International Journal of Injury Control and Safety

Promotion

ISSN: 1745-7300 (Print) 1745-7319 (Online) Journal homepage: https://www.tandfonline.com/loi/nics20

Burden, pattern and causes of road traffic

accidents in Bhutan, 2013–2014: a police record
review

Chador Wangdi, Mongal Singh Gurung, Tashi Duba, Ewan Wilkinson, Zaw
Myo Tun & Jaya Prasad Tripathy

To cite this article: Chador Wangdi, Mongal Singh Gurung, Tashi Duba, Ewan Wilkinson, Zaw
Myo Tun & Jaya Prasad Tripathy (2018) Burden, pattern and causes of road traffic accidents in
Bhutan, 2013–2014: a police record review, International Journal of Injury Control and Safety
Promotion, 25:1, 65-69, DOI: 10.1080/17457300.2017.1341930

To link to this article: https://doi.org/10.1080/17457300.2017.1341930

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INTERNATIONAL JOURNAL OF INJURY CONTROL AND SAFETY PROMOTION, 2018
VOL. 25, NO. 1, 65–69
https://doi.org/10.1080/17457300.2017.1341930

Burden, pattern and causes of road traffic accidents in Bhutan, 2013–2014: a police
record review
Chador Wangdia, Mongal Singh Gurung a
, Tashi Dubaa, Ewan Wilkinsonb, Zaw Myo Tunc and Jaya Prasad Tripathyd
a
Department of Public Health, Ministry of Health, Thimphu, Bhutan; bInstitute of Medicine, University of Chester, Chester, UK; cSaw Swee Hock School
of Public Health, National University of Singapore, Singapore; dThe Union South East Asia Office, International Union Against Tuberculosis and Lung
Disease, New Delhi, India

ABSTRACT ARTICLE HISTORY

Road traffic accidents (RTAs) are a major cause of death and injury globally. There was little information on Received 16 March 2016
the burden and causes of RTAs in Bhutan. The study estimates the burden and characteristics of RTAs and Accepted 6 May 2017
describes the victims of RTAs in Bhutan. A descriptive cross-sectional study conducted analysing police KEYWORDS
case records. In 2013–2014, 1866 accidents resulted in 1143 injuries and 157 deaths. We identified 39% Mortality; economic cost;
more deaths from RTAs than that submitted to WHO in 2013 as the 30-day mortality. The main causes surveillance; operational
were careless driving and drunk-driving. Drivers and passengers constituted 86% of the deaths with few research; SORT IT; road traffic
pedestrian deaths. Data for in-hospital deaths or after discharge were not available. Productivity loss due accident; Bhutan
to RTA is around 1% of national GDP. There is significant mortality and morbidity from RTAs in Bhutan.
There is no coordinated system for data collection and surveillance to monitor SDG goal 3.6.

Background demographic characteristics of people who were injured or

Road Traffic Accidents (RTAs) are a major cause of death and
injury and an increasing public health problem globally, caus-
ing more than 1.2 million deaths annually. (World Health
Organization, 2015a). The magnitude of the problem has been
recognized by declaration of the Decade of Action for Road
Safety 2011–2020 by the UN General Assembly (United
Nations Road Safety Collaboration, 2015).
There is some evidence that the numbers of RTAs are pla-
teauing, but this is more visible in high-income countries than
in low and middle income countries (LMICs). The greatest toll
is in the LMICs, with 90% of global road traffic deaths (Hyder
et al., 2012; World Health Organization, 2015a). RTAs most
commonly affect the economically productive age group and is
the leading cause of death among young people aged between
15 and 29 years. In economic terms, RTAs cost more than 3%
of the gross national product globally and up to 5% in LMICs,
which is more than the developmental aid grants received from
all donor countries (World Health Organization, 2015a).
There is now a target in the Sustainable Development Goals
(SDGs) to halve the number of deaths and injuries due to
RTAs by 2020 compared to 2015 (World Health Organization,
2015b). This means, it is essential to have accurate and reliable
information on deaths and injuries due to RTAs to monitor
this target. However, there has been no systematic attempt to
study the burden and causes of RTAs in Bhutan.
Therefore, we planned a nationwide cross-sectional study in
Bhutan to (i) assess the burden of RTAs in terms of injuries,
deaths and estimated lost output as a result of deaths, (ii)
explore the pattern and causes of RTAs and (iii) describe the
died in RTAs during 2013–2014.
Methods
Study design
A descriptive cross-sectional study of RTAs in Bhutan.
General setting
Bhutan is a landlocked country in the heart of the Himalayas
with a population of 745,153 (National Statistics Bureau,
2015). It lies in the young Himalayan Mountains with one set-
tlement separated from other by rugged mountainous terrain.
The country is administratively divided into 20 districts and
205 blocks. The larger centres of population are in Thimphu
and Chukha districts with a population of 124,397 and 88,968,
respectively, while the rest live in small settlements distributed
across the other 18 districts. The per capita Gross Domestic
Product (GDP) of Bhutan is USD 2611.74 with a poverty rate
of 12.0% and a general literacy rate of 63.0% (National Statis-
tics Bureau, 2015).
Study setting
There are 20 districts in Bhutan. In each district, the police
department records every reported RTA and prepares a case
sheet for each, using a semi-structured reporting format. The
case sheet captures information on the socio-demographic
details of those who were injured or died in an RTA, cause of

CONTACT Chador Wangdi chador@health.gov.bt

© 2017 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (http://creativecommons.org/licenses/by-nc-nd/4.0/),
which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way.
66 C. WANGDI ET AL.
the accident and other details of the event. The records from
each police station are sent monthly electronically to the
Crime Section, Police Head Office in Thimphu, the national
capital.
Study population
Police records of all RTAs reported in Bhutan during the
period 2013–2014 were collected for this study.
Operational definitions
In this study, death and injury refers to the status of the RTA
victim as reported in the police records. The causes of RTAs
from police records were categorized into four groups: human
factors, environmental factors, mechanical factors and others.
Variables and data sources
The records of all RTAs in Bhutan during the period of 2013
and 2014 were obtained from the Crime Section, Police Head
Office at the national capital of Thimphu. These records had
information on variables such as: age and sex of the victims
who were injured or who died due to RTA, the main factor
thought to have caused the RTA (human, mechanical, environ-
mental/road conditions), type of vehicle involved, victim’s road
user status (driver, passenger, pedestrian, motorcyclist, etc.).
The number of registered vehicles in 2013 and 2014 was col-
lected from the Road Safety and Transport Authority (Source:
Road Safety and Transport Authority). Other aggregate data
for Bhutan such as the GDP per capita, life expectancy and
annual GDP growth were obtained from the National Statisti-
cal Bureau, Bhutan (National Statistics Bureau, 2015).
Discount rate: discounting in economic evaluation implies
that costs and benefits occurring at different points in time are
valued differently. In general, individuals prefer to experience a
good (e.g. health care) or consume a product now relative to
doing so in the future. The strength of this preference is
expressed by the discount rate. Once costs have been valued,
they should be adjusted for differences in timing by discount-
ing future costs to a present value (Van Hout, 1998).
Data analysis
Anonymized data were entered into an electronic data form in
EpiData entry version 3.1 and analyzed in EpiData analysis
version v2.2.2.183. Data were double entered and validated
using EpiData entry software. The number and rate of RTA
and RTA-related deaths and injuries were calculated per
100,000 population and per 10,000 vehicles to provide data for
international comparisons. The causes and characteristics of
RTAs were summarized, and age and sex distribution of those
injured and died presented. Lost output was calculated using
number of life years lost from the age of the victim’s death
against the retirement age, and then converted into economic
terms using GDP per capita of the country. A discount rate of
5% and annual GDP growth of 7.7% (average of last 10 years)
were used (Annual GDP Growth, 2014). The method of esti-
mating the lost output was based on the method by Rezaei and
colleagues (Rezaei, Arab, Matin, & Sari, 2014; Silcock, 2003).
Table 1. Number and rate of road traffic accidents, injuries and deaths in Bhutan,
2013–2014.
Characteristics 2013 2014
Number of RTAs 1062 804
Number of injuries 541 602
Number of deaths 82 75
Death rate/100,000 population 11.2 10.5
Injury incidence rate/100,000 population 73.8 80.8
Death rate/10,000 vehicles 12.1 10.9
Injury incidence rate/10,000 vehicles 79.6 87.6
Ethical approval
Administrative approval was obtained from the Ministry of
Health, Bhutan to conduct the study. Ethical approval was
obtained from the Research Ethics Board for Health (REBH),
Ministry of Health, Bhutan and The Union Ethics Advisory
Group, Paris, France. Consent for the study was waived as it
was based on analysis of secondary data.
Results
Between January 2013 and December 2014, there were 1866
RTAs with a total of 157 deaths and 1143 injuries. The number
and rate of injuries and deaths in each year are shown in
Table 1. There was a lower incidence of RTA and fatality in
2014 compared to 2013 while the number of injuries increased.
There were 68,744 vehicles registered as of December 2014 (94
per 1000 population), of which 89% were registered in Thim-
phu and Chukha districts where 85% of the RTAs occurred.
Causes of RTA
Human factors was the commonest cause (87%) followed by
environmental factors and road conditions (6%), mechanical
factors (4%) and others (3%). Of the human factors, ‘careless’
and ‘reckless driving’ was the major cause (781, 42%) followed
by drunk-driving (301, 16.1%), not giving the right way (240,
13.0%) and over speeding (156, 8.4%).
Type of accident
Out of the total of 1866 accident cases recorded in 2013 and
2014, 769 (41%) involved collision of two vehicles followed by
561 (30.1%) from collision with stationery object, 237 (19.7%)
from going off the road, 150 (8.0%) from knocking down the
pedestrian and 19 (1.0%) from others such as hitting animals.
Characteristic of people killed and injured in RTAs
There were 125 (80%) males and 28 (18%) females killed and
759 (66%) males and 307 (27%) females injured. People aged
25–44 years were most likely to be killed or injured (Table 2).
Similar numbers of drivers and passengers were reported
killed, which is three times the number of pedestrians and only
two cyclists/motorcyclists were killed (Figure 1).
 INTERNATIONAL JOURNAL OF INJURY CONTROL AND SAFETY PROMOTION 67

Table 2. Age and gender distribution of injuries and deaths due to road traffic headquarters, which should be more accurate than other sour-
accidents in Bhutan, 2013–2014. ces. Second, Strengthening the Reporting of Observational
Characteristics Death, n (%) N = 157 Injury, n (%) N = 1143 Studies in Epidemiology (STROBE) guidelines were followed
Age to report the findings of this study (von Elm et al., 2007).
0–14 years 25 (16) 163 (14)
15–24 years 21 (14) 262 (23) Third, data were double entered directly from original police
25–44 years 76 (48) 444 (39) records and validated to ensure data quality and to avoid tran-
45–64 years 29 (18) 122 (11) scription errors.
65 and above 5 (3) 21 (2)
Missing values 1 (1) 131 (11) There were some limitations in this study. (1) It used retro-
Gender spective data which may be inaccurate or incomplete. It is
Male 125(80) 759(66) believed that the police records obtained were complete for the
Female 28(18) 307(27)
Missing values 4(2) 77(7) RTAs reported. However, under-reporting is a major issue
with both fatal and non-fatal RTAs (Dandona, Kumar, Ameer,
Reddy, & Dandona, 2008; Periyasamy, Lynch, Dharmaratne,
Nugegoda, & Ostbye, 2013). (2) The international definition of
death due to RTA is ‘death within 30 days of an RTA’ (Peden
et al., 2004). Our data only included the deaths known to the
police. It is not known how many died on the way to hospital
when not accompanied by police, and within 30 days either in
hospital or after discharge, as there was no way of collecting
this data with the available resources. (3) The loss of output
due to RTA fatalities was estimated to be about 1% of the coun-
try’s GDP. This is a low percentage compared to estimates for
the cost due to RTAs from other countries which are up to 5%
in LMICs (World Health Organization, 2015a). This is due to a
number of factors including the total number of deaths within
30 days of an RTA is not known; it does not include the lost
output of those who were injured or disabled. No data were
available on the cost of damage to vehicle, medical costs, out-
Figure 1. Deaths and injuries from road traffic accidents by road user status, Bhu- put loss of family members becoming carers and other intangi-
tan, 2013–2014.
ble costs. It does not include the potentially disastrous impact
of losing the main wage earner in a family.
Economic and productive life years lost from mortality Despite the above-mentioned limitations, the reported
number of deaths in this study in 2013 was higher than those
The mean age at death due to road traffic injury is 29 years. reported for Bhutan in 2013 to the WHO (World Health Orga-
Average age of retirement in Bhutan is 59 years. Therefore, the nization, 2015a). Our data are likely to be more reliable because
average working years lost from RTA is 30 years.This does not it was collected directly from the individual case reports
take account of the fact that not everyone has a pension and obtained from the Police Head Office (Crime Section).
may continue to work beyond 59 years. Considering the GDP The pedestrian death rate in Bhutan is remarkably low com-
per capita of Bhutan to be USD 2380.9, a discount rate of 5% pared to other South-East Asia region (SEAR) countries. There
and the annual GDP growth of 7.7% (average of the last 10 are a few possible explanations for this. Bhutan has relatively
years), the estimated lost output from road traffic mortality per fewer registered vehicles per 1000 population (94), as com-
year is 16.8 million USD which is approximately 1.0% of the pared to the South-East Asia region (SEAR) (125 registered
GDP of the country. vehicles per 1000 population) with the highest being in Thai-
land (412/1000 population) (World Health Organization
Regional Office for South-East Asia, 2013). Bhutan is a tiny
Discussion
Himalayan country in which a large majority of the population
This is the first study in Bhutan looking at the burden of RTAs lives more than two hours walk from the nearest major road
in terms of deaths, injuries and lost output. In light of the new (Keith Lane Driving in Bhutan, 2009). With poor road net-
SDG for reducing deaths from RTAs, the fact that we found working and difficult geographical terrain, The environment is
more deaths from RTAs than had been reported to WHO as not conducive for walking on roads. Thus, people prefer using
deaths within 30 days of an RTA is of concern, as it means public transport or personal two/four-wheelers. This might
there is no effective surveillance system in place. Males and explain low pedestrian deaths and also high fatality rates due
those aged 25–44 were most likely to be injured or killed. Reck- to acccidents involving four wheelers and other heavy vehicles.
less or careless driving and drunk-driving were the most com- However, there is a different school of thought which points
mon causes of accidents. Drivers and passengers rather than at under-reporting of deaths due to RTAs, especially those
pedestrians and motorcyclists were more likely to be killed or involving pedestrians. WHO’s 2015 Global Status Report on
injured. Road Safety reports that only 13% of traffic deaths in the
There were three major strengths in this study. First, it used South-East Asia region are pedestrians and goes on to say that
two-year nationwide data obtained from the police these rates are relatively low in the South-East Asia Region,
68 C. WANGDI ET AL.
particularly considering the pedestrian crowd and the level of
safety measures in place to protect different road users (World
Health Organization, 2015a). This can be reasoned by the fact
that several studies in India and other SEAR countries have
reported gross underestimations in officially reported statistics
about road traffic deaths due to pedestrians and motorized
two-wheeler riders. (Bhalla et al., 2017; Hsiao et al., 2013;
Raban, Dandona, & Dandona, 2014). This might also partly
explain fewer pedestrian deaths and deaths of motorcyclists/
cyclists reported in this study. The preponderance of younger
males dying or being injured is similar to findings reported
elsewhere in other LMICs in this part of the world (Dandona,
Kumar, Ameer, Ahmed, & Dandona, 2008; Ditsuwan, Veer-
man, Barendregt, Bertram, & Vos, 2011; Hsiao et al., 2013;
Mishra, Sinha, Sukhla, & Sinha, 2010). Drivers and passengers
constituted 72% of deaths. This is unusual, as globally almost
half of all deaths on the roads are among those with the least
protection – pedestrians, motorcyclists and cyclists – and
hardly any other country has such a low percentage of pedes-
trian deaths (Dandona et al., 2008; Ditsuwan et al., 2011; Hsiao
et al., 2013; Mishra et al., 2010). The reason for this is not
known and warrants further exploration.
Death rate (11.2/100,000 population in 2013) is lower than
most countries in the SEAR region (overall 18.5 per 100,000
population) such as Nepal, Sri Lanka, Thailand, Timor Leste
and India except Maldives (World Health Organization, 2015a;
World Health Organization Regional Office for South-East
Asia, 2013). However, the missing 30-day mortality data and
under-reporting means a direct comparison is not valid.
The findings of this study have key practical implications. In
order to implement the SDG 3.6 ‘to halve the deaths and inju-
ries from RTAs by 2020’ from 2015 (World Health Organiza-
tion, 2015b), it is essential to have accurate data on the number
of RTAs, injuries and 30-day mortality due to RTAs for 2015
and every succeeding year up to 2020. This will require a coor-
dinated approach by the police department, Road Safety and
Transport Authority and the Health Department to bring
together all the required data in a robust process to establish a
surveillance system. The current system of death certification is
not thought to be comprehensive enough to be reliable.
Much is known about the causes of RTAs and the ways to
reduce the impact, which these results confirm. The fact that the
majority of deaths occur in drivers and passengers demonstrates
the importance of systematic enforcement of seat belt legislation.
As in most parts of the world (World Health Organization,
2015a), the majority of RTAs are due to driver negligence or
drunk-driving. This needs to be addressed by better enforcement
of existing traffic legislation and improved driver training.
Conclusion
This study demonstrates that there is a significant mortality
and morbidity from RTAs in Bhutan and that at present there
is no systematic way of collecting the data required to address
the SDG target 3.6 to reduce the morbidity and mortality of
RTA. This has resulted in inconsistent data being submitted to
WHO for the number of deaths within 30 days of an RTA
(World Health Organization, 2015a). A robust RTA surveil-
lance system needs to be established.
Acknowledgments
This research was conducted through the Structured Operational Research
and Training Initiative (SORT IT), a global partnership led by the Special
Programme for Research and Training in Tropical Diseases at the World
Health Organization (WHO/TDR). The model is based on a course devel-
oped jointly by the International Union Against Tuberculosis and Lung
Disease (The Union) and Medecins sans Frontieres. The specific SORT IT
programme which resulted in this publication was jointly developed and
implemented by: The Union South-East Asia Regional Office, New Delhi,
India; the Centre for Operational Research, The Union, Paris, France; the
Operational Research Unit (LUXOR), Medecins Sans Frontieres, Brussels
Operational Center, Luxembourg; School of Public Health, Post Graduate
Institute of Medical Education and Research, Chandigarh, India; and the
Department of Preventive and Social Medicine, Jawaharlal Institute of
Postgraduate Medical Education & Research, Puducherry, India.
Disclosure statement
No potential conflict of interest was reported by the authors.
Funding
The programme was funded by the Department for International Devel-
opment (DFID), UK. The funders had no role in study design, data collec-
tion and analysis, decision to publish or preparation of the manuscript.
ORCID
Mongal Singh Gurung http://orcid.org/0000-0001-6481-6242
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