Over the past ten years, high-income countries in the North have provided considerable financial aid to establish and support national blood transfusion services in low-income countries in sub-Saharan Africa. This action has largely been driven by concerns relating to the contribution of blood transfusion to the HIV epidemic in the region, leading to the overwhelming objective of “safe blood.” Whilst there have been definite benefits to transfusion services, we believe this aid has resulted in unintended but serious negative outcomes, which we describe here and argue should prompt a re-thinking of how to provide support to blood transfusion services in sub-Saharan Africa.

Support has targeted either single countries such as Malawi, Rwanda, Burkina Faso, and Uganda [1],[2] or multiple countries [3]. Funds, available only for limited periods, have been used to support a combination of infrastructure design and construction; purchase of equipment; screening for transfusion-transmitted infections and quality assurance; and the recruitment of blood donors. As a direct consequence of this funding, some of the underlying principles of transfusion services practised in the high-income donor countries have been applied in sub-Saharan Africa recipient countries (Box 1). These principles may be based on sound practice in wealthy countries but do not necessarily apply to sub-Saharan Africa at this time. We argue that considering the needs of sub-Saharan Africa, external aid was to some extent misdirected in the areas of donor recruitment, overall organisation, and availability of products.

Current Transfusion Practice in Sub-Saharan Africa

It is important to recognise the particular circumstances and specific needs of recipient countries, which differ considerably for historical and economic reasons. Whereas blood product use in wealthy countries is largely pre-planned and predictable, the vast majority of blood product use in sub-Saharan Africa is for emergencies, therefore truly saving lives when delivered quickly [4]. Depending on the country, 50% to 80% of transfusions are related to just a few clinical circumstances: severe haemorrhage in women related to pregnancy and childbirth; trauma usually as a consequence of road traffic crashes; and severe anaemia in young children, often due to malaria. Timely access to blood transfusion has a clear role to play in achieving two of the Millennium Development Goals—reducing death rates by two-thirds in children under-five and by three-quarters in mothers. For severe malarial anaemia the product of choice, which has been shown to save lives and is recommended by the World Health Organization (WHO), is whole blood [5]–[8].

Before national blood transfusion services were established, blood provision in sub-Saharan Africa was totally decentralised, with blood banks operating in individual hospitals and often collecting 1,000 to 10,000 units a year. These blood banks were, and still are, an integral part of the hospitals they serve and are located close to patients, clinicians, and hospital managers [9]. Blood donors are often family or replacement donors, who are recruited from the relatives or friends of patients [10]. Replacement donors are described as such because for each unit of blood that is transfused, the onus is on the wider family circle to replace it in order to maintain supply [10],[11]. Paid donors may be called upon when family or friends are unable to meet this responsibility. Collecting blood from paid donors is banned in most countries in sub-Saharan Africa because they are notoriously unsafe but, in some settings without access to computerised donor registries, distinguishing them from family donors is often challenging [12].

Transfusion services in sub-Saharan Africa have been organised in this way because of culture, climate, communications, and, most importantly, because resources are limited. This fragmentation makes coordination of blood services and implementation of good laboratory practices and their quality assurance difficult, and imposes an additional burden on families in already stressful circumstances. Patients often present to hospital late in the course of their disease process [6]–[8]. Because life is at risk, the family traditionally congregates to support the patient and supplies blood when it is asked for.

If transfusion costs are not met by governments or health insurance funding, the cost of a unit of blood can often be prohibitive for families [13]. If transfusion costs are covered by governments or insurance, the cost can substantially affect the limited budgets of hospitals (for blood banks) or government (for blood centres) [10]. To produce a unit of whole blood from a family donor costs two to four times less than a unit from a voluntary non-remunerated, blood donor (VNRD) [10]. Maintaining centralised blood centres and managing the quality assurance and donor recruitment processes is expensive, so it is not surprising that, when external support is discontinued, the cost of blood products far exceeds the locally available budget.

The three principles outlined in Box 1, when imposed without careful consideration of local conditions, can undermine efforts to improve the supply of safe blood. Although the conditions of external financial assistance are discussed at the government level, practitioners on the ground are rarely consulted [14]–[17].

Centralisation

Evidence indicates that for both severe haemorrhage and malaria-related severe anaemia, mortality increases significantly if transfusion is delayed more than 1 hour [4],[18]. Rapid availability of blood is therefore critical. However, low and unpredictable blood demand in small hospital blood banks means that they cannot justify keeping a fully tested bloodstock from family-replacement donors. It is also difficult for small blood banks to establish and maintain high-quality procedures when fewer than ten units/day are collected and there is high staff turnover [14]. Conversely, reliance on a distant centralised source for blood in settings where communications are unreliable, fuel shortages are common, and roads may be impassable, will inevitably result in delays and stock-outs.

Sole Reliance on Volunteer Non-remunerated Donors

When applied dogmatically, the VNRD-only policy can prolong or worsen the chronic blood shortages experienced in blood systems that previously relied on family-replacement donors [7]. Neither VNRD nor family-replacement donors alone have been able to provide an adequate blood supply [19],[20], and diversity in donor sources is desirable [21]. Security of supply is difficult to achieve exclusively with VNRD who, in most countries, are predominantly secondary school students unavailable during school recesses and exam periods. Thus, the blood supply for as much as 3 months of the year is restricted. In contrast, family-replacement donors are available year round. The majority of blood donors in sub-Saharan Africa are first-time donors. Studies of HIV and hepatitis B virus prevalence in first-time donors have shown a similar risk profile in VNRD and family-replacement donors [11],[22]–[26]. Regular donors, irrespective of type, are substantially safer than first-time donors [11]. The higher costs of blood donated by VNRD compared with family-replacement donors [9],[11] result from the infrastructure necessary to recruit and retain them [20].

Blood Component Preparation

We recognise that the component model in the developed world has some justification from the perspectives of both quality and safety. However, in sub-Saharan Africa a policy of systematic component preparation from all donations can result in serious negative consequences (Box 2). Figure 1 illustrates the situation of individual blood centres in five countries that receive no external support for their blood services (left) and four countries that are supported by wealthy countries (right). The nationally funded blood services prepare and transfuse almost exclusively whole blood whereas the externally supported group, with the exception of one centre in Côte d'Ivoire, prepares almost exclusively red cell concentrates [27]. Only one study has presented the clinical side effects of transfusion in sub-Saharan Africa but did not compare whole blood with blood components [28].

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Figure 1. Proportion of blood and blood components prepared in nine sub-Saharan African countries.

The first five countries (Congo to Niger) do not receive affluent country support, whereas the remaining four countries do. Information was assembled from references [12],[13],[27]. RCC, red cell concentrate; PC, platelet concentrate.

https://doi.org/10.1371/journal.pmed.1001309.g001

Summary and Proposals

Undoubtedly, donor countries would be concerned if the indiscriminate transposition to sub-Saharan Africa of principles underpinning transfusion services in high-income countries resulted in the undesirable outcomes described above. Clearly, such negative consequences are not the intention of these programmes, which have built and equipped large blood centres, trained a generation of transfusion specialists, and have had some success in developing VNRD programmes. However, acknowledging that these outcomes are possible and that patients' lives may be endangered warrants careful reflection and a search for alternatives. Allowing an unnecessary increase in the cost of blood relative to the rest of health care costs, in the context of an average health care budget at US$10–US$30/person/year, can undermine the fundamentals of effective blood services. In our view, reflection and systematic analysis is required to assess three key questions (Box 3).

In the medium and long term, improving the evidence base to answer these three key questions must be a priority. There are already programmes estimating the cost-effectiveness of blood safety interventions [29], and a working party of the International Society of Blood Transfusion is dedicated to assessing different approaches to blood transfusion in developing countries [30]. On the basis of current evidence, it is suggested that leading funding organisations should focus on achieving adequate blood supply in order to save lives in the context of emergency blood transfusion in sub-Saharan Africa.