Interventions to Prevent Injuries and Reduce Environmental and Occupational Hazards: A Review of Economic Evaluations from Low- and Middle-Income Countries

Collectively, unintentional injuries and interpersonal violence accounted for at least 8 percent of deaths and 9 percent of disability-adjusted life years (DALYs) in low- and middle-income countries (LMICs) in 2012 (WHO 2016). Diseases related to air pollution and inadequate water and sanitation measures accounted for 15 percent of attributable deaths and 10 percent of attributable DALYs in LMICs in 2013 (IHME 2015). Millennium Development Goal 7 has inspired steady progress on water- and sanitation-related indicators, although many countries have not yet reached target levels of coverage (Luh and Bartram 2016) or the newer targets for Sustainable Development Goal 6 (UN 2016). Health losses from road traffic injuries (RTIs), interpersonal violence, and outdoor air pollution continue to rise (WHO 2016).A common feature of the seemingly disparate conditions covered in this volume is that they can be addressed largely through population-based policies and regulations using intersectoral approaches. For example, risks related to most types of injuries can be substantially reduced through educational programs and legal regulations (Ditsuwan and others 2013). The regulation of air pollution usually occurs within the purview of the public sector environmental agency, as does the provision of clean water and basic sanitation services that are then implemented by public works agencies (Pattanayak and others 2010). Reducing the health risks associated with these environmental hazards involves partnerships between ministries of health and ministries responsible for environment, transportation, and public works. As another example, reduction of occupational hazards is considered the responsibility of employers and employees alike, but it is often monitored and regulated by ministries responsible for labor.This chapter summarizes the evidence of the costs and benefits of interventions to prevent injuries and reduce occupational and environmental risks in LMICs. Although the interventions reviewed reflect a set of conditions and risk factors more narrow than those covered in this volume, they are the major drivers of disease burden in these cause and risk factor groups in LMICs. The overarching objective of this chapter is to summarize the evidence on value for money to reduce the burden of injuries and environmental and occupational risks in these settings. Evidence on the costs and cost-effectiveness of treating the medical consequences of injury, trauma, and environmental exposures can be found in other volumes of this series.Although externalities and their policy solutions, such as tradable emissions, that are associated with air and water pollution are critical for human health, this chapter does not review these economic issues as they relate to environmental health. Readers are referred to environmental economics textbooks and manuals for discussions of these issues (Maler and Vincent 2005). This chapter focuses exclusively on studies of costs and cost-effectiveness (including benefit-cost studies) that have been conducted in LMICs.The economic evidence is modest for injury and ambient environment interventions compared to other conditions, but important lessons can be learned about the types of interventions to receive the highest priority for public investment. Benefit-cost analysis (BCA) is the standard approach in environmental economics. Cost-effectiveness analysis (CEA) is typically applied to health sector interventions, but environmental and other intersectoral interventions—such as development and education—are more suited to BCA because many of the costs and benefits are likely to accrue outside the health sector, and many of these direct benefits can be more easily valued in monetary terms. For example, improved water reduces the risk of morbidity and mortality from diarrheal disease, but it also has many nonhealth benefits, such as its intrinsic value to the consumer and positive effect on tourism. Further, these benefits may even be worth more in monetary terms than the health benefits. This chapter presents CEA and BCA evidence side-by-side with some comments on differences in methods and results.