Characterising differences in red blood cell usage patterns between healthcare sectors in South Africa: 2014–2019

Abstract

Background

South Africa aims to transition from a two-tiered healthcare system (public and private) to universal health coverage. Data on red blood cell (RBC) product usage reveal disparities between the sectors. Blood transfusion services further need to understand differing disease profiles and transfusion prescribing practices between the sectors to ensure blood security should the transition to a two-tiered health system come to fruition.

Materials and methods

Operational data for public and private healthcare RBC requests between 1 January 2014 and 31 March 2019, obtained from the South African National Blood Service (SANBS), were retrospectively analysed. Sector-specific demographic and utilisation trends were compared for the dominant clinical disciplines. Pre-transfusion haemoglobin (Hb) patterns were also delineated for 2018.

Results

Between 2014 and 2019, 2,356,411 public and private sector RBC transfusion events resulted in the issue of 4,020,094 RBC units (1,553,159 transfusion events and 2,495,054 units within the public sector versus 803,282 transfusion events and 1,525,040 units in private). The dominant clinical disciplines within the public sector were Medical (32.9%), Gynaecology/Obstetrics (27.3%), General Surgery (13.6%), and Paediatrics (including Paediatric Surgery) (6.5%), compared to Intensive Care Units (33.2%), Medical (28.3%), General Surgery (10.4%), and Haematology/Oncology (8.3%) in the private sector. Median pre-transfusion Hb values for 2018 were lower in the public than in the private sector: 6.9 g/dL public sector versus 8 g/dL private sector.

Discussion

Clinical drivers of RBC usage within the public and private healthcare sectors in South Africa differ significantly. Disparate pre-transfusion Hb between the sectors are likely due to differing disease profiles and severity, as well as differences in practice in prescribing transfusions. Implementation of a nationally co-ordinated Patient Blood Management programme may help to address these disparities and help ensure a sustainable blood transfusion system.

INTRODUCTION

In 2019, the population of Sub-Saharan Africa reached 1.107 billion individuals¹. The region has the highest maternal mortality ratio (533 per 100,000 live births) and accounts for 68% of all worldwide maternal deaths². Promptly administering a blood transfusion during an obstetric haemorrhage is essential to avert the death of the patient^3,4. However, in Sub-Saharan African countries such care is disproportionately available to high-income or wealthy individuals^5,6.

The South African healthcare system is made up of two distinct sectors: public and private⁷. In 2018, only approximately 13% of the South African population serviced by the South African National Blood Service (SANBS) ascribed to a medical aid scheme, yet they utilised 38.21 units of red blood cells (RBC) per 1,000 of the population, while the remaining approximately 74% relied predominantly on the public sector and utilised only 11.02 RBC units per 1,000 of the population^8,9. The public healthcare sector is mainly funded from tax revenues¹⁰ and suffers from a shortage of human resources⁷, equipment, and medicines¹¹. The private healthcare sector is mostly funded through tax rebates and medical aid scheme contributions¹², and is markedly better resourced than the public healthcare sector⁷. The percentage of General Domestic Product (GDP) spent on health in 2015 was approximately equal between the healthcare sectors despite the proportions of the population serviced by the respective sectors: 4.3% in the private sector vs 4.2% in the public sector^13,14. Apart from district hospitals, community health centres and primary healthcare clinics within the public healthcare sector, healthcare across both sectors is still considered “pro-rich”¹⁵. Despite the differences between the two healthcare sectors, the blood product providers within South Africa, namely the South African National Blood Service (SANBS) and Western Cape Blood Service (WCBS), provide equitable products and services across both sectors, with approximately 60.7% of products supplied by the SANBS going to the public sector⁹. Under the planned National Health Insurance (NHI) scheme, healthcare funding would be shifted from the two-tiered system to universal health coverage^16,17. Therefore, blood product providers need to understand the disease spectrums and prescribing practices driving usage within each of the healthcare sectors. The NHI Bill was introduced to the National Assembly on 8 August 2019; as of 18 May 2021, the bill is still going through public hearings¹⁸.

According to South African guidelines, the haemoglobin (Hb) threshold for RBC transfusion is generally <6 g/dL, with higher thresholds for certain specific conditions^19,20. The overall approach to transfusion is to critically assess each case and to compare the advantage of administering a transfusion with the possible risks associated with the transfusion procedure itself²¹. However, despite these guidelines, there is substantial inter-hospital and inter-clinician variability²².

A previous evaluation of RBC products had found that the mean 5-year per capita RBC utilisation differs markedly between the public and private healthcare sectors of South Africa⁹. The public sector had significantly lower transfusion rates at an average 11.6 units per 1,000 of the population, while the private sector had rates comparable to high income countries at an average 36.7 units per 1,000 of the population⁹. Differences in disease patterns and severity, healthcare access, and clinician prescribing practices may be driving the differences between the two sectors⁹. This study aims to build upon the prior investigation into RBC utilisation⁹, and quantify the differences in disease spectrums and transfusion prescribing practices underpinning the disparate RBC usage between the healthcare sectors. These findings may help inform the implementation of systems to ensure sustainable blood provision during and after the possible transition to universal health coverage.

MATERIALS AND METHODS

The South African National Blood Service (SANBS) is the blood product and service provider for eight out of the nine provinces in South Africa. As the dominant transfusion service within the country, it provides blood products to around 340 public and 250 private hospitals via its 83 blood banks. All RBC product requests submitted to the SANBS for patients classified at admission as either public or private between 1 January 2014 and 31 March 2019 were included within this retrospective analysis. Although product requisitions may contain requests for multiple RBC products and/or units, each requisition, irrespective of the number of products or units specified, is assigned a distinct requisition number representing a unique transfusion event.

Data collection

De-identified, operational data were obtained from the SANBS blood product requisitions and recorded on the MEDITECH blood establishment computer system (Medical Information Technology, Westwood, MA, USA) for the period 1 January 2014 till 31 March 2019 and were included in this investigation. The dataset included general demographic information of the blood recipients such as age and gender, the type of patient admission (Antenatal, Ward, Public or Private), and the clinical discipline that the patient was classified under. In general, healthcare workers (HCW) provide self-reported clinical disciplines for a particular blood requisition event based on either the main clinical discipline into which the patient is admitted or the discipline of the clinician ordering the transfusion. Clinical discipline was used as a proxy for diagnosis within the analysis due to the consistent nature of the reporting and the lack of codified diagnoses on the blood requisition forms. The clinical disciplines listed on the pre-printed blood requisition forms are as follows: Medical, Gynaecology/Obstetrics, Burns, Cardio-Thoracic Surgery, General Surgery, Haematology/Oncology, Infectious Complications, Intensive Care Unit, Orthopaedics, Paediatrics, Paediatric Surgery, Trauma, and Other. Completion of this section of the form is not compulsory. Approximately 97.9% of the transfusion events within the study period had a recorded clinical discipline. Similarly, about 98.5% of the RBC units issued had a clinical discipline specified. Furthermore, information associated with the requested and issued blood products, such as type of product, number of units, and whether any cancellations of products occurred, together with the specified purpose of cancellation, was also collected.

Data analysis

The data were analysed using R studio version 1.3.959²³, running R statistical software version 4.0.3²⁴. Descriptive statistics were used to characterise demographic trends in RBC transfusion events by clinical discipline stratified by healthcare sector. Utilisation trends were compared between the public and private healthcare sectors by calculating the percentage of the respective sector RBC units that were issued to a particular discipline within the study period. In addition, per capita transfusion events and utilisation patterns were determined by dividing the discipline- and/or sector-specific amounts by the respective healthcare sector population as estimated from General Household Surveys for 2014 up till 2019^8,25–29 and expressing the outcome per 1,000 of the respective population. Furthermore, differences in transfusion prescribing practices between the public and private healthcare sectors were analysed using the median and interquartile range pre-transfusion Hb values for requisitions during 2018. These Hb values were stratified by age, gender, and clinical discipline to eliminate the effect of confounding produced by these variables. Only 2018 Hb data were included in the latter investigation as the pre-transfusion Hb values were not routinely recorded prior to the latter part of 2017 and only data for three months of 2019 were available at the time of investigation. Thus, 2018 had the least number of missing pre-transfusion Hb values (58,360 M; 12.84%) between the latter part of 2017 up till March 2019.

In addition to the missing values, the Hb dataset contained unlikely pre-transfusion Hb values of <1 g/dL that was assumed to be due to data capturing errors; these were re-assigned as missing values. Multiple imputation was then employed using the MICE package³⁰ in R statistical software²⁴ under the assumption of missing at random³⁰ (Online Supplementary Content). The dataset used for imputation contained the pre-transfusion Hb values along with the variables age³¹, gender³², clinical discipline, and patient type (Public or Private). These variables were considered to be possible predictors for the missing pre-transfusion Hb values due to their expected association with either the variability observed in the pre-transfusion Hb values or as contributing factors for the values being missing³³. These predictor variables were used to define a predictor matrix and applied to the imputation set to impute the missing pre-transfusion Hb values.

Data considerations

Since this investigation extends a prior investigation by Bolton et al.⁹ of blood usage patterns in South Africa, the data considerations therein still apply. That is, the operational data recorded on MEDITECH required manual insertion; this is not an error-free process. However, the size of the dataset, as well as the required traceability should limit the influence of such errors. In addition, the number of units of blood products issued for transfusion is, by definition, the difference between the units ordered and the units cancelled; however, discrepancies were observed. Missing issued counts were imputed as described in the Online Supplementary Content, and although on average patient age was well-captured, date of birth, for example, was not. Finally, only the SANBS utilisation data were employed during this investigation; this implies exclusion of any Western Cape data.

The further imputation of the pre-transfusion Hb values for 2018 did not affect the overall trends observed in the median pre-transfusion Hb values (Online Supplementary Content) and is therefore not expected to influence the validity of the study outcomes. Furthermore, the investigation of transfusion prescribing practices only involves a single year of data (i.e., 2018). Although not sufficient to make any definitive conclusions, it serves as a valid preliminary investigation from which critical insights can be derived for further study.

Since the classification of patients to either Paediatrics or Paediatric Surgery by clinicians on requisition forms is independent of age, the demographic and utilisation trends for Paediatrics (which for this analysis included Paediatric Surgery) included all requisitions registered under this clinical discipline. Similarly, all requisitions registered under Gynaecology/Obstetrics were considered to determine the demographic and utilisation trends within this clinical discipline. However, for the investigation of prescribing practices (involving the pre-transfusion Hb stratified by age, gender, and clinical discipline), only children aged 13 years and under were included under Paediatrics, and only females under Gynaecology/Obstetrics. Within the public sector, 714 (0.24%) Gynaecology/Obstetrics requisitions were recorded for males and 69 (0.023%) requisitions were recorded as sex unknown. For the private sector, 158 (0.10%) requisitions were associated with males with one requisition associated with an unknown sex. Most of the males registered under Gynaecology/Obstetrics are assumed to be erroneous gender entries, with a possibility of a small number of men registered in this clinical discipline due to a shortage of beds at the respective medical facility (see Supplementary Online Content). In terms of Paediatrics, 915 (0.3%) public sector requisitions and 313 (0.2%) private sector requisitions were associated with either an unknown age or an age over 13 years. This is assumed to occur in settings where there is a shortage of beds available or due to specific conditions requiring the patient to be treated as a paediatric patient.

Although the data analyses considered all the clinical disciplines outlined on the SANBS blood requisition forms, only those clinical disciplines that dominated in terms of RBC transfusion events or usage were selected for discussion.

Ethical considerations and data sharing

Ethical approval was obtained from the Human Research Ethics Committees (HREC) of the SANBS (HREC reference n. 2017/7) and the Stellenbosch University (HREC reference n. N18/10/128_RECIP_SANBS_2017/7). SANBS guidelines allow for the sharing of de-identified data, subject to the SANBS HREC approval, and the conclusion of the appropriate contractual or non-disclosure agreements.

RESULTS

Trends in public and private healthcare sector transfusion events by clinical discipline

Of the 2,356,441 RBC transfusion events analysed between 1 January 2014 and 31 March 2019, 1,553,159 (65.9%) occurred in the public sector and 803,282 (34.1%) in the private sector (Table I). Per capita, this equates to 6.29 transfusion events/1,000 public sector population compared to 16.76 transfusion events/1,000 private sector population^8,25–29. For the two sectors combined, the distribution of transfusion events across the dominant clinical disciplines was Medical (30.4%), Gynaecology/Obstetrics (18.1%), Intensive Care Unit (ICU) (13.8%), General Surgery (11.6%), Paediatrics (7.7%) and Haematology/Oncology (5.5%). Within disciplines, the public sector patients accounted for most of the transfusion events in the Gynaecology/ Obstetrics (90.3%), Paediatric (86.4%), General Surgery (70.4%), and Medical (69.8%) disciplines as opposed to the Haematology/Oncology (53.9%) and ICU (80.7%) disciplines, where the private sector patients accounted for the majority of transfusion events. Private sector per capita transfusion events for the ICU and Medical disciplines showed the greatest difference: 5.49 and 4.51 transfusion events/1,000 private sector population compared to 0.25 and 2.02 transfusion events/1,000 public sector population, respectively^8,25–29. Across both sectors, females accounted for most of the transfusion events in the Medical, General Surgery, Gynaecology/ Obstetrics, and Haematology/Oncology disciplines. Conversely, male recipients dominated in the Paediatrics and ICU disciplines. Within the Medical specialty, the ratio of female to male transfusion events was 1.6 in the public sector vs 1.2 in the private sector. The median ages revealed a younger population in the public sector vs the private sector: 40 years in the public sector vs 56 years in the private. In terms of the General Surgery specialty, the male to female relationship is more comparable between the sectors (50.0% females vs 49.9% males in the public sector compared to 53.4% females vs 46.6% males in the private sector); however, the median ages still point towards an older demographic in the private sector, with 57 years vs 48 years in the public sector.

Table I.

Demographic characteristics of the public and private sector red blood cell transfusion events by dominant clinical disciplines: 2014–2019^*

Clinical Discipline	Public Sector	Private Sector	Total
TRANSFUSION EVENTS	1,553,159 (65.9%)	803,282 (34.1%)	2,356,441
GENERAL SURGERY	193,139 (70.4%)	81,080 (29.6%)	274,219 (11.6%)
Age (years)	48 (33–63)	57 (43–70)
Gender
Female	96,506 (50.0%)	43,294 (53.4%)
Male	96,379 (49.9%)	37,753 (46.6%)
Unknown	254 (0.1%)	33 (0.0%)
GYNAECOLOGY/OBSTETRICS	384,047 (90.3%)	41,435 (9.7%)	425,482 (18.1%)
Age (years)	29 (23–37)	34 (28–41)
Gender
Female	379,713 (98.9%)	40,322 (97.3%)
Male	3,997 (1.0%)	1,108 (2.7%)
Unknown	337 (0.1%)	5 (0.0%)
HAEMATOLOGY/ONCOLOGY	59,499 (46.1%)	69,641 (53.9%)	129,140 (5.5%)
Age (years)	39 (23–55)	57 (41–68)
Gender
Female	34,829 (58.5%)	35,063 (50.3%)
Male	24,577 (41.3%)	34,408 (49.4%)
Unknown	93 (0.2%)	170 (0.2%)
INTENSIVE CARE UNIT	62,832 (19.3%)	263,292 (80.7%)	326,124 (13.8%)
Age (years)	33 (20–49)	56 (39–69)
Gender
Female	31,145 (49.6%)	126,840 (48.2%)
Male	31,577 (50.3%)	136,356 (51.8%)
Unknown	110 (0.2%)	96 (0.0%)
MEDICAL	499,163 (69.8%)	216,120 (30.2%)	715,283 (30.4%)
Age (years)	40 (29–56)	56 (42–70)
Gender
Female	310,046 (62.1%)	119,365 (55.2%)
Male	188,356 (37.7%)	96,660 (44.7%)
Unknown	761 (0.2%)	95 (0.0%)
PAEDIATRICS †	157 071 (86.4%)	24 824 (13.7%)	181 895 (7.7%)
Age (years)	0 (0–1)	0 (0–3)
Gender
Female	72,309 (46.0%)	11,716 (47.2%)
Male	83,896 (53.4%)	13,099 (52.8%)
Unknown	866 (0.6%)	9 (0.0%)

^*Data reported as median (interquartile range) or number of transfusion events (%).

^†Includes paediatric surgery.

Trends in public and private healthcare sector red blood cell utilisation according to clinical discipline

A total of 4,020,094 RBC units were issued across the public and private sectors between 1 January 2014 and 31 March 2019, of which 2,495,054 units (62.1%) were issued to the public sector and 1,525,040 units (37.9%) to the private sector. The Medical (32.9%) and ICU (33.2%) disciplines used the greatest number of RBC units within the public and private sectors, respectively. The comparative per capita usage for the medical discipline was 3.33 RBC units/1,000 public sector population vs 9.02 RBC units/1,000 private sector population. In addition, per capita usage in the ICU discipline was 0.40 RBC units/1,000 public sector population compared to 10.57 RBC units/1,000 population^8,25–29. Thereafter, the dominant clinical disciplines in terms of percentage utilisation within the sectors were Gynaecology/Obstetrics (27.3%), General Surgery (13.6%), and Paediatrics (6.5%) for the public sector, and Medical (28.3%), General Surgery (10.4%), and Haematology/Oncology (8.3%) for the private sector (Figure 1).

Figure 1.

The percentage of red blood cell (RBC) units issued by clinical discipline in the public and private healthcare sectors

(Paediatrics include paediatric surgery). (N= 4,020,094)

Trends in pre-transfusion haemoglobin levels between public and private healthcare sector according to clinical discipline

Of the 454,473 public and private healthcare RBC requisitions for 2018, 297,495 (65.5%) were within the public sector and 156,978 (34.5%) within the private sector. In general, the median (interquartile range) pre-transfusion Hb values within the public sector was 6.9 g/dL (5.7–8.0 g/dL) compared to 8.0 g/dL (7.1–8.8 g/dL) in the private sector. Table II presents the median pre-transfusion Hb values for men and women per healthcare sector for the dominant clinical disciplines. Across all the disciplines, the median private sector pre-transfusion Hb values were higher than those in the public sector. Figure 2 shows the comparative median healthcare sector pre-transfusion Hb levels for these RBC requests by dominant clinical discipline, age, and gender. Furthermore, pre-transfusion Hb was consistent across the age groups for all except one of the dominant clinical disciplines, namely Haematology/ Oncology (Figure 2).

Table II.

Median (interquartile range) haemoglobin in g/dL for male and female patients by dominant clinical discipline and healthcare sector for 2018

Clinical discipline	Public sector			Private sector
	Overall	Males	Females	Overall	Males	Females
General surgery	7.0 (5.9–8.0)	7.0 (5.9–8.0)	7.0 (5.8–8.0)	8.0 (7.3–8.7)	8.0 (7.3–8.7)	8.0 (7.3–8.7)
Gynaecology/Obstetrics	7.0 (5.9–7.7)		7.0 (5.9–7.7)	8.0 (7.0–8.5)		8.0 (7.0–8.5)
Haematology/Oncology	7.0 (6.0–7.7)	7.0 (6.0–7.5)	6.9 (6.0–7.8)	7.9 (7.0–8.3)	7.8 (7.0–8.2)	7.9 (7.2–8.4)
Intensive care unit	7.0 (6.4–8.0)	7.1 (6.5–8.1)	7.0 (6.3–8.0)	8.0 (7.4–8.8)	8.0 (7.4–8.8)	8.0 (7.4–8.8)
Medical	6.0 (4.9–6.8)	6.0 (5.0–6.9)	6.0 (4.9–6.8)	7.5 (7.0–8.5)	7.6 (7.0–8.5)	7.5 (7.0–8.5)
Paediatrics	8.0 (7.0–9.1)	8.0 (7.0–9.1)	8.0 (7.0–9.2)	9.0 (8.0–10.0)	9.0 (8.0–10.0)	9.2 (8.0–10.0)

Figure 2.

The comparative median pre-transfusion haemoglobin (Hb) levels (g/dL) of public and private healthcare sector red blood cell (RBC) requisitions for 2018

Requisitions were stratified by age, gender, and clinical discipline (Medical, Intensive Care Unit, General Surgery and Haematology/Oncology, Gynaecology/Obstetrics and Paediatrics [including Paediatric Surgery]).

DISCUSSION

The trends in public and private healthcare sector utilisation reveal notable differences in underlying disease spectrums. Although clinical discipline is not a truly definitive reflection of diagnosis, it does provide a broad indication of the spectrum of diseases that could be associated with the greatest RBC utilisation.

The differences between population characteristics and underlying spectrums of disease driving the RBC utilisation between the public and private healthcare sectors reflect different economic realities. The trends in the public healthcare sector are comparable to patterns in other middle-income countries, with paediatrics and pregnancy-related events driving usage³⁴, while the trends in the private sector resemble patterns observed in high-income countries. To illustrate the latter, we can consider Australia, regarded as a high-income country³⁵. Here the median age of the population has been steadily rising and in 2019 stood at 37.41 years³⁶. RBC utilisation between 2008 and 2010 was dominated by patients aged 65 years and older³⁷. Between June 2007 and February 2008, Shortt et al. undertook a study into the clinical utilisation trends of RBC products produced and distributed by the Australian Red Cross Blood Service (ARCBS). The demographic profile of the recipients reflected a median age of 69 years and slightly more male recipients (53%). Their major finding concerned the dominating clinical disciplines, namely Haematology/ Oncology (33.6%), Surgical (including cardio-thoracic, orthopaedic- and general-surgery) (27.8%), and Medical (13.5%)³⁸. The similarity of the utilisation patterns between Australia and the South African private healthcare sector reflects transfusion drivers of high income countries: support for surgical procedures aimed at treating lifestyle diseases and chronic conditions, and treatment of malignancies³⁴. In contrast to these high income country utilisation patterns, the comparable utilisation trends between Namibia (a middle-income country³⁵) and the South African public healthcare sector is remarkable.

Trends in RBC utilisation in Namibia between 2014 and 2019 (B. Lohrke, personal communication, 2020) reveal the leading clinical discipline for RBC usage to be Internal Medicine (42.8% adult; 37% paediatric), Paediatrics (22%), Gynaecology/Obstetrics (17.8%), Surgery (8.2% adult; 7% paediatric), and Trauma (4.8% adult; 5% paediatric). These similarities are likely reflective of similar population demographics, under-resourced healthcare systems, and a lack of early access to healthcare.

There was a marked difference in pre-transfusion Hb between the public and private healthcare sectors, with a consistently higher Hb threshold, independent of age and gender, in the private sector. The only clinical discipline with noticeable variability in Hb values between different age categories was in Haematology/Oncology; however, the median Hb values for this discipline has multiple confounding factors which may contribute to the observed variability between the age groups. The combination of both haematologic and oncological patients created a category with a very broad range of conditions and diseases, each with unique treatment guidelines and modalities^39–42, and within this broad range of diseases, individual patients may be at different spectrums of the course of the disease which would further impact the transfusion requirements of the individual patient^39,41,42. It is evident that combining these two categories of patients results in substantial variability in terms of the effect of the conditions on the patients, which could be reflected in their pre-transfusion Hb values.

On the other hand, the observed differences in pre-transfusion Hb values between the healthcare sectors could simply be an artefact of the populations accessing the respective healthcare sectors. The most financially vulnerable individuals are, for the most part, dependent on the public sector⁴³. The long waiting times, distance to the facilities and access to affordable transport to reach the public healthcare facilities could all contribute to these patients arriving at the public facilities at a more advanced state of their underlying condition compared to those with the means to seek medical care early in the disease⁴³. In contrast, the difference in Hb values could also be due to differences in transfusion prescribing practices through the actual application of different Hb baseline triggers; namely, restrictive (<7 g/dL)⁴⁴ within the public healthcare sector and liberal (9–10 g/dL)⁴⁴ within the private healthcare sector.

The variability could be underpinned by multiple factors. For instance, there is little clear evidence concerning issues related to blood transfusions⁴⁵. Barrett et al. investigated the level of transfusion knowledge and training at the Universitas Academic hospital complex in Bloemfontein, South Africa, during 2018. Most of the respondents to the enquiries carried forward by Barrett et al. acknowledged a lack of training in transfusion medicine, and reported that blood wastage was mostly attributed to prescribing transfusions without a clear clinical indication for the procedure^45,46. In addition, the majority of the clinicians used only Hb triggers as a justification for transfusion, with <7g/dL indicated by most as the transfusion threshold applied⁴⁶, even though it is well known that Hb thresholds in isolation should not be the only deciding factor for transfusion⁴⁶. RBC transfusion should involve a careful balance between administering the required amount of product to ensure optimal patient outcomes while limiting wastage due to needless transfusions, which are not only potentially harmful for the patient but also have financial implications¹⁹.

Another possible factor at play could be differing expectations of the populations serviced by the respective healthcare sectors. More specifically, private patients have greater access to legal action if they feel that a clinician was at fault regarding their treatment. This may cause clinicians to err on what they perceive to be the side of caution and apply a more liberal transfusion strategy, especially as very few private hospitals have blood bank facilities on site, thereby increasing the risk of delayed transfusion in the event of an emergency. However, in reality, such non-evidence-based liberal practices, whether based on out-dated practices or the lack of onsite blood banks, may increase the medico-legal risk. In addition, more restrictive transfusion practice in the public sectors may be influenced by the academic hospitals and the potential implementation of Patient Blood Management (PBM) principles^47–49. Finally, the public healthcare sector is predominantly state funded⁵⁰, which would imply limited finances for administering blood transfusions. Therefore, decision makers could be attempting to reduce costs by only administering blood transfusions when really necessary, i.e., adopting a restrictive strategy.

There is no single explanation for the observed differences in pre-transfusion Hb values between the healthcare sectors, but rather a combination of possible factors. Achieving a balance in utilisation between the sectors would require addressing multiple aspects of the management of these procedures. Both healthcare sectors could benefit from more training in transfusion medicine for clinicians and nurses, with a particular emphasis on patient blood management. This is defined as “an evidence-based concept aiming at pre-emptively reducing the need for red blood cell (RBC) transfusions to improve patient safety and outcome”⁵¹. Furthermore, there should be better management of transfusion practices within the private healthcare sector. One possible solution is the establishment of PBM programmes, which have been proven to positively impact transfusion practice^48,49 (in the absence of such bodies) or greater access for the blood product providers to appropriate forums within the private sector. Currently, private healthcare facilities in South Africa either lack such an oversight, or do not provide access to those who operate in the transfusion services to the relevant meetings (P-L Wessels, Lead Consultant Patient Blood Management, private communication, 2021). Such bodies “can provide important oversight of transfusion practice, disseminate transfusion guidelines and monitor the implementation of programs related to transfusion medicine in the hospital”, and also be a driving force for the application of patient blood management within their facilities⁵².

CONCLUSIONS

South Africa plans to transition from a two-tiered healthcare system to universal health coverage. With a donor pool of less than 1% of the South African population⁵³, it is evident that this scarce resource requires very careful management. The current system has markedly different blood utilisation patterns between the different healthcare sectors, and these must be addressed to ensure an equitable and sustainable blood provision model should universal health coverage be fully implemented. Different disease spectrums, alongside possible differences in clinician prescribing practices were found to underpin the disparate utilisation trends between the health sectors in South Africa. While healthcare access remains of paramount importance, systems for more comparable transfusion practices between the sectors should be considered. Although the disease spectrums are population-dependent and for the most part unavoidable, ensuring oversight of transfusion practice may go a long way in promoting standardised blood usage. This would involve both a more robust transfusion training programme for clinicians, as well as functioning and transparent transfusion committees and patient blood management systems. Addressing all these aspects could bring about a more uniform approach to blood transfusions across the healthcare sectors, as well as prevent potentially inappropriate blood transfusion procedures.