The Unintended Consequences of a Centralized Blood Banking Policy on Blood Product Availability Following Acute Hemorrhage in Sub-Saharan Africa

Safe and reliable transfusion services remain largely unavailable to the world’s poorest, especially in sub-Saharan Africa.¹ The WHO responded to this crisis with a strategy focused on centralizing blood transfusion services, the exclusive use of volunteer donors, donor blood testing, and transfusion stewardship.² Based on our experience in Malawi, this policy has unintentionally decreased the availability of blood products for patients with acute hemorrhage.

In response to this policy, the Malawi Blood Transfusion Service (MBTS) was established in 2003, replacing an in-hospital model with a government-sponsored centralized service. By 2008 over two-thirds of the country’s blood donation was centralized and donation became increasingly dependent on unpaid volunteers rather than family member replacement.³ Unfortunately, in 2014, reported data from MBTS showed that on a per-capita basis, blood donation had decreased compared to 2011, meeting only one-third of blood products requested, largely due to a reliance on secondary and college students who donated 80% of MBTS blood.⁴ Prospective data from our study of nearly 300 patients with upper gastrointestinal bleeding in Malawi corroborates that supply has worsened over time, showing that the adjusted number of units transfused per patient decreased by nearly 50% from 2011 to 2013. (Figure 1).

Figure 1.

Linear regression model showing the predicted value with 95% confidence interval of the total number of transfused units of whole blood by admission date during the study adjusted for presenting hemoglobin.

The fundamental weakness in the WHO blood banking policy is its categorization of blood donors and emphasis on strict centralization. The WHO recognizes three types of donors: volunteer donors, replacement donors by family or friends, and compensated donors.⁵ In 2004, over 80% of blood donation in sub-Saharan Africa was from replacement donors, but the rate is now closer to 40%.³ The policy emphasis on volunteer donors focuses on improving safety from infectious diseases, especially HIV. Working with the WHO, the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) has been instrumental in this strategy by setting transfusion policy priorities focused on HIV transmission prevention or through direct funding for national transfusion services.⁶ These policies assume that volunteer donors have a lower risk profile than compensated or replacement donors for key infectious diseases but available evidence does not support this assumption. Several studies from sub-Saharan Africa have failed to show a safety benefit from HIV transmission comparing replacement and volunteer donors.⁵ Instead, evidence shows that it is repeat donation from volunteer donors, that improves safety.^7,8

There are also significant financial implications to having a centralized blood banking system.⁵ Bates estimated that a centralized, volunteer-based system in sub-Saharan Africa is four to eight times more expensive per unit of blood.⁹ The additional costs come from expansive quality assurance programs, blood distribution to medical centers, and donor recruitment. Furthermore, the blood donor recruitment strategy developed in most centralized 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 phenomenon has been documented in other African countries such as Burkino Faso.¹⁰

With centralization, there must be timely and efficient distribution networks. Unfortunately, mature blood distribution networks are yet to be actualized in most developing countries. For example, Malawi’s capital Lilongwe still sends its donated blood to Blantyre, 360 km away, for testing at MBTS before it is transported back to Lilongwe for use.⁴ This type of centralization 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.

We need a hybrid approach that maintains the establishment of centralized blood banking infrastructure, while simultaneously supporting regional and local hospital transfusion facilities.⁶ This will result in blood product utilization at the site of donation and has several policy advantages. First, it acknowledges the importance of centralized 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. Third, replacement donors are often interested in donating again, providing a potential sustainable source of donation.¹¹

Evidence suggests this model works. In 2010, Bugge found a reliable and readily available blood supply at a Malawian district hospital that was using both centralized volunteer blood and local family replacement donations, effectively using a “natural” hybrid model.¹² A hybrid model must also include strategies for culturally appropriate donor recruitment that target community leaders, and provider education programs 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 their patient populations. More detailed and accurate data on supply and demand is needed to ensure that changes in policy will actually help bridge this gap. The WHO strategy as it currently stands, though 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.