Abstract
<title>Abstract</title> <p>Background Governments across low- and middle-income countries have created earmarked road-safety funds, yet available audit and health-economic methods are rarely integrated to assess whether these instruments convert public revenue into health gains efficiently and equitably. Objective To develop and apply an 11-stage life-cycle health-economic and performance audit framework for assessing value for money in earmarked road-safety financing. Methods We synthesised International Organization of Supreme Audit Institutions (INTOSAI) performance-audit standards, World Health Organization (WHO) Safe System and health-economics frameworks, and established health-economic evaluation methods. We applied the framework to Karnataka, India’s Road Safety Fund using publicly available audit, finance, appropriation, and fatality records. Results The framework spans fiscal governance (4 stages), programme delivery (4 stages), and health-economic evaluation (3 stages), following earmarked revenue from identified need to population outcome. Applied to Karnataka, six stages had some public evidence (2 well covered, 4 partially covered) and five were not covered. Audits documented fund-creation delay (14 months), same-year cess transfer shortfalls exceeding ₹248 crore, early allocation concentrated in enforcement and police works (> 99%), and a ₹54.35-crore trauma centre completed but never staffed. Needs assessment, planning, procurement economy, causal impact evaluation, and household financial protection remained unmeasured. The framework identified nine governance gaps, nine priority reforms, and ten high-value research studies. Conclusions Current audit practices establish fiscal accountability but leave health-economic performance largely unmeasured. The life-cycle framework bridges this gap and is applicable to earmarked health-financing instruments beyond road safety.</p>