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Fishman, E., Schepers, P., Kamphuis, C.B.M. Dutch cycling: Quantifying the health and related economic
benefits, Am J Public Health. 2015;105(8):e13-e15.
Dutch cycling: Quantifying the health and related economic benefits
Elliot Fishman, PhD, Paul Schepers, PhD, and Carlijn Barbara Maria Kamphuis, PhD
This brief was accepted April 15, 2015.
ABSTRACT
The Netherlands are well-known for their high bicycle usage. The approach of the Health
Economic Assessment Tool and life table calculations were used to quantify the population-
level health benefits due to Dutch cycling levels. The results show that, due to cycling, about
6,500 deaths are prevented each year, Dutch people have half-a-year longer life expectancy,
and that these health benefits translate in economic benefits corresponding to some 3% of
Dutch GDP. Our study confirms that investments in bicycle-promoting policies (e.g.
improved bicycle infrastructure and facilities) are likely to yield a high benefit-cost ratio in
the long term.
INTRODUCTION
The Netherlands are well-known for their high cycling levels.
1, 2
Currently, about 27% of all
trips in the Netherlands is made by bicycle.
3
Investments in bicycle paths, bike parking, traffic
calming, and other policies contribute to these high cycling levels, and therefore, the Dutch
approach is internationally recognized as an example for other countries.
1, 2
Although the
health benefits of cycling as a means to reduce the risk of sedentary lifestyle diseases and all-
cause mortality are well-known,
4-6
no previous study has actually quantified the health
benefits and related economic benefits at a population level in the Netherlands, which has the
highest level of bicycle use in the world.
1
Quantifying and monetizing these benefits is
important to inform policy makers in the field of transport.
7
Therefore, this paper sets out to
examine the health benefits and health-related economic benefits of population cycling levels
in the Netherlands.
METHODS
Data on age group-specific cycling levels (i.e. average time spent cycling weekly per person),
population counts, and mortality rates in the Netherlands in 2010-2013 were retrieved from
Statistics Netherlands.
3
Data about cycling levels had been collected by means of a travel
diary survey (National Travel Survey, or “Onderzoek Verplaatsingsgedrag in Nederland”)
among a nationally representative random sample of about 50,000 persons each year. All
types of travellers and households and all days of the year are proportionately represented.
The approach of the Health Economic Assessment Tool (HEAT) developed by the World
Health Organization (WHO) was used
8
to estimate the mortality rate reduction and number of
deaths prevented each year due to cycling. The tool estimates the value of reduced mortality
that results from specified amounts of cycling (or walking). Based on a recent meta-analysis

Fishman, E., Schepers, P., Kamphuis, C.B.M. Dutch cycling: Quantifying the health and related economic
benefits, Am J Public Health. 2015;105(8):e13-e15.
of studies about the impact of cycling on all-cause mortality,
4
HEAT assumes a reduction in
mortality risk of 10% (95% confidence interval: 6 to 13%) for an exposure to cycling of 100
minutes per week. This risk reduction is controlled for other forms of physical activity, such
as leisure time or occupational physical activity, and other health behaviours like smoking.
4
Negative side-effects due to increased exposure to road safety and air pollution risks are
controlled for because the meta-analysis was about all-cause mortality. HEAT only considers
ages between 20 and 65 years. Younger people are excluded because the evidence base for the
health effects of physical activity on young people is not as large as that for adults. Older age
groups are excluded because countries often lack mobility data for older age groups.
8
However, since the underlying meta-analysis did provide information for ages of 65 and
over,
4
The annual number of deaths prevented per age group, was calculated by the product of
the mortality rate reduction and the mortality rate (annual number of deaths per 100,000) for
that age group.
To calculate the economic health benefits of cycling, HEAT uses a standard value of a
statistical life (VSL) to monetize the number of deaths per year prevented by cycling
participation. Certain costs such as expenditures related to medical treatment are not reflected
in the VSL estimates but these are relatively small. HEAT applies a VSL of $3.6 million for
the EU-27 countries, but advises a locally agreed VSL where available.
8
The Dutch VSL is
€2.8 million per death at the 2013 price level.
3, 9
Lastly, Dutch hazard rates were entered in the open-access life-table calculations, IOMLIFET,
to estimate the life expectancy increases by age group in response to the reduced risk of
mortality as calculated by the HEAT approach.
10
RESULTS
The weekly time spent cycling is about 74 minutes per week for Dutch adults of 20 to 90
years of age (Table 1). This level of cycling is fairly stable over adulthood and reaches its
peak around 65-70 years, in early days of retirement, and strongly drops after the age of 80
years. The mortality rate reduction, which is a direct result of the average time spent cycling
of a certain age group, is therefore also highest between 65 and 70 years. As a result of the
mortality reduction of all age groups together, about 6,500 deaths per year are prevented due
to cycling in the Netherlands. With a VSL of € 2.8 million per prevented death, the total
economic health benefits of cycling are estimated at € 19 billion per year. Life table
calculations suggested people in the Netherlands would die about half a year earlier without
cycling. More than half of this total life expectancy increase is achieved by cycling among
adults aged 65 and older.

Fishman, E., Schepers, P., Kamphuis, C.B.M. Dutch cycling: Quantifying the health and related economic
benefits, Am J Public Health. 2015;105(8):e13-e15.
TABLE 1. Health economic assessment based on time spent cycling and mortality rates of the
Dutch population between 20 and 90 years in 2010-2013
Input data
Outcome HEAT approach
Life table
calculation
Age
group
Average
weekly
minutes of
cycling p.p.
Popula-
tion
(x
1,000)
Average annual
mortality rate
per 100,000 pop.
Mortality
rate
reduction
(%)
1
Number of
deaths
prevented
per year
2
Annual benefit
of current
Dutch cycling
(billon €)
3
Increase of
average life
expectancy
4
20-30
73
2,058
31
7.3
47
0.1
0.01
30-40
69
2,087
53
6.9
77
0.2
0.02
40-50
69
2,573
135
6.9
241
0.7
0.03
50-60
79
2,320
390
7.9
715
2.0
0.08
60-65
89
1,071
757
8.9
719
2.0
0.07
65-70
94
872
1,232
9.4
1,009
2.8
0.09
70-75
88
652
1,963
8.8
1,127
3.2
0.10
75-80
73
507
3,422
7.3
1,274
3.6
0.09
80-85
36
369
6,328
3.6
842
2.4
0.05
85-90
24
216
11,663
2.4
606
1.7
0.03
Total /
Average
74
12,725
878
7.4
6,657
18.6
0.57
1
Based on an estimated mortality rate reduction of 10% per 100 minutes of cycling per week according to the meta-analysis.
5,7
For instance,
for the age group of 20-30 years 73/100 = 7.3%
2
The product of the mortality rate reduction, population and mortality rate (per 100,000 population)/100,000
3
The product of the number of deaths multiplied by the standard value of a statistical life year (VSL) of 2.8 million euro.
4
Based on lifetable calculations using IOMLIFET with Dutch mortality rates between 2010 and 2013
3
DISCUSSION
Cycling levels in the Netherlands have great population level health benefits: about 6,500
deaths are prevented annually and Dutch people have half-a-year longer life expectancy.
These large population level health benefits translate into economic benefits of €19 billion per
year, which represent more than 3% of the Dutch Gross Domestic Product (GDP) between
2010 and 2013.
3
About 6,500 deaths that are saved annually due to cycling is a huge number, but becomes
even more impressive when compared to the population-health effects of other preventive
measures. An overview of Mackenbach et al (2013) showed that the 22 new preventive
interventions that have been introduced in the Netherlands between 1970 and 2010 (e.g.
tobacco control, population based screening for cancer, and road safety measures), altogether
avoid about 16,000 deaths per year.
11
Still, our results are likely to be an underestimation of the true total health and economic
benefits. The benefits calculated are for health only (excluding, for instance, reduced traffic
congestion), and within the health category, only for mortality and not for prevented
morbidity. There is considerably uncertainty regarding the monetization of morbidity,
5
which
is why it is not included in the WHO’s HEAT Model.
8
Compared to the capital investments by all levels of Dutch government in road and parking
infrastructure for cycling of almost €0.5 billion per year over the last decades
12
, the annual
benefits of €19 billion are much higher than the annual costs. We acknowledge that this

Fishman, E., Schepers, P., Kamphuis, C.B.M. Dutch cycling: Quantifying the health and related economic
benefits, Am J Public Health. 2015;105(8):e13-e15.
comparison excludes private spending on bicycles and savings on fuel costs if the same trips
would be covered by car. Moreover, next to safe and efficient cycling infrastructure and
facilities, also geographical factors, like the Dutch flat terrain, and mild climate, and cultural
factors are likely to contribute to high volumes of cycling.
13
These are unrelated to capital
investment by governments. However, infrastructural and safety measures are important to
facilitate cycling.
13
For instance, elderly, the group among whom the largest health and
economic benefits can be achieved, indicated to prefer separate bicycle paths.
14
The Dutch
case shows it is likely that investments in bicycle-promoting policies (e.g. improved bicycle
infrastructure and facilities) yield a high benefit-cost ratio in the long term. We therefore
recommend investments in bicycle policies as suggested earlier by Pucher and Dijkstra.
1, 2
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Fishman, E., Schepers, P., Kamphuis, C.B.M. Dutch cycling: Quantifying the health and related economic
benefits, Am J Public Health. 2015;105(8):e13-e15.
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