In 2020, Arthur Mpimbaza, a child health researcher at Makerere University in Uganda, published a study in The Lancet on the effects of the scarcity of blood products on children affected with severe malaria in sub-Saharan Africa. According to the study, these effects range from adverse outcomes significantly affecting people’s quality of life to more detrimental outcomes such as avoidable deaths. We know that the lack of blood products stems from a deficiency in the healthcare system. Recent discussions at the 11th summit of the Africa Society for Blood Transfusion (ASfBT) that took place in Uganda demonstrate the efforts that African countries have made—and are making— to address this vital issue, especially in terms of national blood transfusion centralization and transportation services. However, more needs to be done.
The data
Blood transfusion, a not-so-popular topic, is one of the backbones of healthcare systems. It plays a vital role in patient management, especially in the management of infectious diseases, obstetrics medicine, hemoglobinopathies, trauma medicine and cancer management. As an illustration, the WHO states that in low-income countries, 65% of all blood donations are given to children under 5 years of age, the majority of whom are due to anaemia caused by infectious diseases, mainly malaria. Despite the dire need for blood, the blood donation rate in low-income countries is one of the lowest in the world: 4.6 per 1,000 people, compared to 11.7 per 1,000 and 33.1 per 1,000, respectively, in middle-income and high-income countries.
The WHO blood donation rate target is 10 donations per 1,000 people. Moreover, the WHO recommends that all blood collection, testing, processing, storage, and distribution operations be coordinated at the national level through effective organization and integrated blood supply networks. To encourage consistent application of standards and consistency in the quality and safety of blood and blood products, the national blood system should be regulated by a national blood policy and legislative framework. By 2013, 122 of 167 countries had enacted a national blood policy, while 108 countries had explicit legislation governing the safety and quality of blood transfusion. The numbers show that more needs to be done in low-income countries. As explored in another article on the six building blocks of efficient health systems, the gaps can be identified at two levels: the fourth block – medical products availability – and the last block – leadership and governance.
The major obstacles preventing African countries from meeting the required blood donation target relate mainly to financial, organizational and socio-economic limitations. The lack of government support or sponsors begets a lack of infrastructure, equipment and trained personnel. All of this prevents the population from donating and, in turn, benefiting from transfusion when in need.
Organizational challenges revolve around five activities: blood collection, blood screening, blood processing, blood storage and blood delivery. In practice, one needs to ensure that the following are in place.
- A donor and repeat donor base at a local level is extremely crucial.
- The technological ability of basic screening of donated blood for HIV, Hepatitis B & C and Syphilis.
- The capacity to process and separate blood components.
Most African blood transfusion services cannot process blood and separate its components. Yet, this is required by the current modern processing of blood. Indeed, separating blood components into red blood cells, platelet concentrates, and plasma allows each to be used in specific clinical conditions, which saves many lives from one donation as opposed to using non-separated blood or whole blood for one patient at a time. Adding storage and transportation services to the list of challenges would help one understand why blood transfusion must occupy an independent place in healthcare systems.
Country-specific initiatives
Although blood donors can be paid donors or family members and relatives donating for their loved ones, the WHO has developed its blood donation structure around voluntary, non-remunerated blood donors (VNRBDs). Interestingly, Barro et al. report that the highest increase (85 per cent) in volunteer and non-remunerated blood donors (VNRBD) is seen in African countries, with 21 countries reaching the level of 80-100 per cent VNRBD despite the overall donation rate remaining below the WHO target of 1-2 % of each country’s total population. It is worth noting that VNRBD requires centralized blood transfusion centres that regularly encourage the population to donate voluntarily, which means that there have to be local centres throughout a country to facilitate these donations and regular blood donation campaigns.
A case in point is the annual blood donation exercises resumed in January 2021 by the Rwandan Defense Forces and Rwanda Biomedical Center working together, boosting the national blood reserve that had taken a hit during the pandemic. Another example is the Ghana Foods and Drugs Authority (FDA) which has been conducting annual blood donation campaigns to refill its blood reserve. These are exemplary government actions that save lives and strengthen national blood transfusion logistic systems.
In terms of blood transportation services, there have been incredible strides, too. In 2016, Rwanda (and later on Ghana) signed a contract with Zipline, a US-based startup, in its plan to streamline its blood delivery network. Zipline delivers, via drone services, lifesaving products, including blood and medical equipment such as PPEs and vaccines. On the African continent, it started operating in Rwanda and expanded to Ghana, where it was one of the national healthcare providers that helped distribute medical equipment in the heat of the COVID-19 pandemic. It has now expanded its services to Nigeria since 2022. Its impact in facilitating the logistics for blood availability in medical emergencies plays a vital role across the remote places of these countries. For example, it has reduced the delivery time of blood from an average of four hours to 20-30 minutes across 21 district hospitals when it started operations in Kigali in 2021, boasting an achievement of providing 75% of the blood needs of the capital city.
The African Society for Blood Transfusion
Achieving a stable national blood transfusion service requires continuous high-level advocacy to include it in the national budget and partnership with independent sponsors. It is in that spirit that the African Society for Blood Transfusion (AfSBT), in collaboration with other regional bodies, was created to uphold ethical and professional blood transfusion standards and abilities across the African continent. With its presence across the five African regions (ECCAS, EAC, Maghreb, ECOWAS, SADC) and its accreditation system, the AfSBT strives to standardize blood processing practices on the continent, thereby continuously optimizing safety, accessibility and sustainability of national blood programmes in participating nations.
Modern healthcare heavily relies on good governance at the national level, and blood transfusion is no exception. Blood transfusion services are an essential part of national healthcare systems, and investing in them considerably plays a role in efficient health delivery. Through public-private partnerships and adequate health financing policies, efficient blood product collection and availability can be achieved as the challenge is mainly organizational.
All in all, Africa can overcome and fill these gaps in our healthcare systems, but it requires people-centred governance systems.
