Consequences of centralised blood bank policies in sub-Saharan Africa
Authors: Jared R Gallaher, Gift Mulima, Dawn Kopp, Carol G Shores, Anthony G Charles
Journal: The Lancet Global Health (2017)

Safe and reliable transfusion services remain largely unavailable to the world's poorest populations, particularly in sub-Saharan Africa.1Kralievits KE Raykar NP Greenberg SL Meara JG The global blood supply: a literature review.Lancet. 2015; 385: S28Summary Full Text Full Text PDF PubMed Google Scholar WHO responded to this crisis with a strategy focused on centralising blood transfusion services, the exclusive use of volunteer donors, donor blood testing, and transfusion stewardship.2The LancetImproving blood safety worldwide.Lancet. 2007; 370: 361Summary Full Text Full Text PDF PubMed Scopus (27) Google Scholar On the basis of our experience in Malawi, we think that this policy has unintentionally decreased the availability of blood products for patients with acute haemorrhage. In response to this policy, the Malawi Blood Transfusion Service (MBTS) was established in 2003, replacing an in-hospital model with a government-sponsored centralised service. By 2008, over two-thirds of the country's blood donation was centralised and donation became increasingly dependent on unpaid volunteers rather than family member replacement.3Tapko JB Toure B Sambo LG Status of blood safety in the WHO African region. World Health Organization: Regional Office for Africa, 2014http://apps.who.int/iris/bitstream/10665/104446/1/9789290232469.pdfGoogle Scholar However, in 2014, data from MBTS showed that blood donation per-capita had decreased compared with 2011, meeting only one-third of blood products requested, largely because of a reliance on secondary and college students who donated 80% of MBTS blood.4Lilongwe News AgencyBlood shortage hits Malawi hospitals: MBTS sounds alarm. Malawi Nyasa Times.http://www.nyasatimes.com/blood-shortage-hits-malawi-hospitals-mbts-sounds-alarm/Date: 2015Google Scholar Prospective data from our study of 293 patients with upper gastrointestinal bleeding in Malawi corroborates that supply has decreased over time, showing that the number of units transfused per patient, adjusted for haemoglobin concentrations, decreased by nearly 50% between 2011 and 2013 (figure). The fundamental weakness in the WHO blood banking policy is the categorisation of blood donors and emphasis on strict centralisation. WHO recognises three types of donor: volunteer donors, replacement donors (family or friends), and compensated donors.5Allain JP Volunteer safer than replacement donor blood: a myth revealed by evidence.ISBT Sci Ser. 2010; 5: 169-175Crossref Google Scholar In 2004, over 80% of blood donations in sub-Saharan Africa were from replacement donors, but that number is now closer to 40%.3Tapko JB Toure B Sambo LG Status of blood safety in the WHO African region. World Health Organization: Regional Office for Africa, 2014http://apps.who.int/iris/bitstream/10665/104446/1/9789290232469.pdfGoogle Scholar The policy emphasis on volunteer donors focuses on improving safety from infectious diseases, particularly HIV. Collaboration between WHO and the US President's Emergency Plan for AIDS Relief has been instrumental in this strategy by setting transfusion policy priorities that focus on HIV transmission prevention or through direct funding for national transfusion services.6Ala F Allain JP Bates I et al.External financial aid to blood transfusion services in sub-Saharan Africa: a need for reflection.PLoS Med. 2012; 9: e1001309Crossref PubMed Scopus (49) Google Scholar These policies assume that volunteer donors have a lower risk profile than compensated or replacement donors for key infectious diseases, although available evidence does not support this assumption. Several studies from sub-Saharan Africa have failed to show a safety benefit with respect to HIV transmission when comparing replacement donors and volunteer donors.5Allain JP Volunteer safer than replacement donor blood: a myth revealed by evidence.ISBT Sci Ser. 2010; 5: 169-175Crossref Google Scholar Instead, evidence shows that it is repeat donation from volunteer donors that improves safety.7Allain JP Sarkodie F Asenso-Mensah K Owusu-Ofori S Relative safety of first-time volunteer and replacement donors in West Africa.Transfusion. 2010; 50: 340-343Crossref PubMed Scopus (61) Google Scholar, 8Allain JP Moving on from voluntary non-remunerated donors: who is the best blood donor?.Br J Haematol. 2011; 154: 763-769Crossref PubMed Scopus (62) Google Scholar Centralised blood banking systems also have considerable financial implications.5Allain JP Volunteer safer than replacement donor blood: a myth revealed by evidence.ISBT Sci Ser. 2010; 5: 169-175Crossref Google Scholar Bates and colleagues9Bates I Manyasi G Medina Lara A Reducing replacement donors in sub-Saharan Africa: challenges and affordability.Transfus Med. 2007; 17: 434-442Crossref PubMed Scopus (64) Google Scholar estimated that a centralised, volunteer-based system in sub-Saharan Africa is 4–8 times more expensive per unit of blood than a hospital-based system. Additional costs accumulate from expansive quality assurance programmes, blood distribution to medical centres, and donor recruitment. Furthermore, the blood donor recruitment strategy developed in most centralised blood-banking systems is dependent on local schools and universities as the primary donor source population, a strategy that is only viable when educational institutions are in session. This problem has been documented in other African countries such as Burkina Faso.10Dahourou H Tapko JB Kienou K Nebie K Sanou M Recruitment of blood donors in Burkina Faso: how to avoid donations from family members?.Biologicals. 2010; 38: 39-42Crossref PubMed Scopus (17) Google Scholar With centralisation, timely and efficient distribution networks are key. However, mature blood distribution networks are yet to be established in most developing countries. For example, blood donated in Malawi's capital Lilongwe is sent to Blantyre (360 km away) for testing at MBTS before it is transported back to Lilongwe for use.4Lilongwe News AgencyBlood shortage hits Malawi hospitals: MBTS sounds alarm. Malawi Nyasa Times.http://www.nyasatimes.com/blood-shortage-hits-malawi-hospitals-mbts-sounds-alarm/Date: 2015Google Scholar This type of centralisation is impractical and unsustainable for the delivery of emergent and elective surgical services, particularly when family members are available and willing to donate blood locally. Health-care systems need a hybrid approach that maintains the establishment of centralised blood banking infrastructure, while simultaneously supporting regional and local hospital transfusion facilities.6Ala F Allain JP Bates I et al.External financial aid to blood transfusion services in sub-Saharan Africa: a need for reflection.PLoS Med. 2012; 9: e1001309Crossref PubMed Scopus (49) Google Scholar This will result in blood product use at the site of donation and has several policy advantages. First, this approach acknowledges the importance of centralised regulation and quality assurance, but provides more flexibility for implementation in resource-poor environments. Second, it encourages the concurrent use of replacement and volunteer donors, which should increase supply. Finally, replacement donors are often interested in donating again, providing a potential sustainable source of donation.11Asenso-Mensah K Achina G Appiah R Owusu-Ofori S Allain JP Can family or replacement blood donors become regular volunteer donors?.Transfusion. 2014; 54: 797-804Crossref PubMed Scopus (23) Google Scholar Evidence suggests that this hybrid model works. In 2010, Bugge and colleagues12Bugge HF Karlsen NCT Oydna E et al.A study of blood transfusion services at a district hospital in Malawi.Vox Sang. 2013; 104: 37-45Crossref PubMed Scopus (34) Google Scholar found a reliable and readily available blood supply at a Malawian district hospital that was using both centralised volunteer blood and local family replacement donations, effectively using a natural hybrid model. A hybrid model must also include strategies for culturally appropriate donor recruitment that target community leaders, and provider education programmes aimed at improving transfusion stewardship. Countries in sub-Saharan Africa need long-term technical and financial support to develop sustainable blood banking systems that can meet the transfusion needs of patient populations. More detailed and accurate data on supply and demand is required to ensure that changes in policy will help bridge this gap. WHO strategy as it currently stands, although commendable and well intentioned, has not served surgical patients in resource-poor settings well. The time has come for a more flexible policy that will lead to dependable access to life-saving allogeneic blood product transfusions in sub-Saharan Africa. We declare no competing interests. Financial support was provided by the North Carolina Jaycee Burn Center in the Department of Surgery at the University of North Carolina and a UNC Faculty Research Grant for all aspects of the study.