Evidence-based, collaborative approaches to strengthen data management for national blood systems: Examples from Liberia and Malawi

Introduction

Safe blood transfusions are an essential component of health care, particularly in low- and middle-income countries (LMICs), where access to safe blood is critical in treating leading causes of mortality, including malaria- and HIV/AIDS-associated anemia, hepatitis, trauma and postpartum hemorrhage.

The World Health Organization (WHO) recommends that national blood transfusion services collect data as part of a comprehensive quality management system. This data is crucial for decision-making, continuous improvement, and compliance with blood transfusion process standards.

However, blood systems in LMICs often lack the resources and capacity to track and analyze data on appropriate use and demand for blood products, inventory management, and blood transfusion reactions. This hinders their ability to optimize the use of available blood products, improve transfusion safety, and monitor blood donation trends, all of which are vital for improving overall health outcomes.

In Liberia and Malawi, two Sub-Saharan African countries with high burdens of malaria, HIV and post-partum hemorrhage requiring access to safe blood, national blood systems face significant challenges in their ability to collect, monitor and evaluate data. This includes the ability to collect indicators on the quantity of blood available at facilities, conditions for and number of blood transfusions, incidents of transfusion-transmitted infections, and occurrences of transfusion reactions along with their potential causes.

To address this gap, the USAID Health Systems Strengthening Accelerator (Accelerator) partnered with the national blood transfusion services of Liberia and Malawi to improve tools and systems for routine blood data collection, management, and utilization. This brief summarizes the approach and lessons learned from these efforts, offering insights that may be helpful for improving routine safe blood data management in other settings.

Challenges in routine safe blood data management

In Liberia, the Ministry of Health (MOH)’s National Blood Safety Program (NBSP) oversees provision of safe blood products. However, an assessment conducted in 2022 found that the lack of defined performance indicators and essential data tools hindered informed decision-making, allowing risks like adverse reactions and transfusion-transmitted infections to persist.

With support from the Accelerator, the NBSP worked with the MOH Health Information Systems to develop new Blood Transfusion Ledgers and Blood Safety Ledgers for all public health facilities providing blood transfusion services, as well as Regional Blood Centers. These ledgers include critical information, such as blood donor contact information, blood type, presence of transmissible infections, occurrence of transfusion reactions, to name a few. Developing these ledgers was a crucial first step to standardize facility data collection in Liberia for integration into the national health information system.

In Malawi, limited visibility into blood use at the facility level hinders the Malawi Blood Transfusion Service’s (MBTS) ability to effectively monitor and oversee access to quality, safe blood products in facilities. To address this challenge, the MBTS partnered with the Accelerator to implement a more advanced standardized blood data collection system in Malawi’s pilot at Queen Elizabeth Central Hospital (QECH) – the country’s largest public referral and teaching hospital.

The new data management system enables vein-to-vein blood tracking to improve visibility into blood utilization. This in turn will allow decision-makers to more accurately manage inventory and monitor appropriate use and handling of blood products, ultimately improving the overall quality management system.

Approach

In both Liberia and Malawi, the Accelerator worked with key blood system stakeholders to implement these improvements to the existing data management systems. This included first working with stakeholders to identify the precise needs, and then developing an improved tool responding to the specific blood system context.

For instance, in Liberia the Accelerator and NBSP reviewed and assessed previously deployed facility ledgers and their existence at facilities – only one in 15 facilities visited in a 2022 assessment was actively using the previous facility ledger. Next the team developed an improved ledger during a consultative convening of key blood system actors in March 2024, including representatives from the MOH HIS team and clinicians. The convening provided consensus on the precise indicators and format for the ledgers. Finally, the new ledgers were validated by MOH and printed for national dissemination in June 2024.

Similarly, in Malawi the Accelerator and MBTS conducted baseline a assessments of blood data collection at QECH to understand current blood data collection processes and tools. Next, they co-created blood indicators and revised existing data collection tools to be used in the facility wards and in the laboratory. The revised tools and approach were then piloted at QECH from March – May 2024. In total, 3,817 transfusions were conducted during this period.

Lessons learned from the pilot were synthesized and disseminated to MBTS, QECH, and national stakeholders through a series of meetings in June 2024 to guide the future nationwide scale-up of blood data collection, ensuring broader and more effective implementation.

Lessons learned and recommendations

Based on experiences from Liberia and Malawi, the following key recommendations for strengthening routine safe blood data management were identified:

• Build awareness on the importance of blood safety: In contexts where blood data tracking has been nonexistent or ad-hoc, advocate for the integration of blood-related indicators in standard facility data management systems to promote blood safety.
• Promote the value of blood data: Highlight the role of accurate blood data in informed decision-making and overall health system strengthening.
• Establish a cohesive blood data collection system: Engage strong leadership at all levels to collaboratively define and develop safe blood indicators and recording tools and standardize and formalize blood data collection processes.
• Sustain high-quality safe blood data management: Ensure that blood safety indicators are incorporated into routine health information systems and implement behavior change interventions to enhance blood data documentation at the facility level and for future national scale-up efforts.

Conclusion

The experiences of Liberia and Malawi demonstrate how data on blood, a neglected yet critical health area, can be strengthened as a part of national routine health and logistics management information systems.

These efforts have also highlighted the need for taking a collaborative, consultative approach to ensure improved tools and approaches responded to the needs of various stakeholders involved in the national blood system, e.g., both the clinicians providing blood transfusions and stakeholders within the national transfusion services overseeing national supply and quality assurance.

By taking an evidence-based, collaborative approach to strengthening data management systems, these countries are paving the way for more resilient and efficient national blood systems.