The rising toll of motorcycle deaths in low- and middle-income countries is part of a global trend. Road traffic death from all vehicles causes an increasing proportion of all deaths within the global burden of disease. Road traffic injuries kill 1.24 million people every year—twice the number of deaths caused by malaria.^source

Vietnamese motorcyclists have felt this impact in a big way. In 2007, traffic accidents killed around 14,000 Vietnamese, of which 60 percent were motorcycle riders, and caused over 30,000 head and severe brain injuries.^sourceThe toll of motorcycle injuries was emotional as well as economic. As early as 2003, road accidents cost Vietnam at least US$900 million each year, equal to 2.7 percent of the country's gross domestic product.^source

Despite their risks, motorcycles had become ubiquitous in Vietnam as the economy took off and the pace of life sped up. From the early 1990s to the early 2000s, the number of motorcycles on the road steadily climbed. The recorded number quadrupled in just five years, from 5 million in 2002 to over 20 million by 2007—one for very four Vietnamese people.^source

During a motorcycle accident, high-quality helmets can reduce the risk of death by 40 percent and the risk of serious injury by over 70 percent. And mandatory helmet can persuade riders to wear helmets and thus reduce the frequency and severity of head injuries.^source Yet in the early 2000s, despite Vietnam's efforts to require helmet use, less than one-third of motorcyclists were donning helmets.^source With so many drivers and passengers on Vietnam's crowded streets, the country  had a sky-high traffic fatality rate.^source

The Vietnamese government had begun to take on motorcycle safety as early as the mid-1990s. However, the mandatory helmet use law encountered major implementation and enforcement barriers, such as imposing only a minor fine for noncompliance.^source And the toll of motorcycle-related deaths continued to grow, reaching an all-time high in 2002. Then, new leadership in the government's National Traffic Safety Committee (NTSC) and other factors created a window for action. Bui Huynh Long, the incoming director of the NTSC, had come from the Ministry of Transport, where he had a track record of supporting helmet legislation.^source His committed leadership gave international supporters in the Global Road Safety Partnership a solid government partner for collaboration.^source

Long's arrival at the NTSC coincided with helmet initiatives from several international partners. Among them was the Hanoi-based Asia Injury Prevention (AIP) Foundation, founded by Greig Craft. Craft suspected that a law would only change behavior if people had helmets they were willing to wear. This led the AIP Foundation to open a factory in 2002 in Hanoi, which produced roughly half a million high-quality helmets for use in tropical settings in its first dozen years of operation.^source

In 2007, Vietnam’s Prime Minister Nguyen Tan Dung helped introduced a new compulsory helmet law, "Resolution 32," which made helmet use mandatory in Vietnam for all motorcycle drivers and passengers on all roads. Unlike previous reforms, the new law was supported by the Communist Party. Provincial  party chairs got involved by heading local NTSC chapters, and they became responsible to the government and party leadership for traffic accidents in their localities.^source Party leaders and other government workers also signed commitments to wear helmets.

Three months before Resolution 32 came into effect, the government required all its employees to don a helmet. Following this strong lead in, the law went into full effect nationwide. The inaugural “Helmet Day” was held on December 15, 2007.^source

Helmet Day signaled the launch of the comprehensive helmet law: all riders and passengers needed to wear helmets on all roads—no exceptions.^source But the strong legislation needed more than a flashy kickoff to improve health. Ongoing enforcement, penalties, adjustments, communications, and measurement were paramount to its successful implementation.

The law gave riders an incentive to comply: a substantial fine, equaling more than 10 times previous penalties. If caught without a helmet, motorcyclists had to pay VND10,000–VND200,000 (US$6–12), one-third of the average monthly income.^source This was more than the price of some helmets, making it more economical to buy a helmet than go without. ^source The traffic police were responsible for catching offenders and received training to do so effectively. In the year after the new law took force, police ticketed nearly 680,000 riders for failure to comply.^source

A hard-hitting, award-winning public education campaign complemented the legislation.^source The campaign used concerts, billboards, and television commercials to educate people about the benefits of helmets and the penalties for noncompliance. It also addressed the reasons people gave for non-compliance, such as “it ruins my hair” and “it will look awful with my trendy clothes.”^source

Still, the Vietnam government faced several challenges to enforcing mandatory helmet use. First, the motorcycle helmet market expanded massively as demand grew, but quality did not follow suit. Young people were soon seen wearing trendy, yet flimsy helmets with cartoon and sports logos.^source Second, riders found new loopholes to exploit. For example, riders would wear a helmet but leave the chin strap unhooked.^source Finally, the new law did not cover children under age 16. 

In some instances, the government overcame these hurdles. In response to people not wearing the strap of their helmets, the government created a new policy that made the penalty for doing so equal to that of riding without a helmet. The government also expanded the law’s protection to cover children ages six and older. But not all of the government’s policy amendments have had the desired impact. While it strengthened standards to regulate the helmet market, less than 20 percent of helmets passed safety tests in 2011.^source

Observational studies confirm that widespread behavior change followed the launch of Resolution 32. In the first days following Helmet Day, police and volunteers monitored compliance on street corners. Starting in 2007, researchers from the Hanoi School of Public Health and the World Health Organization (WHO) collaborated to track helmet use before and after the law. They observed more than 500,000 motorcycle riders and passengers in 45 randomly selected sites in three provinces. Before Helmet Day, 40 percent of riders wore helmets. By early 2011, 93 percent were wearing helmets.^source

The Ministry of Health also established a hospital-based surveillance system to track road traffic injuries and deaths. From a sample of 20 hospitals, researchers from the Ministry and WHO saw a 16 percent reduction in road traffic head injuries and 18 percent reduction of road traffic deaths in the three months after the law was enacted.^source Unfortunately, several hospitals stopped participating in the surveillance system over time, limiting analysis of the law’s long-term impact.^source According to ongoing surveillance at one of Vietnam’s large surgical centers in Hanoi, there were nearly 8 percent fewer head injuries among traffic accident patients in 2010 than before the law—a statistically significant difference.^source

Hospital costs to treat brain injuries, such as those caused during motorcycle accidents, can be expensive.^source One study found that the average medical costs in Vietnam for a person suffering from a severe head trauma came to US$2,370, which exceeded the national GDP per capita of US$1,910 in 2013.^source Treatment for catastrophic conditions can impoverish entire families and thus magnify the economic effects of a crash.^source As many as 70 percent of traffic accidents victims lose income, and two-thirds of them must take on debt to compensate.^source

A global study found significant evidence that mandatory helmet laws, combined with enforcement, can greatly reduce the burden of traffic injuries on families, the health system, and the economy. They concluded  that legislation is among the most cost-effective interventions available.^source

Researchers for Millions Saved estimate that the law averted 90,582 DALYs from prevented deaths and nonfatal injuries.^source Taking into account the cost of helmets and additional police officers to enforce the law, the calculation for a cost-effectiveness ratio yielded US$1,249 per DALY averted. This ratio falls above the range reported elsewhere (US$469 and $769 per DALY averted). Nonetheless, the cost-effectiveness ratio is close to the GDP per capita in Vietnam.

The success of the 2007 helmet law was made possible by strong leadership, a vibrant partnership, a hefty fine, and culturally appropriate approaches.^source The prime minister and his party threw their weight behind simple legislation that reduced confusion about enforcement. Since then, policy adjustments have closed loopholes and given the helmet law sharper teeth.

Communication and program activities helped Resolution 32 take hold across the country. Political leaders at all levels featured prominently in media spots in advance of the new legislation, supported by traditional and new international partners.^source AIP Foundation’s engagement with the World Bank-initiated Global Road Safety Partnership brought funding from Ford Motors and Toyota.^source And Bloomberg Philanthropies supported social marketing and legislative action to increase traffic police power.^source

The hefty fine was one of the law's essential design elements. Not only was the fine large enough to get people to pay attention, the consistency of the disincentive and frequent presence of traffic police officers helped ensure the law was a deterrent.^source Plus, riders who were stopped by the police risked being cited for other traffic violations.

Helmet Day worked because it used a culturally appropriate approach. In Vietnam, where conformity is highly valued, it was important to orchestrate a population-wide launch where everyone could see everyone else adopting the new law.^source In other words, helmet-wearing became a new social norm.

Vietnam’s helmet law suggests that a law can successfully change behavior, especially in countries where the government exercises strong control. But even then, the law needs effective enforcement with high penalties to ensure compliance. 

The government still faces several persistent challenges: children's helmet wearing, helmet quality, and correct usage. There are clear steps the government can take to overcome these challenges. People who cannot afford helmets need donated ones, and babies and young children need affordable, small tropical helmets. And everyone needs helmets that meet the national safety standard. Substandard helmets must attract the same penalty as no helmet, and riders must learn that chin straps are essential to their protection in a crash.^source

The AIP Foundation is helping other countries learn about the lessons from Vietnam. It now has offices in Cambodia, China, Thailand, Uganda and Tanzania. Its helmet factory has also sparked interest. Officials from Cambodia considered a similar endeavor to support their new helmet requirement.^source

Legislation on helmets have advanced globally, yet only one-third of countries rate enforcement of their helmet laws as "good." ^source Encouraging helmet wearing is a central goal of the Global Plan for the Decade of Action for Road Safety, and a 2014 United Nations General Assembly resolution, "Improving Global Road Safety," asks member states to enact legislation on motorcycle helmets. One clear priority: to collect and disseminate more and better evidence from low-and-middle-income countries on how to improve road traffic safety at scale.