Safe Blood

A timely and safe blood transfusion can be the difference between life and death in many health emergencies. Transfusions are integral to quality care in maternal child health, surgery, trauma care, oncology and malaria treatment. But building and maintaining strong systems for collecting, screening, storing, distributing, transfusing and monitoring safe blood is complex and requires unique expertise.

Multiple challenges hinder blood system performance in low- and middle-income countries including critical underfunding, over-reliance on donor funding, poor coordination between relevant stakeholders, health system fragmentation and a lack of technical assistance to strengthen safe blood within national health systems.

Many countries are requesting support to strengthen their ability to source adequate and safe blood, ensure availability in health facilities, and safely transfuse blood and blood products to patients for life-threatening conditions without adverse outcomes.

Postpartum hemorrhage, or excessive bleeding after childbirth, is a leading cause of maternal mortality worldwide, affecting 14 million women annually and resulting in about 70,000 deaths. It accounts for over a quarter of maternal deaths worldwide. For severe postpartum hemorrhage, a blood transfusion can be a life-saving intervention. Challenges in the blood systems of many low- and middle-income countries can undermine the provision of safe blood services when they are needed most.

Current country and global efforts to support national blood systems are inadequate, fragmented and untargeted. R4D sees country demand for technical assistance to improve this. Key opportunities include:

• Making safe blood a priority in national health planning and financing
• Improving coordination among stakeholders
• Mobilizing funding – especially from domestic sources
• Developing and disseminating policies, strategies, procedures and guidelines
• Improving quality assurance and safety monitoring practices
• Training health care workers on safe blood management and transfusion
• Collecting data on blood management, blood use, health conditions and adverse outcomes
• Transitioning procurement of equipment and consumables (like blood bags and lab items) away from donors or parallel supply chains to national systems
• Increasing blood supply by raising awareness and educating communities on voluntary blood donation to address stigma

There are also multiple opportunities for maternal child health (MCH)-focused funders, implementers and providers to contribute to wider blood system strengthening efforts in countries. While national systems for blood collection, processing, and supply are intended to be centralized, maternal child health programs are key customers of the blood system and can strengthen it in significant ways. MCH programs can:

• Lead advocacy and engagement to adequately resource the national blood system as a critical component of urgent and emergent clinical care
• Support integration of blood service supplies into national procurement and logistics management information systems, in partnership with national supply chains
• Capture more rigorous data on blood transfusions and outcomes to improve the evidence base
• Train health care workers on blood transfusion guidelines and protocols. National blood services typically do not exercise influence on clinical processes and quality assurance; MCH and other programs can help fill the gap with trainings and production and dissemination of job aids
• Raise awareness and reduce stigma around blood donations by leveraging the community health workforce, health promotion departments, and social and behavioral change interventions and partners to improve public perceptions

R4D’s approach aims to strengthen countries’ own abilities and resources to accelerate progress toward self-reliant blood systems and reduce dependence on donor assistance over time.

Our approach is responsive to country priorities and includes:

• Facilitating collaboration and engagement between relevant stakeholders within countries
• Facilitating opportunities for cross-country learning among peers
• Coaching and capacity building – leveraging local, regional, and where needed, global expertise to support change agents
• Co-creating policies, strategies and tools by translating global knowledge and evidence into locally feasible solutions
• Evidence generation, learning and adapting – conducting implementation research and other analytical support to discover what is and isn’t working and improve system design

The R4D-led Health Systems Strengthening Accelerator project funded by USAID is providing technical assistance in Liberia, Malawi and Rwanda to help strengthen national safe blood systems and improve access to safe blood transfusion services.

In partnership with change agents in each country and together with the USAID Market Access and Innovative Finance program, we applied the USAID Safe Blood Starter Kit — now developed into the WHO Blood System Self-Assessment tool — to understand the existing safe blood systems and country contexts, identify key challenges and opportunities, and co-create interventions to address challenges prioritized by each country. After completing the Safe Blood Starter Kit assessment in December 2022, R4D began providing technical assistance across a range of areas that aim to address both foundational and operational challenges in national blood systems.

Our work includes:

• Improving coordination: Facilitating a steering committee in Malawi and technical working groups in Liberia and Rwanda for stakeholder convening, coordination and cooperation to begin to reduce the fragmentation between safe blood systems and the wider health sector.
• Strengthening governance: Supporting greater stewardship and governance of safe blood systems and operations through the development of a national safe blood policy and strategy in Liberia.
• Enhancing normative guidance: Developing clinical guidance, training materials and standard operating procedures to improve quality of care. For instance, in Rwanda, R4D supported the development of a comprehensive national hemovigilance strategy and in/pre-service training materials for clinical staff. Additionally, in Liberia, R4D held a 3-day blood drive at a vocational school in Monrovia as an effective test run to then improve standard operating procedures for conducting blood drives.
• Strengthening resource planning: Estimating the national requirement for blood products, supplies and consumables in Liberia and Malawi to aid blood collection efforts and resource planning.
• Mobilizing resources: To enable sustainable funding of the national blood systems in Liberia and Malawi, R4D is helping to develop a resource mobilization strategy and supporting public sector budgeting for the blood service. For example, R4D has supported the development of a Safe Blood Investment Case in Malawi and convened high-level stakeholders from the Malawi Blood Transfusion Service, the ministries of Finance and Health, and other actors under an MBTS-led task force for “blood budget coordination.” Similarly, with R4D support, Liberia’s National Blood Safety Program secured additional funding under the Liberia Institutional Foundations to Improve Services for Health Project funded by the World Bank’s Global Financing Facility.
• Improving data for decision-making: Supporting routine and reliable data collection; for example, in Liberia and Malawi, development and piloting of clinical and supply chain indicators through national health and logistics information systems. In Malawi, R4D has recently launched a pilot blood data collection exercise at the Queen Elizabeth Central Hospital to obtain implementation learnings for scaling up such routine data collection nationally.
• Fostering cross-country learning: Facilitating cross-country learning on blood system improvement to develop staff and leadership capacity, as well as produce tools and knowledge products.

Photo: In June 2023, R4D supported Liberia’s National Blood Safety Program (NBSP) and Ministry of Health Department of Policy, Planning and M&E to host a workshop in Buchanan, Liberia to validate the updated draft Liberia National Blood Safety Policy 2024-2033 and Strategic Plan 2024-2028. Key stakeholders pictured include representatives from NBSP, several departments from the Ministry, County Health Teams and R4D. © Results for Development