Resumen

HOLA

Muertes por accidente de tránsito en Ecuador son 20,4 muertes por cada 100.000 personas. Los hombres son los más afectados por los accidentes de tránsito: 4,2 veces más que las mujeres (33 vs. 7,8 muertes por 100.000 personas, respectivamente). Los accidentes de tráfico muestran una disminución: de 22 muertes por 100.000 personas en 2010 a 18 muertes por 100.000 personas en 2016. La estimación de DALY por el método de esperanza de vida utiliza ponderación de β=0.04, r=0.03, C=0,1658. El promedio de años de vida perdidos es 141.430 DALY o 897 DALY por 100.000 personas (95% CI 892-902). El costo de DALY , utilizando el enfoque del capital humano, es de US $ 806.8 millones equivalente al 0,89% del producto interno bruto ( PIB ), el 81% causado por la pérdida de hombres y el 19% por la pérdida de mujeres. Este porcentaje del PIB perdido por muertes es equivalente a como si cada individuo en Ecuador pagara US $ 358 al año. Las provincias de mayor población (Guayas, Pichincha, y Manabí) contribuyen con el 52% de la población total, el 67% de la cantidad de vehículos y el 49% del total de muertes por accidentes de tráfico. Sin embargo, si analizamos las muertes por número de personas y número de vehículos, estas provincias no son las más peligrosas para morir en un accidente de tráfico. Considerando la cantidad de muertes por cada 100.000 personas, las provincias más peligrosas son Sucumbíos (33,5), Cotopaxi (32,0), Orellana (31,2), juntas, constituyen solo el 5,9% de la población y el 3,8% del total de vehículos. Sin embargo, la tasa promedio de muertes en estas tres provincias es 1,58 veces el promedio nacional (20,4 por 100.000 personas). Teniendo en cuenta el número de muertes por cada 100,000 vehículos, las provin - cias más peligrosas son Napo (460), Imbabura (429) y Morona Santiago (400), en conjunto, constituyen solo el 4,5% de la población y el 1,9% del total de vehículos, la tasa promedio de muertes en estas tres provincias es 2,7 veces el promedio nacional (156 por 100.000 vehículos).

Introduction

Policy is an analytic category, the contents of which are identified by the analyst rather than by the policy-maker or pieces of legislation or administration (Heclo, 1972, p. 85), public policy is an intellectual creation whose content should be identified (Majone, 1997, p. 35), therefore, quantifying deaths and health loss from injuries by traffic accidents provides a tool for policymaking to regulate traffic to eliminate what kills and disables people. More than 1.3 million people die each year in road traffic accidents, making road traffic injuries the tenth leading cause of death in the world (WHO, 2016). The World Health Organization (WHO) estimated road traffic accidents as the ninth cause of death in the world in 2004 and projected as the third leading cause of death for 2030 (WHO, 2008a). These projections show the threat that traffic accidents will take as a cause of death.

In 2015, deaths for all causes were 769 deaths per 100,000 people; 8.7% of these deaths are caused by unintended injuries, 27% of unintended injuries correspond to traffic accident deaths. Overall, deaths by traffic accidents represent 2.4% of total deaths in the world.

Death rate per 100,000 people in the region (Americas) is lower than in the world (666 vs. 769), however, deaths caused by unintended injuries as percentage of total deaths is higher (9.7% vs. 8.7%) while the percentage of deaths caused by traffic accidents is lower than the world total (24 vs. 27%). In Ecuador, death rate of road injuries, as percentage of total deaths (4.0%), is higher than the one observed in the world (2.4%) and in the region (2.4%). Also, traffic accident deaths as percentage of unintended injuries (32%) are higher than the percentage observed in the world (27%) and in the region (24%) (WHO, 2016, 2017a).

Deaths by traffic accidents are seventh among the leading causes of death. However, if we rank the leading cause of deaths by sex, road traffic injuries are the second among men after heart diseases and before diabetes, and fiftieth among women (INEC, 2016). Traffic as a source of road fatalities, then, is a threat for premature death and disabilities which leads to the question of what are the consequences of it? What is the productivity costs of traffic accidents and how can they be measured? How big are the costs of deaths and injuries due to traffic accidents in Ecuador? These costs include the cost of years of life lost from premature death and years of life lived in state of less than optimal health. These estimates are necessary to have an idea of the magnitude of the problem, identify areas to allocate resources and design policies for prevention.

The aim of this work is to estimate the value of the productivity lost due to premature mortality and disability result of traffic accidents in Ecuador during the years 2010-2016, because of the concern about the high traffic accident rate (Tecniseguros, 2018) since the improvement of the roads in the country. Data is available until year 2016. The productivity loss is calculated for every death person regardless of age and sex, then the estimation is based on the potential contribution of every person given the national average productivity. Section two of the document presents the data and an analysis and description of the state of general deaths and traffic accidents deaths in Ecuador during the period of study. Section three presents the model to estimate the Disability-Adjusted Life Years (DALY). Section four presents the results of the study and finally, section five concludes.

Data

Ecuador is located in the northwest of South America and has a surface of 259,374 km and a population of 14.4 million people (INEC, 2010). Politically, is divided in 24 proviand a population of 14.4 million people (INEC, 2010). Politically, is divided in 24 provinces, from which, three provinces, Guayas (25.1%), Pichincha (18.0%) and Manabí (9.3%), concentrate more than half of the population and constitute 13.6% of the total country surface.

The evidences come from registers taken annually by de National Institute of Statistics and Censuses (INEC). The data are collected in death forms, which are designed and distributed by the INEC to the respective offices of Civil Registry, Identification and Certification, provincial Statistics Offices of the Ministry of Public Health and to public and private hospitals and clinics. The Civil Registry, Identification and Certification is the responsible for the registration and legalization of the vital fact. The statistics of this vital fact are data of the deceased: sex, date of birth and death, age at death, geographical place of death, place of occurrence of death, person certifying the death, marital status of the deceased; habitual residence of the deceased; area (urban, rural), literacy and instruction and ethnicity. Once the forms are filled out in the respective offices they are sent to the INEC, for processing and publishing (INEC, 2010).

For traffic accident deaths, the INEC uses data collected by de Transportation National Agency, institution in charge of the national transportation (ANT). The register of deaths due to traffic accidents are classified according to the International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) in the category of External causes of morbidity and mortality: v01-v89 (WHO, 2018).

Deaths by age show high mortality the first year of life, 1,117 deaths, decreasing persistently up to the age of 13 with 149 deaths, then it increases reaching 363 deaths per year at 20 years of age. From 20 to 40 years, number of deaths stabilizes around an average of 357 deaths per year. From 41 to 100 years, the death population shows a pattern of a J-shaped relationship of values across ages, reaching its peak at 84 years with 1,439 deaths (Graph 1a). Deaths by sex and age follow the same pattern, approximately, as the whole population deaths, except that man deaths are always higher than women’s up to 83 years old, from where women’s deaths are higher than men’s (Graph 1b).

Deaths in Ecuador

General deaths were relatively constant during 2010-2016: average number of deaths was 63,948 with little variation through the years (coefficient of variation 3.3%), which represent 0.41% of the population. The number of deaths by sex shows men’s deaths are higher than women’s (56% vs. 44%, respectively). However, mortality among women shows a growth rate higher than among men (2.25% vs. 1.18%, respectively) (Table 1).

Traffic accident deaths in Ecuador

Deaths in traffic accidents during the years 2010-2016 show a decrease through time: in 2010, deaths caused by traffic accidents represented 5.5% of total deaths or 22 deaths per 100,000 people, while in 2016 they were 4.5% of total deaths or 18 deaths per 100,000 people, this decline represents a 3.3% annual reduction of deaths per 100,000 people (Table 2).

Deaths caused by traffic accidents by age show a pattern of low frequency in young ages up to 21 years old, where the occurrence of deaths reaches its peak of 92 deaths (Graph 2a) from this age on, deaths decrease continuously to reduce to one death for ages older than 90. The number of deaths by decades of age show its peak at the age interval of 21-30 years old (26%), the 44% of total deaths happen to be younger than 30 years old. This pattern of deaths supports the structure of deaths, in 2010, general deaths, the second demographic group of people dying is 15-49 years old (21.5%) after persons older than 65 (54.3%) (Villacís & Carrillo, 2012). This framework of mortality is common to Latin American countries, where it is hypothesized that high mortality among young people, mainly men younger than 40 die due to the “masculinities of under-development”: studies show that in Latin America the health burden for men is 26% higher than it is for women (Baker, 1997; Cleaver, 2002, p. 3).

Men are the most affected by traffic accidents than women, 33.0 vs. 7.8 deaths per 100,000 people, respectively. This is 4.2 times higher for men than for women. Men´s deaths show a peak of occurrences at 20 years of age, 81 deaths per 100,000 people. From this age, deaths decrease sustainably up to one death per year for 100 people. The pattern of behavior shown by women is relatively flat (slope -0.0669 deaths per year of age) around an average of 7.8 deaths per 100,000 people (Graph 2b).

The average of road traffic fatalities is 20.4 deaths per 100,000 people, this frequency is more than twice the occurrence in Japan (8.4) and above the European Union (11) and United States (15.2) (WHO, 2004).

Graph 3 presents the five provinces with the highest and lowest death rates per 100,000 people for men (Graph 3a) and women (Graph 3b). The complete list of the provinces ranked by death rate due to traffic accidents is in Table A1.

Guayas, the province with the largest population, presents a death rate of 34.4 per 100,000 people for men which puts it in the position 10th. Pichincha and Manabí present death rates lower than the average. The death rates for women in Guayas and Manabí show lower than the average, while in Pichincha the death rate is higher than the average: position 11 with a death rate of 8.6 deaths per 100,000 people. This rate is above the national average, 7.8 deaths per 100,000 people (Graph 3b).

Vehicles and traffic accident deaths in Ecuador

In 2016, there were 2,056,213 vehicles, 67% of those are concentrated in three provinces (Pichincha 36%, Guayas 23% and Manabí 8%). The average number of persons per car is 7.7 while in Guayas is 8.2, Manabí 9.3 and Pichincha 3.9 persons per car.

The provinces with the largest population (Guayas, Pichincha, and Manabí) together contribute with the 52% to the total population, 67% to the number of vehicles and 49% of total deaths due to traffic accidents. However, when we analyze deaths per population and deaths per number of vehicles, the most populated provinces are not the most dangerous for dying in a traffic accident.

Table 3 presents the provinces with the highest number of deaths per number of people and number of deaths per number vehicles. It is shown that the most dangerous provinces considering number of deaths per 100,000 people, are Sucumbíos (33.5), Cotopaxi (32.0), Orellana (31.2), in that order. Together, they constitute just the 5.9% of the population and 3.8% of the total vehicles, however, the average rate of deaths of these three provinces is 1.58 times the national average: 32.2 vs. 20.4 deaths per 100,000 people.

In the same way, considering the number of deaths per 100,000 vehicles, Napo (460), Imbabura (429) and Morona Santiago (400) are the provinces where their traffic is the most dangerous in the country, their average of 429 deaths per 100,000 vehicles is 2.7 times the national average. Also, these provinces show a high number of people per vehicle, more than twice the average of vehicle occupancy, which in case of a traffic accident the consequences are in the same proportion, more than twice the victims. If we consider one traffic accident in Pichincha, in average yields 3.9 persons involved in that accident, while the same event in Imbabura would cause 5 times as much persons with a potential of death and injury.

The most dangerous provinces to die by traffic accidents coincide with provinces located in the Amazonia region: Morona Santiago, Napo, Orellana, Sucumbíos and two provinces in the Mountain region: Imbabura and Cotopaxi. These conditions of danger with respect to the frequency of deaths by traffic accidents can be related to certain structural characteristics of the country and of the provinces:

These features explain why in these provinces, the number of deaths due to traffic accidents are the highest, in spite of the low population and low number of cars; which means, the poorer the province the less value the life.

The model

We use the DALY to estimate the economic consequences of premature death and injuries caused by traffic accidents, it quantifies the burden of traffic accidents from mortality and disability. It is a measure of the health gap that combines life-time lost due to premature mortality and non-fatal conditions of traffic accidents.

Once we have the amount of lost years of healthy life (DALY), it is possible to estimate the economic cost for society setting that amount as an opportunity cost to society: the ideal health situation where the society lives an advanced age free of threat of dying and living without disabilities due to traffic accidents. In this way, the decision takers can estimate the gains of modifying the causes of this resource waste.

The DALY measures burden from traffic accidents as the sum of years of life lost (YLL) and the equivalent years of life lost from the disability (YLD) for people living with its consequences:

DALY = YLL + YLD

where:

N = number of deaths

L = standard life expectancy at age of death in years

I = number of disability cases

DW = disability weight

L = average duration of the disability until remission or death (years)

The model also applies several social value weights in the calculation: these includes time discounting and age weights. Detail on these features, following Murray (1996) and Devleesschauwer, Havelaar, Maertens, Haagsman, Praet (2014), is presented in .

Combining the social weighting functions: value of life and time discounting, we have years of life lost ():

,

where,

K = age - weighting modulation factor

C = constant: 0.1658

r = discount rate: 0.03

β = parameter from the age weighting function: 0.04

a = age of death

L = expectation of life at age a,

To estimate years lived with disability (YLD), we use the relationship of number of injured per number of deaths in a traffic accident. The number of injured for every death reported (non-fatal injuries/deaths) is estimated using reported injuries by traffic accidents.

The weighted average of number of injuries/deaths, by the country’s population density, gives = 36 (s = 43) injured for every death in a traffic accident. This average corresponds with the highest estimate reported by the WHO of 35.7 injured persons for every death (WHO, 2004, 2008a, 2009). Then, for every death in a traffic accident one can expect at least 36 victims due to non-fatal injuries.

Serious post-crash disabilities due to traffic accidents occur in about from 1% (Bull, 1985) to 87% (Ameratunga et al., 2004) of total casualties. Furthermore, the WHO (2011) reports that 2.6% of traffic accident victims suffer the consequences of a sever disability (WHO, 2011) and have to live the rest of their life with that disadvantage.

Then, for our purposes, for every death in a traffic accident there are 36 injured and from them, 2.6% suffer severe disabilities, thus, for every death, 0.936 persons survive with severe disabilities until death. That is to say that for every death person, at least one survivor to the accident live with a severe disability or for every 10 deaths 9 persons survive with severe disability.

Results

We estimated DALY for the years 2010-2016 using the life expectancy for Ecuador (WHO, 2017b); for YLL () C = 0.1658, discount rate r = 0.03 and age weighting β = 0.04 and for YLD, we assume that for every death, there are 0.936 non-fatal injured who must live with a disability from the date of the accident to death. Using these assumptions and based on individual characteristics at the time of death including age and sex, Table 4 presents the DALY with age weighting and discount rate 0.03 estimates.

Traffic fatalities caused 141,430 DALY or 897 DALY per 100,000 people with a 95% confidence interval goes from 892 to 902 DALY per 100,000 people (Kleinman, 1977).

Since there is no consensus of whether or not to apply age weighting and time discounting, we estimate DALY without age weighting and without time discount [DALY (0, 0)], we get 740 DALY per 100.000 people: which means that giving importance to the productivity variation of the individual and accounting for time discounting the consequences of traffic fatalities are costlier and should be taking into account.

These figures are comparable with the occurrence in Thailand 893 DALY per 100,000 persons, (Bundhamchareon et al., 2002). Table 5 shows DALY outcomes for some other countries.

Since one DALY equals one lost year of healthy life, each DALY is used to measure total burden of traffic accidents, both from years of life lost and years lived with a disability. Assuming that every DALY costs to society the average production of the country and since the average GDPper capita of the period is US$ 5,705, we have that the national economic costs of road traffic is US$ 806.84 million or 0.89% ofGDP per year, 81% caused by males and 19% due to females.

Road crash costs, expressed as a percentage of GNP, range from 0.3% in Vietnam to 4.6% in USA. Overall, in most countries, costs exceed 1% of GNP (Jacobs, Thomas, & Astrop, 2000, p. 11). Sven-Ake Blomberg (1999) reported for Brazil 0.5% ofGDP, Korea 8.1%, New Zealand 4.2%, among others.

In terms of cost per capita to society, considering the average GDP (US$ 90,217 million) and average population (15.8 million inhabitants) during the 2010-2016 period, the cost of DALY due to traffic accidents would be US$ 358 per capita. This amount is equivalent as if each inhabitant in Ecuador would be paying one minimum salary per year. The minimum salary fixed annually by the government was US$ 354 in 2015 (MT, 2015).

Conclusions

Considering the period of study, 2010-2016, traffic accidents cause, 3,201 deaths per year equivalent to 5% of total deaths (deaths by traffic accidents represent 2.4% of total deaths in the world) and an estimated of 2,996 persons with non-fatal injured who have to live with a disability from the date of the accident to death, they are the sixth cause of death (worldwide, it is third cause). Men are the most affected by traffic accidents than women, 33.0 vs. 7.8 deaths per 100,000 people, respectively. This is 4.2 times higher for men than for women.

Road traffic fatalities are more than twice the occurrence in Japan and above the European Union and United States, 44% of total deaths occurs among younger than 30 years old. These traffic fatalities in Ecuador caused 141,430 DALY or 897 DALY per 100,000 people, figures comparable with the occurrence in Thailand and lower than those in Serbia and above the Netherlands.

The DALYcost to society is 0.89% of GDP per year, 81% caused by males and 19% by females. The loss of productivity is equivalent to as if each inhabitant in Ecuador had to pay annually the equivalent of a minimum salary. This loss of productivity may be considered to support decision makers in allocating resources among competing priorities.

The most populated provinces are not the most dangerous for dying in a traffic accident. Sucumbíos, Cotopaxi and Orellana provinces are the most dangerous provinces: the average rate of deaths of these three provinces is 1.58 times the national average. They represent just the 5.9% of the population and 3.8% of the total vehicles.

Considering the number of deaths, Napo, Imbabura and Morona Santiago are the most dangerous provinces: the average rate of deaths of these three provinces is almost three times the national average. They constitute just the 4.5% of the population and 1.9% of the total vehicles.

Some features that are common to the most dangerous provinces to die by a traffic accident are located in the Amazonia area (Sucumbíos, Orellana, Napo and Morona Santiago) and two in the central region (Imbabura and Cotopaxi). These provinces, besides the loss of productivity due to the high number of fatalities caused by traffic accidents, show other characteristics that could explain the high rates of traffic fatalities:

These hypotheses need to be addressed in future studies to identify how to organize society with respect to traffic behavior and review public policy aiming to improve society quality of life. Additionally, in 2015, there were 3,065 traffic accidents caused by driver´s inexperience (47%), no observance of road signs, speeding, alcohol (44%), pedestrians (5%), bad roads, weather conditions, car failure (5%) (INEC, 2015). These tragedies are consequences of perverse incentives of the law: price regulation which causes competition to get more passengers per trip and not by service quality, this situation makes transportation vehicles speeding to win passengers and make happen the traffic accidents with all their consequences. The main cause of traffic accidents (47% of total traffic accidents) is the driver´s inexperience, drivers are issued driver´s licenses without enough training and some of them have failed exams (Vivanco, 2018).

The public transportation market consists of 428 cooperatives with 11 thousand buses carrying 130 million passengers with total sales of $720 million annually, it represents around 1% of the gross domestic product (GDP) (Rivera, 2018). It would be an attractive market for companies that offer better service with technology and innovation. The government part would be freeing prices to promote market competition based on differentiated service. The opportunity cost of traffic accidents (DALY = 0.89% GDP) could be allocated to finance public policies of prevention, better roads, programs of driver´s training and society awareness.

During 2010-2016, average assignment to community services was 0.48% of GDP, culture and recreation 0.26% GDP, environment protection 0,16% GDP (CEPAL, 2017). Together these three sectors of social investment add up to 0.9%GDP comparable to the loss due to traffic accidents, then reducing loses in this part of the economy could reinforce activities in these sectors of social investment to minimize deaths and its economic consequences confronted in the country roads.

In 2015, Ecuador is ranked 79 among 230 countries with 19,6 deaths per 100.000 people due to traffic accidents (WB, 2018), it has less traffic accident deaths than Venezuela (41.7), Brazil (22.6), Paraguay (23.4) and Bolivia (23.3) and is fifth in South America. The average for Latin America and the Caribe is 19,54 deaths per 100.000 people. These figures could indicate that to traffic accident records are relatively according to the region records and it is possible to have a real picture of the problem since, in Ecuador, traffic accidents are recorded by the Transit National Agency (ANT) in charge of enforcing the national policy of transportation, INEC is the statistics and censuses institution that systematize the information and its source of traffic accidents and deaths is the ANT. Any difference in cost estimation of deaths would be because of differences in structural condition of the economic circumstances of a specific country.

DALY calculation is restricted to the estimation of years of life lost from the disability (YLD) to the survivors of a traffic accident. Further research is needed to measure DALY of disabilities to make a better estimation of the cost of this threat on the roads. As a final thought, it is advisable to consider integrating road safety in areas of health promotion and prevention of damage, consider epidemiological surveillance system for damages caused by traffic accidents to society: roads, vehicles, people. Access to hospital and emergency care must be improved. Public policies need to integrate health and safety in transport, promote greater attention to road safety considering its effects on health and its costs and convert scientific information into policies.

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