Economic analyses of transport infrastructure and policies including health effects related to cycling and walking: A systematic review☆
Introduction
Physical activity is a fundamental means of improving physical and mental health. For too many people, however, it has been removed from everyday life, with dramatic effects for health and well-being (Cavill et al., 2006). Walking and cycling represent practical opportunities for people to integrate physical activity into everyday life, and are tangible and achievable alternatives to sport and exercise for which important positive health effects have been demonstrated (Andersen et al., 2000; Matthews et al., 2007; WHO, 2002). The promotion of cycling and walking has become an area of emerging interest and high relevance to the development of comprehensive health and environment policies, in particular those related to the implementation of sustainable transport policies. In recent years, support for policies promoting modal shifts towards cycling and walking has been advocated within a number of strategies for health and sustainable development (WHO Europe, 2005; WHO-UNECE, 2008; European Commission, 1999).
In 2006, the WHO Regional Office for Europe undertook a project on economic valuation of health effects from cycling and walking. This project built on previous initiatives including a workshop of the Nordic Council on “Cost–benefit Analysis of cycling” held in February 2005 in Stockholm1; discussions that were held in Switzerland in September 2005 on open questions related to economic valuation of transport-related physical activity; and extensive work by WHO and partners on cost-effectiveness, including the CHOICE project (Choosing Interventions that are Cost-Effective)2 and guidance on cost-effectiveness of environmental health interventions (WHO, 2000). This report pointed out that “there is a serious lack of cost-effectiveness studies for all types of environmental health interventions, and therefore decision makers have limited information on the relative cost-effectiveness of health interventions from which to make evidence-based decisions” (WHO, 2000, p. vi). This also applies to methods for including health impacts in economic assessments of transport projects. Economic assessments are a common part of the professional life of a wide range of professionals including transport planners and environmental managers, who see economic valuation (primarily cost–benefit analysis) as an essential pre-requisite to funding any new scheme, programme or policy. A new road will only be built if its projected benefits outweigh its costs. While the costs are relatively straightforward (tarmac, construction, maintenance, etc.) the benefits are very variable. Many different aspects such as environmental impacts, land use, congestion and time use are already well covered in most cost–benefit analysis studies of transport interventions. Yet too often these do not take account of the wide variety of benefits to health of new schemes, projects or policies.
In recent years, a few countries (e.g. the Nordic Council) have carried out pioneering work in trying to assess the overall costs and benefits of transport infrastructures taking health effects into account, and guidance for carrying out these assessments has been developed. However, important questions remain to be addressed regarding the type and extent of health benefits which can be attained through investments in policies and initiatives which promote more cycling and walking.
For example, people have differing views on the value of time, or the importance of issues such as journey ambience. In recent years this approach has begun to be applied to projects concerning cycling and walking, and this opens up many more new issues concerning what should be included in any analysis. If a new bike path is built, what should be counted? All cyclists? New cyclists? New cyclists cycling over a recommended minimum amount? And what health effects should be considered as a result of their cycling? Change in risk of chronic disease such as coronary heart disease or stroke? Improvements to mental health? Or even less tangible outcomes such as quality of life?
This issue is even more important when the results of early cost–benefit analyses of cycling and walking projects are considered. Consideration of the health impacts have, in many cases, resulted in relatively high benefit–cost ratios (BCRs) compared to traditional transport economic appraisals (Nordic Council, 2005). If these cannot be justified with transparent methods, they may arouse suspicion among supporters of motorised transport. This underlines the importance of developing a strong, agreed, evidence-based methodology to help the decision-making process (Grant-Muller et al., 2001).
The overall aim of this project was therefore to review recent approaches to cost–benefit analysis of transport-related physical activity. Based on the approaches developed to date, options for the further development of a more harmonized methodology were to be proposed as guidance for Member States on approaches to the inclusion of health effects through transport-related physical activity in economic analyses of transport infrastructure and policies. This paper reports on the first part of the project.
Section snippets
Study inclusion criteria
To be included in this review, the study had to:
- 1.
present the findings of an economic valuation of an aspect of transport infrastructure or policy;
- 2.
include data on walking and/or cycling in the valuation (including changes in modal share, distance walked, etc.);
- 3.
include health effects related to physical activity in the economic valuation;
- 4.
be in the public domain. This included government and other reports that were publicly available; reports on websites; as well as papers from peer reviewed
Quality of reviewed studies
Table 2 shows the quality assessment for each study. Three studies were classified as (2++) quality, i.e. as being of ‘high’ quality: Macdonald (2006); Rutter (2006); and Saelensminde (2004). These studies were very transparent in their methods, explained their calculations and assumptions, and included a wide variety of appropriate costs and benefits. The authors reported sensitivity analyses and included a thorough and clear discussion of the results.
There were six studies classified as (2+)
Discussion
This review has focused on the methodologies used for including the health impacts of physical activity in economic analyses of walking and cycling. First we will briefly consider the results of the studies, however, before going on to comment on the methods.
This review has shown that cost–benefit analyses of cycling and walking infrastructure generally produce positive benefit–cost ratios. Although these should be treated with caution due to the diverse methods used, it can be concluded that
Conclusion
To our knowledge, this is the first review conducted on this topic. The Nordic Council report brought a number of economic appraisals together but it did not objectively review the approaches. The Department for Transport in the UK is currently reviewing its ‘New Approach to Transport Appraisal’ including additional focus on health, but again this is not based on a systematic review of approaches to date.
This comprehensive review has demonstrated the need for a more harmonized approach to the
Acknowledgements
We would like to express our gratitude to the members of the advisory group who contributed to this project both through extensive comments and inputs throughout its development and/or participation in the international consensus workshop (14–15 May 2007, Graz, Austria).
This project has been supported by the Austrian Federal Ministry of Agriculture, Forestry, Environment and Water Management, Division V/5-Transport, Mobility, Human Settlement and Noise and the Swedish Expertise Fund and
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The views expressed in this paper are the authors’ and do not necessarily reflect those of the World Health Organization.