taken to represent the aggregate behavior of the driving population). When compared
to psychological approaches, one benefit of economic approaches is that they are more
tractable and it is easier to develop hypothesis tests for them (Michon 1989).
The first analysis of road safety within the economic literature corresponds to Peltz-
man (1975), with an application of the risk-compensation theory. The author focused
on United States regulatory measures implemented in the mid-1960s to improve vehi-
cle safety. He challenged the effectiveness of these policies by estimating a model that
assumes that drivers are rational agents who choose between safety and driving inten-
sity. Line A in Fig. 2 represents the trade-off between the probability of an accident
and driving intensity. As can be seen, more driving intensity is associated with forgo-
ing some safety. When safety devices are available or mandated, the price of driving
intensity declines (resulting in a turnover of the trade-off rate to line B). The distance
between points C and D represents the magnitude of the effect of the devices. The
Martinez et al. Lat Am Econ Rev (2019) 28:17 Page 11 of 30

Fig. 2 Risk compensation (Source: Peltzman (1975))

author states that if one treats driving intensity as a normal good, the consumption
equilibrium lies in point E instead of D. He claims that lowering the cost of driving
intensity will lead to an increase of consumption and thereby enlarge the safety risk.
To test this theory, the author analyzes the determinants of the accident rates for
the period before the federal regulation is implemented and uses these estimates to
project, for the following period, the rates that could have occurred without the pol-
icy. The effects of regulation are then obtained by comparing the expected rates with
actual rates. The author estimates the following reduced form:

R = f (P, Y , T , A, S, K , u),

where R is the adjusted total death rate (per vehicle mile); P is the cost component of an
accident based on physician and hospital costs, and insurance premiums; Y is the real
labor income per working-age adult; T is the time trend; A is the amount of alcoholic
intoxication among the population at risk (measured by per capita consumption of dis-
tilled spirits); S is the average speed of motor vehicles on non-interstate rural roads at
off-peak hours; K is the ratio of the 15–25 year old population to the rest of the driver-
age population;
 and u represents
  random
 factors. The expected derivatives are the fol-
lowing: ∂P 0, ∂Y (?), ∂P 0, ∂A 0, ∂S 0, and ∂K
∂R ∂R ∂R ∂R ∂R ∂R
> 0.
The first utility-based framework of the risk-compensation theory corresponds
to O’Neill (1977). According to the author, a safety improvement is one that would
reduce accidents given fixed driver behavior. However, drivers may respond to it by
driving less carefully than before, thus diverting the improvement toward some non-
safety goal such as quicker arrival at a destination. In this model, the driver’s only
motivation is to arrive at his or her destination, and the driver’s only range of choices
is the selection of speed (v). Let UT be the utility per hour of traveling without acci-
dents, UA the utility of having an accident, and p the accident rate per mile. For sim-
plicity, it is assumed that UT and UA are independent of v and p . It is assumed that
there is a one-to-one relationship between these two variables: the faster the driver
goes, the more likely he or she is to have an accident. Therefore, choosing v and
choosing p are equivalent. The driver will then choose the value of p that maximizes
the following expected utility function:
Martinez et al. Lat Am Econ Rev (2019) 28:17 Page 12 of 30

UT
EU (p) ≡ + pUA .
v(p)

In an extension of this model, the authors include a parameter σ that represents

changes in the driving environment, such as infrastructure conditions, and then, v
is expressed as v(p, σ ). A low σ represents a low degree of safety and causes higher p
to be associated with a given speed v . If the safety parameter σ is shifted, the driver
will be led to choose a new p to maintain the previous condition. A detailed analysis
of this model reveals that the direction of change of the accident rate depends on the
shape of the functions relating speed and the accident rate before and after the safety
change, but not on the driver’s utilities for speed or accidents. Therefore, all rational
drivers should increase their accident rate in response, or all should decrease it. There
is no possibility of a mixed reaction in which some drivers increase their accident rate
and others decrease it, depending on their utilities.
Janssen and Tenkink (1988) proposed a modified version of the previous model to
analyze how individuals trade off risk versus travel time. Following the previous for-
mulation, let L be the length of the trip in units of distance. The driver will choose v ,
such that:

L
UL = UT · + L · p · UA ,
v

where the first term represents the driver’s expected loss by undertaking a trip lasting L/v
hours. The second term is the expected accident loss on the trip. Depending on the exact
nature of the relationship between speed and its consequences in terms of accidents, the
driver’s response will achieve risk homeostasis, meaning that individuals tend to stay at a
relatively stable equilibrium in terms of the level of risk that they are willing to take.
As discussed, risk compensation is a natural part of human behavior when individu-
als pursue multiple goals with limited resources. Following this principle, Blomquist
(1986) proposed an economic model that involves utility maximization of traffic
safety behavior, based on drivers having useful information to make rational deci-
sions. As in the previous models, p , the probability that a motorist is involved in an
accident is influenced by the driver’s own safety effort ( e ) and exogenous safety meas-
ures (s) that are beyond the driver’s immediate control. Let p(e, s) be the production
function with pe < 0 , pee > 0 , ps < 0 , pss > 0 , and pes > 0 . The loss L which a driver
suffers, given that an accident occurs, depends on the driver’s own safety effort and
exogenous safety factors: L(e, s), with Le < 0 , Lee > 0 , Ls < 0 , Lss > 0 , and Les > 0 .
Finally, there is a disutility D associated with the driver’s safety effort and exogenous
safety factors, such that D(e, s), with De > 0 , Dee > 0 , Ds ≥ 0 , Dss ≥ 0 , and Des ≥ 0 .
This element can represent a driver’s inconvenience, discomfort, energy, or money. If
the motorist has a resource constraint represented by income ( I ) and is risk-neutral,
then the expected utility is:

U = p(e, s)[I − D(e, s) − L(e, s)] + [1 − p(e, s)][I − D(e, s)].

The optimal level of the driver’s safety effort is determined by ∂U ∂e = 0, or

−De = pe L + pLe , the point at which the marginal value of the driver’s utility cost equals
Martinez et al. Lat Am Econ Rev (2019) 28:17 Page 13 of 30

the marginal benefit of the expected reduction loss. This result also indicates that in gen-
eral, motorists will change their behavior (e) in response to a change in exogenous safety
(s). By applying the implicit function, it can be demonstrated that

de −pes L − pe Ls − ps Le − pLes
=− < 0.
ds −Dee − pee L − 2pe Le − pLee

The negative sign of this expression implies that an increase in exogenous safety will
induce drivers to adjust their safety behaviors considering risk compensation.
As has been shown before, utility maximization theories include risk as one of the pos-
sible driver choices. However, there are no precise formulations of what motivates the
drivers to choose a certain level of risk. Rothengatter (1988) argues that it is not just risk
(or its avoidance) that motivates drivers to select their speed, but that there may be other
factors, such as the pleasure of driving fast, which calls for a broader utility framework.
The demand for transportation is a derived demand motivated by the desire to access
various activities. And while there is a motivation to reduce travel time, other attributes
should also be considered in the analysis.
Another study that presents a suitable micro-founded formulation of driving behavior
that applies the concept of risk compensation is that of Dulisse (1997). Figure 3 presents
the theoretical foundation of his choice model. Suppose that an individual has to decide
between two goods: safety (S) and some other good (O, which could represent driving
speed, and thus less travel time). Curve 1 represents the combinations of S and O that
yield equal satisfaction to the driver. The point at which the budget constraint (repre-
sented by the straight line A) is tangent to the preferences generates optimal satisfaction.
At point A, the individual consumes S1 amount of safety and O1 amount of some other
good. Assume that because of a safety intervention, keeping all else constant, the indi-
vidual receives an increase in the amount of safety without reducing the amount of other
goods he or she possesses (point B). This process implies a parallel upward shift of the
budget constraint. However, the combination of safety ( S2 > S1) and the other good O1

Fig. 3 Choice theory between safety and other goods (Source: Dulisse (1997))
Martinez et al. Lat Am Econ Rev (2019) 28:17 Page 14 of 30

is not an optimal decision according to the individual’s indifference mapping. By trading

away enough safety in exchange for the other good, the driver reaches point D, where
satisfaction is optimal given the trade-off rate. According to the author, the hypothesis of
risk compensation does not imply that drivers expose themselves to more risk because
of the safety intervention. It implies that they will choose actions that are riskier than the
action previously chosen (from S2 to S3). Even with the riskier actions, it is likely that the
individual will have more safety than before the intervention ( S3 > S1).
In a more recent article, Noland (2013) presents a theoretical framework that uni-
fies many of the previous theories to explain the driver’s offsetting actions as a result of
increases in mobility. This idea fits within the framework of utility maximization origi-
nally proposed by Blomquist (1986), in which drivers make trade-offs between mobil-
ity and safety. If one assumes that individuals decide upon explicit trade-offs between
risk and mobility, Fig. 4 illustrates the isoquant for a given level of technology. The tech-
nology can be safety devices available for vehicles and the existing road infrastructure.
Movements along with a given isoquant represent the trade-off that an individual makes
in selecting a given bundle of safety and mobility.
Any exogenous technological change can have an impact on both mobility and safety,
and is represented by a parallel isoquant to the right of the original one. If the initial lev-
els of mobility and safety are set at point A in the figure, the new levels after a new tech-
nology is introduced will depend on the shape of the driver’s preference curves. Point B
represents the engineering hypothesis, where all the benefits are associated with reduc-
tions in risk (more safety), with no offsetting behavioral reaction. Point D shows a case
where risk might even increase due to large increases in mobility. Point C is the most
likely outcome, where some of the benefits of the new technology reduce risk, while
some increase mobility.
Transport economics views travel demand as a function of the time and price of
travel. Consumers can also purchase more safety technologies such as vehicles fully
equipped with air bags; thus, there is an additional trade-off between costs and risk. For
those choosing to drive a car, the choice of speed provides an explicit trade-off between
time and risk, if drivers accurately perceive either of these factors. Elvik (2010) argues
that drivers’ choice of speed is not objectively rationale. This is largely based on the
misperceptions which drivers have about the relative risk of higher speeds and their

Fig. 4 Trade-offs between safety and mobility (Source: Noland (2013))

Martinez et al. Lat Am Econ Rev (2019) 28:17 Page 15 of 30

misperception of the travel time savings associated with higher speeds. Driver distrac-
tion and fatigue may also play a role in the risk of driving. A relevant question is whether
roads and vehicles perceived to be safer may influence the likelihood of drivers engaging
in distracting behavior or not taking care if they are fatigued. For instance, cell phone
usage is one activity that clearly has benefits to drivers, but that increases risk.
Within this context, Noland (2013) specifies the utility of travel (U) as a function of
price (P), travel time (T), in-vehicle activities (A, such as those that lead to distractions),
capability (C), and risk (R), such that:

U = f (P, T , A, C, R).

Consumers then seek to maximize utility within their constraints and the given tech-
nologies. The utility of travel may also be affected by other factors, such as the reliability
of the journey, the convenience of intermodal exchanges, and the comfort of alternative
modes. These factors can easily be included in a general framework and might even have
implications for risk-taking. For example, if traffic time is unpredictable due to conges-
tion, this may lead to various risk-taking activities to minimize travel time. Increased
comfort may cause travelers to misperceive their capability levels, which can affect atten-
tion levels, with consequent trade-offs with risk.
The specific functional form will determine how a change in risk affects a change in
other attributes, that is, the elasticity of substitution. Maximization of utility represents
the motivation of the driver, which is typically to increase mobility. A key controlling
factor is a trade-off with travel time, which is controlled by the choices of the individual.
As described in this section, theoretical frameworks on road safety have evolved over
time in multiple disciplines of study, providing different explanations as to the main
causes of traffic accidents. However, as discussed in the next section, the empirical evi-
dence that puts these theories and predictions to the test remains limited, particularly
for the LAC context.

4 Road safety interventions

This section reviews the causal evidence on the effectiveness of road safety interventions.
It highlights the studies that have been done in LAC countries, but, given the limited evi-
dence in the region, also provides a broader overview of the literature from which valuable
lessons can be extracted to advance research in this area in LAC. The review is structured
considering interventions within three of the five pillars established by the UN Decade
of Action (WHO 2010): (1) safer roads and mobility, (2) safer vehicles, and (3) safer road
users. The pillars excluded are the road safety management, which has to do with institu-
tional capacity strengthening and data generation, and the post-crash response, as this is
related to health and insurance interventions that are outside the scope of this work.

4.1 Promoting safer road users

4.1.1 Road safety education programs for pedestrians
Education measures to teach pedestrians how to cope with the traffic environment
are frequently included in road safety strategies. Among high-risk populations, chil-
dren between 6 and 10 years old are estimated to have four times the risk of collision
Martinez et al. Lat Am Econ Rev (2019) 28:17 Page 16 of 30

compared to adult pedestrians (Struik et al. 1988; Thomson 2005). The unintentional
injury of children is a significant public health problem worldwide and an important
financial burden for society (Schwebel et al. 2014a, b). In the United States, more than
3000 children aged 1–14 years old die annually from unintentional injuries and more
than 6 million hospital visits are recorded. In Latin America, the total number of deaths
for children in the same age range was 6642 in 2013 (2015). In 2005, the total cost of
medical expenses for U.S. children aged 1–14 who were hospitalized following uninten-
tional injury was more than US$15 billion (National Center for Injury Prevention and
Control 2013). For Latin American countries, Bhalla et al. (2013) estimate that the total
cost of road injuries for children aged 1–14 was between US$500 million and US$1.5 bil-
lion in 2011.
As Schwebel et al. (2014a) indicate, crossing streets safely is a complex process that
requires multiple steps: choosing an appropriate location, judging the speed of oncom-
ing traffic, and crossing the street in a suitable manner. Taking this into account, while
education is considered an essential tool to teach children road safety skills, current
programs may be limited, because they may not target specific skills or may not be tai-
lored for those who are most in need of training (Congiu et al. 2007). Within the set of
policy options and programs to respond to this issue, many countries (particularly high-
income countries) have implemented road safety education programs directed at both
parents and children. Accident and pedestrian observation studies indicate that in many
instances, parents do not provide adequate supervision and control for very young chil-
dren in traffic (Downing et al. 1981). Programs have evolved over time from classroom
training to multimedia and virtual reality training.
Due to the nature of education programs, where treatment is usually assigned at the
individual level, this is an area of study that has great potential for evaluation using ran-
domized-controlled trials. Nevertheless, many studies identified in the literature suffer
from multiple methodological limitations. Duperrex et al. (2002) conduct a systematic
review of randomized-controlled trials of road safety education programs for pedestri-
ans of all ages. As the authors highlight, most studies identified did not comply with ade-
quate randomized allocation procedures4 and lost participants at follow-up. In addition,
in some cases, the outcomes were known by participants, which could have biased their
behavior. Multiple studies relied on small sample sizes, that compromise the balance
between treatment and control groups and limit statistical power. Also, a few studies
discuss or statistically test the similarities between treatment and control groups after
randomization. The authors conclude that pedestrian safety education programs seem
to change road-crossing behavior, but whether this reduces the risk of pedestrian injury
in road traffic crashes is still unknown. They also highlight the lack of evidence coming
from safety education programs that target adult pedestrians, especially elderly people,
as well as the lack of evidence for low- or middle-income countries.
More recently, Schwebel et al. (2014b) updated the systematic review of studies that
evaluate pedestrian safety education programs for children. The authors incorporate
meta-analysis techniques and discuss the effectiveness of different types of behavio-
ral interventions, considering five categories: individualized or small-group training,

4
The Cochrane method followed by this study involves both the rigorous generation of a random assignment process as
well as its strict implementation (http://metho​ds.cochr​ane.org/bias/asses​sing-risk-bias-inclu​ded-studi​es).
Martinez et al. Lat Am Econ Rev (2019) 28:17 Page 17 of 30

classroom training, computer-based or virtual reality training, board games or peer-

group activities, and film or video training. Similar to Duperrex et al. (2002), none of the
studies identified by the authors comes from a developing-country context. The authors
find that behavioral interventions improve children’s pedestrian safety, both immediately
after training and at follow-up several months later. Available evidence suggests that
interventions targeting dash-out prevention, crossing at parked cars, and selecting safe
routes across intersections were the most effective, as was individualized/small-group
training. The authors also find poor methodological quality in many studies and argue
that additional rigorous research is necessary. To assess quality, they consider the fol-
lowing aspects: (1) selection bias, related to poor randomization processes; (2) detection
bias, related to the fact that study populations are aware of the experiment and of the
outcomes being tested; (3) attrition bias or loss of sample over time; and (4) reporting
bias or bias towards reporting only significant results.
Of the articles identified by Duperrex et al. (2002) and Schwebel et al. (2014b), a few
are noteworthy based on the quality of methods and findings. Downing et al. (1981)
evaluate a road safety booklet using a sample of 1560 3 years old and their parents in the
United Kingdom. The program randomly assigned the participants into four categories:
(1) road safety booklet after an informative interview; (2) interview with no booklet; (3)
road safety booklet with an informative letter; and (4) no intervention. The study found
that the booklet had a significant impact on the children’s traffic and road safety knowl-
edge, but there appeared to be no change in mothers’ road safety actions, which could
be related to the difficulty in changing long-standing practices. These results highlight
the difficulty that these programs might encounter in changing regular behaviors, par-
ticularly for older people. Also, there is no evidence of differential effects when compar-
ing approaches that reach households through an interview compared to sending letters,
which is relevant for cost-effectiveness. Finally, there are no heterogeneous effects across
social class, but rural mothers seemed to make less use of the booklet than urban moth-
ers, underscoring the importance of targeting when designing these programs.
Another relevant study by Miller and Davis (1982) evaluates training methods using
multimedia technologies and explores both short- and medium-term outcomes. The
authors analyze the Beltman Program, which was designed to increase knowledge about
pedestrian safety and out-of-school safety behaviors among kindergarten and first- and
second-grade students in the United States. The program included two intervention
groups and one control group. The first intervention group received the Beltman mate-
rials, which included three filmstrips, numerous props, and teaching aids. The program
gave two booster lessons to the second intervention group 4 months after they received
the initial materials. Students’ knowledge scores and observed out-of-school safety behav-
iors by parents were measured at baseline, after the test, and at a 5-month follow-up test.
The authors found significant increases in knowledge in the two intervention groups at
both the first post-test and the follow-up test, but the differences in knowledge scores
between the two intervention groups were not significantly different at either post-test.
Traditional methods of teaching children road safety skills may be difficult to trans-
fer to real-life situations. For this reason, more recent training programs have used
simulated or virtual road environments. Experimental evidence indicates that children
exposed to virtual reality training significantly improved their abilities to cross streets
Martinez et al. Lat Am Econ Rev (2019) 28:17 Page 18 of 30

(Bart et al. 2008; Congiu et al. 2007), with the impact increasing by age. In some cases,
findings show that positive effects are observed both immediately after training and
1 month after training, but that those effects could dissipate over time.

4.1.2 Awareness campaigns
Public awareness campaigns are another hallmark of road safety strategy, but there is
very limited evidence on their effectiveness. As Hoekstra and Wegman (2011) indicate,
ineffective campaign techniques continue to be utilized. From a policymaker’s perspec-
tive, campaigns can be attractive tools given their wide scope or reach and potentially
low cost. From the evaluation point of view, the level at which the campaign is offered
influences the ability to rigorously evaluate it. To the extent that the campaign is tar-
geted at certain populations or households and that the presence of spillover effects can
be ruled out, evaluation becomes more feasible.
A meta-analysis by Elvik et al. (2009) showed that the effects of mass media campaigns
alone are small, especially when compared to the effects of campaigns combined with other
measures. Without enforcement and/or education, mass media campaigns were found to
have virtually no impact on reducing the number of road accidents. However, enforcement
and/or education coupled with mass media showed more promise, with reductions of over
10% in the number of accidents. Local or personally directed campaigns seem to have the
biggest effect on road accidents, but there are a few studies looking at this type of campaign,
which increases the uncertainty about the true value of this parameter. As Hoekstra and
Wegman (2011) argue, insights into human behavior and behavior modification are impor-
tant for road safety campaigns and are a promising area for future evaluation.
One of the first rigorous experiments of an awareness campaign in a developing-
country context was conducted by Habyarimana and Jack (2011), who examined a cam-
paign aimed at improving the safety of long-distance minibuses (known as “matatus”) in
Kenya. In the study, stickers with evocative messages directed to passengers and encour-
aging them to “stand up, speak up, when they witnessed drivers who were going too fast
or driving unsafely, were randomly assigned to just over half of 2276 recruited vehicles.
To obtain high rates of compliance, the program ran a monthly lottery among drivers
participating in the treatment group that offered monetary rewards if their vehicle was
found to have all stickers intact upon inspection by field staff. Independent insurance
claims that data were collected for treatment and control groups before and after the
intervention. Results indicated that placing stickers in matatus was associated with a
reduction in insurance claims by about half to two-thirds, from a baseline annual rate of
about 10%, and that claims involving injury or death fell by 60%. While the authors were
unable to identify the mechanisms underlying this effect, the intervention was more
cost-effective at reducing mortality than other documented public health interventions.

4.1.3 Laws to promote transportation safety

This section reviews the effects of legislation to promote transport safety, specifically
drinking and driving laws and motorcycle helmet laws. It is well established that driving
under the effects of alcohol increases the chance of a road accident. Driving with blood
alcohol content between 0.02 and 0.05 g/dl triples the risk of a road accident. According to
WHO (2015), the risk increases to at least six times with a blood alcohol content between
Martinez et al. Lat Am Econ Rev (2019) 28:17 Page 19 of 30

0.05 and 0.08 g/dl and rises exponentially above 0.08 g/dl. Albalate (2008) evaluates the
impact of reducing the blood alcohol content limit to 0.5 mg/ml in several European coun-
tries over the last decade. The author uses the Community Database on Accidents on
the Roads in Europe (CARE) for the period 1991–2003. Using a difference-in-differences
method with fixed effects, the author shows that lowering the blood alcohol content limit
to 0.5 mg/ml was an effective tool for saving lives in some road user groups, particularly
males, drivers in urban areas, and all drivers between 18 and 49 years old.
A similar study in LAC examined Chile’s 2012 law that lowered the permissible blood
alcohol content threshold from 0.5 to 0.3 mg/ml, and instituted severe financial and
license revocation penalties for offending drivers. Rau and Otero (2017) show that alco-
hol-related car accidents decreased by 32% immediately following approval of the law,
but that effects decrease over time. This was associated with a reduction in injuries; how-
ever, there were no significant effects on fatalities. In a second study using municipality-
level administrative records, Otero (2013) employs a difference-in-differences strategy
to estimate the causal impact of the law on car accidents and fatality rates. Given the
quality of data on the cause of car accidents, the author uses all car accidents due to car
or road technical failures as a comparison group. Results indicate that the law reduced
the number of alcohol-related car accidents by 18% to a quarter of all accidents, which
is entirely driven by non-fatal incidents. Evidence also indicates that the law works by
increasing sober driving, not by reducing drunk drivers’ alcohol consumption.
A second area of legal intervention to improve road safety is motorcycle helmet laws.
Peng et al. (2017) review the literature in the United States and find that laws increased
helmet use and reduced mortality and injuries for motorcyclists. However, several studies
included in the review suffered from methodological limitations, such as not perform-
ing blinded assessment of outcomes, few data points, missing data, etc. A recent study
by Blanco et al. (2017) in the Uruguayan context uses a “natural experiment” whereby a
motorcycle helmet usage law was enforced in one municipality but not in another, and
finds that within 1 month of the law’s enforcement, usage of helmets increased from
under 10% to over 90%, and there was a reduction in the probability of serious injuries or
fatalities by 8.7 percentage points (a 57% reduction relative to the control group).

4.1.4 Incentive mechanisms to promote safe driving

Road safety policies often use incentive mechanisms based on traffic violations to promote
safe driving, such as fines, experience rating, and point-record driver’s licenses. Dionne et al.
(2011) propose a function of convicted traffic offenses and accidents with a proportional
hazard model, and tested the model with data from the Quebec public insurance plan.
The authors find evidence of moral hazard, where drivers who accumulate demerit points
become more careful because they are at risk of losing their license. An insurance rating
scheme introduced in 1992 reduced the frequency of traffic violations by 15%. The authors
use this result to derive monetary equivalents for traffic violations and license suspensions.

4.2 Safer roads and mobility

Road infrastructure is another factor that contributes to accidents. For this reason,
beyond safety education programs and campaigns directed at changing risky behav-
iors, many road infrastructure projects are now introducing road safety components as
Martinez et al. Lat Am Econ Rev (2019) 28:17 Page 20 of 30

part of their design. This section reviews the evidence from two different approaches.
The first involves the adoption of engineering designs that are thought to provide safer
roads, such as adjusting the shape of streets, the width of lanes, slopes, etc. The second
group involves interventions such as adopting technology to promote road safety. These
interventions include signaling, red lights in critical crossing sections of the road, and/or
cameras to identify and penalize bad driving, among others.

4.2.1 Infrastructure designs: converting intersections to roundabouts

Elvik (2007) conducted a meta-analysis of projects implemented outside of the United
States to evaluate the effects of converting intersections to roundabouts on road safety.
The author provides 113 estimated effects derived from 28 studies. Among all the studies,
only three used before-and-after techniques that included a control group.5 The remaining
studies were based on before-and-after methods or comparative analysis of various types
of intersections. None of the studies came from a developing country, and all pertained
to either a European country or Australia. The main conclusions of the analysis were that
roundabouts are associated with a 30–50% reduction in the number of injury accidents.
Fatal accidents are reduced by 50 to 70%. Evidence from the evaluation studies, although
highly uncertain, suggests that the effect of roundabouts on injurious accidents is greater in
four-leg intersections than in three-leg intersections, and it is greater in intersections previ-
ously controlled by yield signs than in intersections previously controlled by traffic signals.
A few studies have evaluated the effects of design parameters for roundabouts. While find-
ings from the studies are not always consistent, most find that small roundabouts (a small
diameter of the central traffic island) are safer than large roundabouts (a large diameter of
the central traffic island).
In general, roundabouts have a favorable effect on traffic safety, at least for crashes
causing injuries. The number of severe crashes (fatalities and accidents involving serious
injuries) appears to decrease after converting intersections into roundabouts. However,
less is known about the safety effects of roundabouts for different types of road users,
such as bicyclists. Daniels et al. (2008) conducted a before-and-after study with the use
of a comparison group on a sample of 90 roundabouts in Flanders, Belgium to assess the
effects of this intervention on bicyclists. The study revealed a significant increase in the
number of severe injury crashes with bicyclists after the construction of a roundabout.
Roundabouts with cycle lanes perform worse regarding injury crashes with bicyclists
compared to three other design types (mixed traffic, separate cycle paths, and grade-
separated cycle paths). Roundabouts that replace signal-controlled intersections seem
to have had a worse evolution compared to roundabouts on other types of intersections.

4.2.2 Technology interventions: speed cameras

Multiple road safety interventions make use of technology to reduce risky behaviors.
One example is the use of cameras to reduce speed. Usually, cameras capture the license
plate of passing vehicles exceeding a speed above the legal limit and mail a fine and pen-
alty points to the driver of the vehicle. The main argument to install speed cameras is
that by reducing speed, they contribute to preventing accidents.

5
These studies are Giæver (1990), Jørgensen and Jørgensen (1992), and Brüde and Larsson (1985). Unfortunately, none
of these studies are available in English.
Martinez et al. Lat Am Econ Rev (2019) 28:17 Page 21 of 30

This type of intervention has been studied extensively, including by Christie et al. (2003),
who analyzed the effectiveness of mobile speed cameras on road traffic injuries in South
Wales in the United Kingdom. The authors study the use of mobile speed cameras at 101
sites to compare the rate of car accidents with a matched control group that was obtained
from Gwent, a neighboring county with almost no speed cameras.6 The authors found that
mobile speed cameras reduced personal injury accidents by 50% and pedestrian accidents
by 78%. One of the main limitations of the study is that it is assumed that cameras did not
cause diversion of vehicles to other sites, which could explain the difference. Also, due to
lack of data, the study was not able to control for other covariates that may have varied
over time differently across treatment and control sites, such as traffic volume.

4.2.3 Technology interventions: red‑light cameras

Many drivers routinely run red lights, placing themselves and other road users at risk for
crashes and serious injuries (Retting et al. 2007). To reduce this problem, multiple coun-
tries have adopted red-light enforcement cameras. The technology usually consists of a
camera that photographs the license plates of vehicles that enter an intersection after
the signal has turned red. After a process of review and validation, an approved citation,
along with the photograph of the violation, is sent to the registered owner of the vehicle
(Garber et al. 2007). There is still no consensus on the effectiveness of red-light camera
programs. Methodologies used to assess these programs have varied, as have the study
conclusions. In general, the main criticism of the studies has been the use of simple
methods (before-and-after comparisons) and small samples (Burkey and Obeng 2004).
Two principal methods used to reduce red-light running involve lengthening the dura-
tion of yellow signal intervals and automated red-light enforcement. Retting et al. (2007)
evaluate the incremental effects on red-light running of first lengthening yellow signal
timing, followed by the introduction of red-light cameras. They worked at two intersec-
tions in Philadelphia, Pennsylvania, where yellow change intervals were increased by about
1 s, followed several months later by red-light camera enforcement. They included two
comparison sites (approx. 50 miles apart) that authors argue were close enough to expect
similar patterns in terms of weather, fuel prices, and economic conditions, and that col-
lected violation data. The baseline recorded the number of red-light running violations,
while the follow-ups included data several weeks after the implementation of the yellow
timing changes, and about 1 year after the beginning of red-light camera enforcement. The
authors estimated the odds of red-light running at the experimental sites relative to the
comparison sites following implementation of yellow timing changes. Results showed that
yellow timing changes reduced red-light violations by 36%. The inclusion of red-light cam-
era enforcement further reduced red-light violations by 96% beyond levels achieved by the
longer yellow timing. This study shows that the provision of adequate yellow signal timing

6
The unit of observation was determined by mapping the cameras, matched sites, and the crashes at both sites. The
authors considered circular zones of different radius around the camera and matched site and a route-based method
that defines exposure at various distances from sites. To determine the effectiveness of the mobile cameras, they com-
puted the ratio of car accidents at the implemented and matched control sites before and after the intervention. For
example, an intervention–control pair with six injurious crashes in the control-before and seven injurious crashes in the
intervention-before period would have a matching ratio of 0.86, and if there were four injurious crashes in the control-
after period, the expected number in the intervention-after period would be 4/0.86 = 4.7.
Martinez et al. Lat Am Econ Rev (2019) 28:17 Page 22 of 30

reduces red-light running, but longer yellow timing alone did not eliminate the need for
better enforcement, which can be provided efficiently by red-light cameras.
Garber et al. (2007) studied the effectiveness of photo-red enforcement programs to
address the problem of red-light running in Northern Virginia jurisdictions. A prelimi-
nary analysis in Fairfax County suggested that red-light running crashes decreased, but
that rear-end crashes increased, after the cameras were installed. The authors’ aim was
to understand whether this result can be generalized to other counties and to quantify
the net change in crash severity arising from this type of intervention. They used a data
set including more than 3500 crashes over a 7-year period (1998–2004) at 28 intersec-
tions with cameras and 44 intersections without cameras. The authors use four method-
ologies ranging from simple before–after comparisons to an empirical Bayes approach.
The authors defined crash severity as the total number of injury crashes and crash cost.7
The results varied depending on the type of crash, the jurisdiction, and the analytic
technique used. The findings show that after cameras were installed, rear-end crashes
increased by 27% and red-light running crashes decreased by 42%, but the trends var-
ied across counties. Overall, total crashes increased after the intervention, but there was
a reduction in crash costs. Authors argue that measuring severity is very sensitive to
assumptions.
A more recent impact evaluation also found positive results from red-light camera
interventions. Hu et al. (2011) analyzed data on fatal crashes from 14 large U.S. cities
with red-light camera enforcement programs and 48 cities without camera programs
for 1992–1996 and 2004–2008. The average annual citywide rate of fatal red-light-run-
ning crashes declined around 14% for both groups, but the rate for cities with camera
enforcement fell 35%. During 2004–2008, the rate of fatal red-light-running crashes city-
wide and at signalized intersections were 24% and 17% lower, respectively, than what
would be expected without cameras. By examining citywide crash rates for cities with
camera programs and using similar control cities, the study accounted for two common
weaknesses of red-light camera research: regression to the mean and spillover effect.

4.3 Safer vehicles
4.3.1 Vehicle inspections and road safety
As cars grow older, their technical condition deteriorates and their chances of being
involved in an accident increase (Fosser 1992). Earlier studies offered inconclusive find-
ings about the impact of vehicle inspections. For example, a study by Crain (1980) in
the United Stated did not find an impact of vehicle inspections on car accident reduc-
tion, while a study by Matre and Overstree (1982), also in the United States, found that
both random and non-random inspections were effective in reducing accident mortality.
In both cases, the studies run regressions at the state level controlling for differences
in vehicle inspection laws across states, and thus, they might not be accounting for all
potential confounders. Some more recent studies introduce time-series analysis and
report that periodic motor vehicle inspection is effective in preventing accidents. For
instance, Sweden introduced mandatory annual inspection of all cars in 1966. According

7
Crash costs are calculated by the U.S. Federal Highway Administration. These costs include damage to vehicles and
other property, costs from providing emergency medical services, medical costs, productivity losses, and “monetized
quality-adjusted life years.” Costs are based on the speed limit (either 45 mph and above or below 45 mph), location type
(e.g., signalized intersection), and crash type (rear-end or angle).
Martinez et al. Lat Am Econ Rev (2019) 28:17 Page 23 of 30

to a time-series analysis conducted by Berg et al. (1984) covering 1955–1981, the authors
concluded that the number of cars involved in police-reported accidents declined by
14% following the introduction of annual inspections, while the number of injurious
accidents decreased by 15%. Another time-series analysis covering 1929–1979 (Loeb
and Gilad 1984) found that periodic motor vehicle inspections in New Jersey, introduced
in 1938, reduced the number of fatalities and accidents. There are some uncertainties in
time-series analyses, as several factors can be expected to affect the number of accidents
during extended periods of time. Some studies have tried to consider some of these fac-
tors, like changes in the use of seatbelts, daytime running lights, and traffic volume.
However, there may be time-changing observable and unobservable variables remaining
that do not allow for isolating the effect of vehicle inspections.
Little (1971) performed a controlled before-and-after study using data from the United
States to identify the effect of motor vehicle inspection on road accidents. The author
designed a treatment group composed of six states and three control groups to test the
null hypothesis that states that begin inspection programs experience no greater decline
in death rates in post-treatment years than in pre-treatment years compared to states
with no inspections. The results indicate that the fatality rate per 100,000 population
increased following the introduction of periodic motor vehicle inspection. The use of
control groups is an advantage of this study, but it does not rule out the effect of unob-
servable and observable (not controlled for) characteristics that change over time and
affect treatment and control groups differently. For example, a high rate of economic
growth in treatment states could lead to an increase in traffic volume and, subsequently,
in the number of road accident fatalities.
The first experimental evaluation of the effects of periodic motor vehicle inspections
on accident rates was conducted by the Norwegian Institute of Transport Economics
(Fosser 1992). The study randomly assigned 204,000 cars to three different experimen-
tal conditions: 46,000 cars were inspected annually during a period of 3 years; 46,000
cars were inspected once for 3 years; and 112,000 cars were not inspected. The num-
ber of accidents was recorded for a period of 4 years. No differences in accident rates
were found between the groups, although the technical condition of inspected vehicles
improved compared to those not inspected.

4.3.2 Fuel economy standards, vehicle size, and road safety

An emerging literature has looked at how fuel economy standards that change the com-
position of the vehicle fleet toward smaller and lighter vehicles can potentially influence
accident fatality risks. These studies shed some light on how regulatory safety standards
in vehicle production could affect road safety. Jacobsen (2011, 2013) estimated the direc-
tion and magnitude of the U.S. fuel economy policy using structural models to provide
empirical estimates of vehicle safety across classes, accounting for unobserved driv-
ing behavior and selection.8 Jacobsen (2011) showed that the distinction between light

8
In general, impact evaluation relies on reduced-form approaches, where the primary interest is the direct relationship
between a program or intervention and certain outcomes. Selection bias and the problem of unobserved counterfactuals
are the primary identification issues for impact evaluators. In some cases, however, one may be interested in modeling
other factors affecting policies and outcomes in a more comprehensive framework. Structural models or simultaneous
equation models can help to create a schematic for interpreting policy effects from regressions, particularly when mul-
tiple factors are at work. These models specify interrelationships among endogenous variables (such as outcomes) and
exogenous variables or factors (Khandker et al. 2010).
Martinez et al. Lat Am Econ Rev (2019) 28:17 Page 24 of 30

trucks and cars in fuel economy rules has very negative consequences for overall safety:
each mile per gallon increment is associated with an additional 150 fatalities per year in
expectation. Jacobsen (2013), however, applied his model to the current structure of U.S.
fuel economy standards, accounting for shifts in the composition of vehicle ownership,
and estimated an adverse safety effect of 33 cents per gallon of gasoline saved.
Road safety can also be affected by vehicle size. This feature of road safety led Ander-
son (2008) to study the effects of size on traffic safety. The author estimated the net effect
of vehicle fleet composition on traffic fatalities using a state-level panel data set. Moreo-
ver, with a random sample of police-reported accidents, he estimated the effects of light
trucks on their own occupants and on other roadway users when an accident occurs.
Finally, combining the results from the state-level and accident-level estimation strate-
gies, he determined the relative crash rate of light trucks as compared to cars to estimate
the total internal and external effects of shifting the vehicle fleet composition from cars
towards light trucks. The results indicated that a 1% point increase in the light truck
share raises annual traffic fatalities by 0.34%, or 143 deaths per year. Of this increase,
approximately one-fifth accrues to the light trucks’ own occupants, and the remaining
four-fifths accrue to the occupants of other vehicles and pedestrians. Using standard
value-of-life figures, the implied Pigovian tax is approximately US$3850 per light truck
sold. Overall, light trucks pose a significant hazard to other users of the highway system,
and, on average, provide no additional protection to their own occupants.
Similarly, Anderson and Auffhammer (2014) looked at the external costs of vehicle
weight, particularly those related to fatal and non-fatal accidents. The authors’ argument
is that heavier vehicles are safer for their occupants but more hazardous for other vehi-
cles. Therefore, any unregulated vehicle fleet should be inefficiently heavy. Using three
separate identification strategies, they showed that, controlling for own-vehicle weight,
being hit by a vehicle that is 1000 lb heavier generates a 40–50% increase in fatality risk.
These results imply a total accident-related externality that exceeds the estimated social
cost of U.S. carbon emissions and is equivalent to a gas tax of $0.97 per gallon (US$136
billion annually). They considered two policies for internalizing this external cost—a
weight-varying mileage tax, and a gas tax—and found that they are similar for most vehi-
cles. Their findings suggest that European gas taxes may be much closer to the optimal
levels than the United States gas tax.

4.3.3 Vehicle recalls and road safety

Another regulatory safety standard targeted at reducing road accidents is vehicle recall.
For instance, in the United States, the number of automobile recalls has increased
sharply in the last two decades,9 but there is still little quantitative evidence of this pol-
icy on safety. Bae and Benítez-Silva (2011) empirically quantified the impact of vehicle
recalls on safety using repeated cross sections on accidents of individual drivers and
aggregate vehicle recall data to construct synthetic panel data on individual drivers of
a vehicle model. They found that a 10% increase in the recall rate of a specific model
reduces the accidents of that model by 0.78 of a percent. They also concluded that recalls

9
According to the Bureau of Transportation Statistics, 8,408,000 vehicles were recalled in 1993, while in 2011, the num-
ber of vehicles recalled was 15,500,000.
Martinez et al. Lat Am Econ Rev (2019) 28:17 Page 25 of 30

classified as “hazardous” are more effective in reducing accidents, and that vehicle mod-
els with recalls with higher correction rates have, on average, fewer accidents in the years
following a recall, which indicates the importance of the role of drivers’ behavior regard-
ing recalls on safety. No similar studies were found for Latin America and the Caribbean.

5 Conclusions
Traffic deaths are one of the leading causes of death in LAC, and deaths and injuries
from traffic accidents impose significant costs on the region. Available evidence (primar-
ily from high-income countries such as the United States, United Kingdom, and Norway)
suggests that effective policies can be implemented to improve road safety. However, evi-
dence-based solutions need to be adapted and rigorously tested in the region. This paper
takes a first step to laying the groundwork for a research agenda on road safety in LAC
by summarizing existing theoretical literature and reviewing empirical evidence to date.
Overall, the paper identified few rigorous impact evaluations on road safety. Most of the
studies are observational, and among those that have tried to estimate causal effects,
many suffered from small sample sizes and from selection of controls groups. Moreover,
the literature has been concentrated in a few areas, such as road safety education, regula-
tory safety standards for vehicles, and institutional and normative frameworks.
Our review of the literature concentrates on three of the five pillars of road safety iden-
tified by the United Nations. The safer roads and mobility pillar highlights the impor-
tance of planning, designing, and constructing safe infrastructure. Roads in developing
countries tend to be used by large numbers of motorcyclists, non-motorized vehicles,
and pedestrians, and they lack safety features to protect these vulnerable populations,
such as pedestrian crossing facilities, motorcycle lanes, and signs, among others (Global
Road Safety Partnership 2016). The causal literature within this pillar is limited, probably
due to the inherent methodological challenges in evaluating infrastructure interventions
that are usually not randomly placed and, in many cases, are undertaken gradually in one
or few locations. However, this review was able to identify some causal studies exploring
the effects of modifying certain infrastructure designs (e.g., roundabouts) within urban
areas. It also identified studies that examine other engineering solutions such as the
incorporation of technologies (speed and red-light cameras) to promote safe behaviors.
The safer vehicles pillar seeks to encourage the purchase, operation, and maintenance
of safer vehicles, ideally harmonizing global safety standards. Since 2010, crash tests on
leading car brands sold across the region have revealed that many models were being
sold without basic safety devices such as anti-lock braking systems and airbags, and had
chassis that crumple far too easily on impact (Stocker 2012). This puts the driving popu-
lation in the region at a higher risk of road accidents. This review presented studies that
evaluate the impact of vehicle inspections, vehicle recalls, and fuel economy standards
that result in lighter and smaller vehicles and which might have an impact on road safety.
The safer road users’ pillar deals with enforcement and legislation, as well as with
awareness campaigns and education programs. This is the area where the largest amount
of evidence was identified, particularly for road safety education programs, includ-
ing several randomized-controlled trials that have been implemented in high-income
countries and that target children below 14 years old. Within this pillar, causal studies
Martinez et al. Lat Am Econ Rev (2019) 28:17 Page 26 of 30

were also identified that explore the impact of awareness campaigns, drunk driving laws,
motorcycle helmets, and other incentive mechanisms that seek to promote safe driving.
This exercise led to extracting some implications for future interventions, either led
by public or private actors, and to highlighting areas of work that need more exploration
within road safety evaluations. For road safety education, vulnerable populations such as
the elderly and children are potential target groups. Education campaigns could consider
testing individualized versus group training and technology-assisted versus non-tech-
nology methods, including education entertainment (films, videos, and booklets). Since
knowledge does not necessarily translate into behavior, education-based interventions
should focus on measuring behavioral outcomes.
For infrastructure strategies, it would be valuable to design impact evaluation stud-
ies that examine the impact of traffics signs on behavior in the LAC context, since
studies to date are based primarily on simulations. There is a large scope for imple-
menting experimental evaluations of technology to promote safe behaviors, including
intelligent traffic lights, red-light cameras, speed cameras, and others. Finally, road
maintenance could also play a role in road safety, so designing studies that examine
multiple methods to achieve adequate road maintenance could be included in the
agenda.
With respect to interventions targeted at vehicles, there is considerable evidence from
studies of periodic vehicle inspections (one using an experimental design, but none of
them in the region), and it would be valuable to understand better enforcement mecha-
nisms for inspection in LAC. There is a dearth of evidence on car production and used
car sales regulations, and much of the literature on the impact of vehicle size and road
safety is based on structural models, which points to the need for more reduced-form
evidence. Finally, within the institutional and normative framework, it is important to
deepen understanding of drunk drinking and compulsory helmet laws as well as other
legal and regulatory frameworks that may improve road safety.
From a methodological point of view, the gold standard in impact evaluation has been
randomized-controlled trials, and the evaluation of road safety interventions offers mul-
tiple possibilities for experimentation. However, as Christie et al. (2003) explain, rand-
omized-controlled trials have been difficult to implement in the field due to differences
in beliefs between academics and some injury control practitioners and politicians that
the existing evidence is sufficiently persuasive. It will be important to continue showcas-
ing the value of building more rigorous causal evidence (Gertler et al. 2016) in this area,
but also to consider that in certain circumstances, the evaluation will require the use
of quasi-experimental designs, based on the characteristics of the intervention. Moreo-
ver, qualitative data are a valuable complement for causal evidence and allow for a more
nuanced understanding of the mechanisms through which impacts happen. Given that
several road safety interventions are implemented at an aggregate geographical level,
such as campaigns in a city, or traffic signs along a highway, and to the extent that road
safety data become more available with high frequency, methodologies such as synthetic
control methods (Abadie and Gardeazabal 2003; Abadie et al. 2009) could open new ave-
nues for evaluation.
Martinez et al. Lat Am Econ Rev (2019) 28:17 Page 27 of 30

Abbreviations
GDP: Gross Domestic Product; LAC: Latin America and the Caribbean; UN: United Nations.

Acknowledgements
The opinions expressed in this publication are those of the authors and do not necessarily reflect the views of the
Inter-American Development Bank Group, its respective Boards of Directors, or the countries which they represent. The
authors would like to thank Dalve Alves for helpful comments on earlier versions of this paper.

Authors’ contributions
SM and PY-P conceived of and outlined the content of this paper. RS and PY-P conducted literature reviews, data analy‑
sis, and preparation of tables. SM, RS, and PY-P drafted and edited sections of the paper. All authors read and approved
the final manuscript.

Funding
Generous funding for the elaboration of this paper and the book series was provided by the Inter-american Develop‑
ment Bank. All opinions are those of the authors and do not necessarily represent the views the Inter-American Develop‑
ment Bank Group, its respective Board of Directors, or the countries which they represent.

Availability of data and materials

All data used in this paper are available online.

Competing interests
The authors declare that they have no competing interests.

Author details
1
Inter-American Development Bank, Washington D.C., USA. 2 IDB Invest, Washington D.C., USA.

Appendix
See Tables 6, 7, and 8.

Table 6 Projected top ten causes of death for 2030. (Source: Prepared by the authors
based on data from WHO (2015))
World High- Low- and middle-income countries
income
countries East Asia Europe Latin America Middle East South Sub-
and Pacific and Central and Caribbean and North Asia Saharan
Asia Africa Africa

Ischemic 9,245,111 1,393,090 2,572,199 1,238,691 627,174 540,877 2,267,077 606,002

heart
disease
Stroke 8,578,124 866,778 3,637,130 771,443 416,674 363,935 1,655,546 866,618
Chronic 4,568,157 445,821 1,507,041 89,278 199,700 70,851 2,092,965 162,501
obstruc‑
tive pul‑
monary
disease
Lower res‑ 3,535,247 524,961 601,006 63,162 282,238 103,462 727,734 1,232,684
piratory
infections
Trachea, 2,413,401 626,552 1,214,598 148,078 117,401 41,767 220,041 44,965
bronchus,
lung
cancers
Other cir‑ 1,929,188 879,264 404,681 72,900 180,821 97,263 160,936 133,324
culatory
diseases
Road injury 1,853,581 72,024 391,304 38,075 131,289 118,637 588,620 513,632
HIV/AIDS 1,793,500 51,463 124,454 114,885 57,198 22,318 105,394 1,317,788
Diarrheal 1,616,713 54,202 70,331 6,912 20,418 15,226 859,824 589,800
diseases
Hyperten‑ 1,457,306 251,561 412,501 87,247 163,892 90,298 292,174 159,632
sive heart
disease
Martinez et al. Lat Am Econ Rev (2019) 28:17 Page 28 of 30

Table 7 Projected top ten causes of death among 15–29 years old for 2030. (Source:
Prepared by the authors based on data from WHO (2015))
World High- Low- and middle-income countries
income
countries East Asia Europe Latin America Middle East South Sub-
and Pacific and Central and Caribbean and North Asia Saharan
Asia Africa Africa

Road 441,351 16,221 75,528 8469 34,313 25,160 126,067 155,593

injury
Self-harm 234,568 20,064 23,043 9811 13,508 3902 120,823 43,418
HIV/AIDS 215,833 1,219 15,713 5249 8275 1814 10,940 172,623
Cardio‑ 194,562 7054 37,876 7997 10,830 16,613 56,371 57,821
vascular
dis‑
eases
Interper‑ 185,828 10,047 13,896 3056 68,948 2929 16,182 70,771
sonal
vio‑
lence
Maternal 95,347 522 4283 334 2394 1931 19,795 66,089
condi‑
tions
Res‑ 87,778 1058 6610 1056 3441 2978 6602 66,032
piratory
infec‑
tions
Diarrheal 99,546 101 8550 162 636 741 25,417 63,939
dis‑
eases
Drowning 68,509 1986 11,053 3864 4889 2420 18,245 26,051
Menin‑ 39,747 157 1601 251 469 567 3576 33,125
gitis

Table 8 National motorcycle helmet laws (percent). Source: Prepared by the authors
based on data from WHO (2018)
Existence Requirement Requirement Applicability Applicability
of a national for motorcycle for motorcycle of national of national
motorcycle helmets helmet to be motorcycle motorcycle
helmet law to meet fastened helmet law helmet law to all
standards to all road engine types
types

Andean South 100.00 60.00 50.00 100.00 100.00

Region
Latin Caribbean 100.00 50.00 50.00 100.00 100.00
Mesoamerica 100.00 14.29 29.00 100.00 85.71
Non-Latin Carib‑ 100.00 83.33 33.33 100.00 100.00
bean
Southern Cone 100.00 100.00 80.00 100.00 100.00

Received: 28 August 2019 Accepted: 30 October 2019

References
Abadie A, Gardeazabal J (2003) The economic costs of conflict: a case study of the Basque country. Am Econ Rev
93(1):113–132
Abadie A, Diamond A, Hainmueller J (2009) Synthetic control methods for comparative case studies: estimating the
effect of California’s Tobacco Control Program. J Am Stat Assoc 105:493–505
Martinez et al. Lat Am Econ Rev (2019) 28:17 Page 29 of 30

Albalate D (2008) Lowering blood alcohol content levels to save lives: the European experience. J Policy Anal Manag
27(1):20–39
Anderson M (2008) Safety for whom? The effects of light trucks on traffic fatalities. J Health Econ 27(4):973–989
Anderson M, Auffhammer M (2014) Pounds that kill: the external costs of vehicle weight. Rev Econ Stud 81(2):535–571
Bae Y, Benítez-Silva H (2011) Do vehicle recalls reduce the number of accidents? The case of the US car market. J Policy
Anal Manag 30(4):821–862
Bart O, Katz N, Weiss P, Josman N (2008) Street crossing by typically developed children in real and virtual environments.
Occup Particip Health 28(2):89–96
Berg G, Danielsson S, Junghard O (1984) Trafiksakerhet och periodisk Fordonskontroll. VTI-Rapport 281. Statens Vag-och
Trafikinstitut, Linkoping
Bhalla K, Diez-Roux E, Taddia AP, De la Peña Mendoza SM, Pereyra A (2013) The costs of road injuries in Latin America.
Technical Note No IDB-TN-597. Inter-American Development Bank, Washington, DC
Blanco M, Cabrera JM, Carozzi F, Cid A (2017) Effects of motorcycle helmet laws on prevention of fatalities: an impact
evaluation. Department of Economics Working Paper Series, Universidad de Montevideo
Blomquist G (1986) A utility maximization model of driver traffic safety behavior. Accid Anal Prev 18(5):371–375
Brüde U, Larsson J (1985) Korsningsåtgärder vidtagna inom vägförvaltningarnas trafiksäkerhetsarbete. Regressions-och
åtgärdseffekter
Burkey M, Obeng K (2004) A detailed investigation of crash risk reduction resulting from red light. Munich Personal RePEc
Archive Paper No. 36261
Christie S, Lyons R, Dunstan F, Jones S (2003) Are mobile speed cameras effective? A controlled before and after study.
Injury Prev 9(4):302–306
Congiu M, Whelan M, Oxley J, D’Elia A, Charlton J, Fildes B (2007) Crossing roads safely: the effects of training on improv‑
ing children’s road crossing decisions. In: Paper presented at the Australasian Road Safety Research Policing Educa‑
tion Conference, Melbourne, Victoria, Australia
Crain W (1980) Vehicle safety inspection systems. How effective? American Enterprise Institute for Public Policy Research,
Washington, DC
Crandall R, Graham J (1984) Automobile safety regulation and offsetting behavior: some new empirical estimates. Am
Econ Rev 74(2):328–331
Daniels S, Brijs T, Nuyts E, Wets G (2008) Roundabouts and safety for bicyclist: empirical results and influence of different
cycle facility designs. In: Paper presented at the National Roundabout Conference, Kansas City, Missouri
Diez-Roux E, Taddia A, De la Peña Mendoza S, Deza de la Vega C (2012) Closing the gap: reducing road traffic deaths in
Latin America and the Caribbean—action Plan 2010–2015. Inter-American Development Bank, Washington, DC
Dionne G, Pinquet J, Maurice M, Vanasse C (2011) Incentive mechanisms for safe driving: a comparative analysis with
dynamic data. Rev Econ Stat 93(1):218–227
Downing C, Murray G, Durow C (1981) Trials of a road safety booklet for a pre-school traffic club. Monograph No LR 992,
Planning and Transport Res and Computation Co Ltd
Dulisse B (1997) Methodological issues in testing the hypothesis of risk compensation. Accid Anal Prev 29(3):285–292
Duperrex O, Bunn F, Roberts I (2002) Safety education for pedestrian for injury prevention: a systematic review of rand‑
omized controlled trials. BMJ 324(7346):1129–1134
ECLAC (2015) Latin America and the Caribbean maintains a high traffic accident mortality rate. Press Release, 11 Novem‑
ber. Economic Commission for Latin America and the Caribbean. https​://www.cepal​.org/en/comun​icado​s/ameri​
ca-latin​a-carib​e-manti​ene-alta-tasa-morta​lidad​-sinie​stros​-trans​ito. Accessed 2 Aug 2018
Elvik R (2002) The importance of confounding in observational before-and-after studies of road safety measures. Accid
Anal Prev 34:631–635
Elvik R (2004) To what extent can theory account for the findings of road safety evaluation studies? Accid Anal Prev
36(5):841–849
Elvik R (2007) Effects on road safety of converting intersections to roundabouts: review of evidence from non-U.S. studies.
Transp Res Rec J Transp Res Board 1847:1–10
Elvik R (2010) A restatement of the case for speed limits. Transp Policy 17(3):196–204
Elvik R, Vaa T, Erke A, Sorensen M (2009) The handbook of road safety measures. Emerald Group Publishing, Bingley
Farmer E, Chambers EG (1940) A study of accident proneness among motor drivers. Rev Stat Econ Books 103(2):254–256
Fosser S (1992) An experimental evaluation of the effects of periodic motor vehicle inspection on accident rates. Accid
Anal Prev 24(6):599–612
Froggatt P, Smiley JA (1964) The concept of accident proneness: a review. Br J Ind Med 21(1):1–12
Fuller R (2005) Towards a general theory of driver behaviour. Accid Anal Prev 37(3):461–472
Fuller R, Santos J (2002) Psychology and the highway engineer. In: Fuller R, Santos J (eds) Human factors for highway
engineers. Pergamon, Amsterdam
Garber N, Abel R, Miller J, Eslambolchi S, Korukonda S (2007) The impact of red-light cameras (photo-red enforcement)
on crashes in Virginia. Document No. FHWA/VTRC 07-R2. Virginia Transportation Research Council and U.S. Depart‑
ment of Transportation Federal Highway Administration
Gertler P, Martinez S, Premand P, Rawlings L, Vermeersch C (2016) Impact evaluation in practice, 2nd edn. World Bank,
Washington, DC
Giæver T (1990) Ulykkesfrekvenser i rundkjøringer og signalregulerte kryss. STF63 A90002
Global Road Safety Partnership (2016) Road Map Strategic Plan 2016–2020. International Federation of Red Cross and
Red Crescent Societies. https​://www.grspr​oadsa​fety.org/wp-conte​nt/uploa​ds/2016/11/GRSP-Road-Map_Strat​egic-
Plan-2016-2020.pdf. Accessed 2 Aug 2018
Habyarimana J, Jack W (2011) Heckle and chide: results of a randomized road safety intervention in Kenya. J Public Econ
95:1438–1446
Hauer E (1997) Observational before–after studies in road safety: estimating the effect of highway and traffic engineering
measures on road safety. Pergamon Press, Oxford
Martinez et al. Lat Am Econ Rev (2019) 28:17 Page 30 of 30

Hoekstra T, Wegman F (2011) Improving the effectiveness of road safety campaigns: current and new practices. IATSS Res
34(2):80–86
Hu W, McCartt A, Teoh E (2011) Effects of red-light camera enforcement on fatal crashes in large US cities. J Saf Res 42(4):277–282
Jacobsen M (2011) Fuel economy, car class mix, and safety. Am Econ Rev 101(3):105–109
Jacobsen M (2013) Fuel economy and safety: the influences of vehicle class and driver behavior. Am Econ J Appl Econ 5(3):1–26
Janssen W, Tenkink E (1988) Considerations on speed selection and risk homeostasis in driving. Accid Anal Prev
20(2):137–142
Jørgensen E, Jørgensen N (1992) Er der mere nyt om rundkørsler? Dansk Vejtidsskrift 12:29–31
Khandker S, Koolwal G, Samad H (2010) Handbook on impact evaluation: quantitative methods and practices. World
Bank, Washington, DC
Little J (1971) Uncertainties in evaluating periodic motor vehicle inspection by death rates. Accid Anal Prev 2(4):301–313
Loeb P, Gilad B (1984) The efficacy and cost-effectiveness of vehicle inspection: a state specific analysis using time series
data. J Transport Econ Policy 18(2):145–164
Michon J (1989) Explanatory pitfalls and rule-based driver models. Accid Anal Prev 21(4):341–353
Miller D, Davis L (1982) Research report—Evaluation of Beltman traffic safety program for children. J Traffic Saf Educ
30(1):13–14
Näätänen R, Summala H (1974) A model for the role of motivational factors in drivers’ decision-making. Accid Anal Prev
6(3):243–261
National Center for Injury Prevention and Control (2013) Web-based injury statistics query and reporting system. http://
www.cdc.gov/ncipc​/wiqar​s
Noland R (2013) From theory to practice in road safety policy: understanding risk versus mobility. Res Transp Econ
43(1):71–84
O’Neill B (1977) A decision-theory model of danger compensation. Accid Anal Prev 9(3):157–165
Otero S (2013) Short-term effects of zero tolerance laws on drinking and driving in Chile. Pontifica Universidad Catolica
de Chile. Dissertation
Peden M, Scurfield R, Sleet D, Mohan D, Hyder AA, Jarawan E, Mathers C (eds) (2004) World report on road traffic injury
prevention. World Health Organization, Geneva
Peltzman S (1975) The effects of automobile safety regulation. J Political Econ 83(4):677–725
Peng Y, Vaidya N, Finne R, Reynolds J, Dumitru C, Njie G, Sleet DA (2017) Universal motorcycle helmet laws to reduce
injuries: a community guide systematic review. Am J Prev Med 52(6):820–832
Rau T, Otero S (2017) The effects of drinking and driving laws on car crashes, injuries and deaths: evidence from Chile.
Accid Anal Prev 106:262–274
Reason J (1990) Human error. Cambridge University Press, Cambridge
Retting R, Ferguson S, Farmer C (2007) Reducing red light running through longer yellow signal timing and red-light
camera enforcement: results of a field investigation. Insurance Institute for Highway Safety
Rothengatter T (1988) Risk and the absence of pleasure: a motivational approach to modelling road user behaviour.
Ergonomics 31(4):599–607
Schwebel D, McClure L, Severson J (2014a) Teaching children to cross streets safely: a randomized, controlled trial. Health
Psychol 33(7):628–638
Schwebel D, Barton BK, Shen J, Wells HL, Bogar A, Heath G, McCullogh D (2014b) Systematic review and meta-analysis of
behavioral interventions to improve child pedestrian safety. J Pediatr Psychol 39(8):826–845
Stocker E (2012) Latin America’s traffic turning deadlier as shoddy cars clog bad roads. The Guardian. 2012. https​://www.
thegu​ardia​n.com/globa​l-devel​opmen​t/2012/jul/24/latin​-ameri​ca-traff​i c-cars-roads​. Accessed 2 Aug 2018
Struik M, Alexander K, Cave T, Fleming A, Lyttle J, Stone A (1988) Pedestrian accident project report no 4: Literature review
of factors contributing to pedestrian accidents. Road Traffic Authority, Hawthorn, Australia
Summala H (1988) Risk control is not risk adjustment: the zero-risk theory of driver behaviour and its implications. Ergo‑
nomics 31(4):491–506
Taylor D (1964) Drivers’ galvanic skin response and the risk of accident. Ergonomics 7(4):439–451
Thomson J (2005) Child pedestrian accidents: what makes children vulnerable? In: Gillham B, Thompson J (eds) Child
safety: problem and prevention from pre-school to adolescence. Routledge, London
Tillmann W, Hobbs G (1949) The accident-prone automobile driver: a study of the psychiatric and social background. Am
J Psychiatry 106(5):321–331
Van Matre J, Overstree G Jr (1982) Motor vehicle inspection and accident mortality: a reexamination. J Risk Insurance
49(3):423–435
Wijnen W, Stipdonk H (2016) Social costs of road crashes: an international analysis. Accid Anal Prev 94:97–106
Wilde G (1982) The theory of risk homeostasis: implications for safety and health. Risk Anal 2(4):209–225
Wilde G, Robertson L, Pless I (2002) Does risk homoeostasis theory have implications for road safety? BMJ
324(7346):1149–1152
World Bank (2017) The high toll of traffic injuries: unacceptable and preventable. World Bank, Washington
World Health Organization (WHO) (2010). Global plan for the decade of action for road safety 2011–2020. World Health
Organization. http://www.who.int/roads​afety​/decad​e_of_actio​n/plan/en/. Accessed 2 Aug 2018
World Health Organization (WHO) (2013) Strengthening road safety legislation: a practice and resource manual for
countries. World Health Organization, Geneva
World Health Organization (WHO) (2015) Global status report on road safety 2013: supporting a decade of action. World
Health Organization, Geneva
World Health Organization (WHO) (2018) Road traffic injuries. https​://www.who.int/news-room/fact-sheet​s/detai​l/road-
traff​i c-injur​ies. Accessed 22 Aug 2019

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