Quantifying the demand for safe blood products and related supplies in low-resource settings is essential for ensuring that health systems can meet critical blood needs, particularly during emergencies. According to USAID, accurate demand forecasting enables countries to allocate resources efficiently, plan supply, and minimize shortages or wastage. By leveraging data-driven insights, quantification helps strengthen supply chains and improve access to essential services, ultimately supporting better health outcomes.

In an ideal world, quantifications for any health system product — be it pharmaceuticals, consumables, medical devices or safe blood — would analyze together historical consumption, service delivery and demographic data to provide an accurate and comprehensive view of demand. However, particularly in low-resource settings, national blood systems lack the capacity and data to conduct robust quantifications.

Based on the data available in a specific setting, the World Health Organization (WHO) offers guidance for countries to estimate blood needs based on one of three approaches:

1. Consumption approach using historical blood usage data
2. Service delivery approach using the number of acute hospital beds
3. Demographic approach using the country’s population

In 2022, Results for Development-led USAID’s Health Systems Strengthening Accelerator (Accelerator), in partnership with the National Blood Services Program (NBSP) in Liberia and Malawi Blood Transfusion Service (MBTS) in Malawi, identified that both countries faced clear gaps in their ability to quantify demand for safe blood.

This was hindering the health system’s ability to appropriately plan for resources and ensure the right amount of safe blood products and related supplies to safely collect, store and transfuse blood were available at the right place and the right time. While the two countries were at different levels of maturity in their ability to quantify safe blood demand, this blog details the specific methodology improvements implemented to strengthen accuracy of safe blood quantification exercises.

Approach

Liberia and Malawi’s national blood systems lie on two different sides of the spectrum in terms of a country’s capacity to quantify safe blood. Liberia is indicative of a data-scarce country which has not yet endeavored to quantify demand for safe blood and related supplies. Alternatively, Malawi has a quantification exercise in place but is keen to improve its accuracy to reduce persistent shortages in access to safe blood. Thus, two different approaches to quantification were taken in each country.

Liberia: data-scarce setting

As of the 2022 assessment, Liberia had not conducted a quantification exercise of safe blood or related supplies required to collect, store and transfuse. This in turn contributed to significant shortages in access to safe blood across the health system, as well as hindered the NBSP’s ability to effectively mobilize resources to meet the blood system’s needs. In partnership with the Accelerator and the National Quantification Technical Committee (NQTC), NBSP sought to conduct the country’s first quantification for safe blood products, reagents and supplies in 2024.

Furthermore, Liberia’s blood system did not have accurate data on blood donation rates, usage patterns, and shortages or wastage rates. As a result, experts opted to rely on a methodology consisting of both service delivery and demographic data. The demographic approach built on the WHO’s recommendation that 10-20 units of blood are required for every 1,000 people in a population.

The service delivery-based approach then combined (1) a review of data from the national Health Information System (HMIS) to identify conditions and estimate the percent of cases where blood transfusions were required with (2) treatment guidelines and expert clinical opinion to estimate the average quantity of blood units required for each condition.

In March 2024, NBSP, NQTC and the Accelerator organized a national quantification workshop consisting of key stakeholders and clinicians from across the country to review the methodology. Ultimately, the first national Blood Products, Reagents, and Supplies Quantification Report in Liberia was validated and finalized in July 2024. The findings of the report are now being used by NBSP to inform resource planning, donor mobilization and procurement decisions.

Malawi: strengthening accuracy

In Malawi, the MBTS sought to strengthen its quantification methodology to improve accuracy, and thus reduce persistent shortages in safe blood. In partnership with the Accelerator, the MBTS developed a quantification model to estimate the country’s overall blood requirement. The model analyzes together historical blood usage data from hospitals, population demographics, disease prevalence and service delivery data.

Both qualitative and quantitative data was collected to inform the model, i.e., key informant interviews at hospitals and blood banks, consumption data from the Laboratory Information Management System, demographic data from the Demographic and Health Survey, to name a few. Once data was collected, the quantification model was built using the Autoregressive Integrated Moving Average Model (ARIMA), which has been used to model blood needs in other countries.

In Malawi, the Blood Needs Quantification Model provides estimates from 2023-2030. The model provides MBTS with specificity to view estimated safe blood needs at both the national and facility-levels on a monthly and annual basis, as well as utilization trends and further details based on blood groups. The model is now being used by MBTS to monitor annual blood demand and utilization to provide MBTS with a more accurate view of access to safe blood within the national system.

Conclusion

The Accelerator’s work with NBSP in Liberia and MBTS in Malawi illustrates how global WHO guidance can be effectively translated into actionable improvements in countries, ultimately enhancing decision-making regardless of a country’s starting point. Liberia and Malawi offer two different examples of countries seeking to strengthen their abilities to quantifications to inform resource planning and supply planning for safe blood.

By exploring the different approaches available to countries, based on where they lie in the spectrum of access to data and capacity for conducting quantifications, it provides a pathway for other countries to follow when seeking to refine and improve their own efforts.

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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.

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Following the Ebola epidemic (2014-16), the Government of Liberia, together with partners, rapidly established and scaled up a national community health system to support a cadre of Community Health Assistants (CHAs) in remote locations to provide a series of basic health services. The first iteration of the national policy on community health over 2016-2021 provided for limited package of mental health services. However, the resources for and implementation of community-level mental health services in practice was scant and largely neglected, with key coordination and capacity gaps undermining the ability of the national community and mental health systems to collaborate and implement effectively.

The Health Systems Strengthening Accelerator supported the Government of Liberia (GOL) in expanding the provision of high-quality mental health and psychosocial support (MHPSS) services. One of the core components of the Accelerator’s scope of work in Liberia was to support the Ministry of Health’s Mental Health Unit in strengthening community-level mental health programming. In order to better understand the challenges and best practices observed in previous and ongoing local initiatives, the Accelerator conducted a rapid desk review of salient community-level mental health interventions in Liberia. The Accelerator’s assessment revealed that:

1. The roles and responsibilities of community health workers in MHPSS were limited,
2. Training of community health workers was severely lacking,
3. CHAs did not coordinate with or receive supportive supervision from trained PHC workers or secondary-level clinicians on mental health, and
4. Coordination, monitoring, and oversight of community-level mental health services was weak overall.

This brief summarizes the results of the desk review, and puts forward recommendations the following for a) revising the package and training module for MHPSS delivery at the community level, and b) sustainably improving how community mental health is implemented and coordinated by integrating certain strategic and promising approaches observed in the Liberian initiatives under review.

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The symposium proved a pivotal moment in advocating for community health workers who should be trained effectively, paid as professionals, adequately supplied, and supportively supervised to advance critical public health goals. With over 700 participants gathered in Monrovia, the symposium included government representation from 46 countries, CHWs from around the world who participated in every session, and high-level representation from Liberia, participating countries, and development partners.

R4D’s Health Systems Strengthening Accelerator team was honored to support the development and delivery of the 2023 CHW Symposium. We facilitated a full-day pre-symposium workshop among 39 country delegations focused on advancing community health roadmaps and improving measurement of progress; and led development of four out of nine of the main symposium’s themed tracks dedicated to institutionalizing financing, professionalizing the community-led workforce, improving the use of data in CHW programs, and gender dimensions in community health programming.

We thank Liberia’s Ministry of Health, USAID, UNICEF, the Global Fund, Last Mile Health, the Community Health Impact Coalition, and all organizing partners for the great team effort that created such a successful global gathering.

R4D strongly supports the symposium’s culminating Monrovia Call to Action, an evidence-based mutual commitment to fund, scale and strengthen community health programs as an integral part of primary health care for the realization of universal health coverage. We commit to support the advancement of CHWs and their integration into strong primary health care systems as we work with governments, civil society, researchers, and other change agents to create self-sustaining systems that support healthy, educated people. 

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About Results for Development
Results for Development (R4D) is a leading non-profit global development partner. We collaborate with change agents — government officials, civil society leaders and social innovators — supporting them as they navigate complex change processes to achieve large-scale, equitable outcomes in health, education and nutrition. We work with country leaders to diagnose challenges, co-create, innovate and implement solutions built on evidence and diverse stakeholder input, and engage in learning to adapt, iterate and improve. We also strengthen global, regional and country ecosystems to support country leaders with expertise, evidence, and innovations. R4D helps country leaders solve their immediate challenges today, while also strengthening systems and institutions to address tomorrow’s challenges. And we share what we learn so others around the world can achieve results for development too. www.R4D.org

Photo © Patrick Adams, RTI International

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As Ghana Country Director at Results for Development (R4D), she leads the organization’s work in Ghana, advancing primary health care reforms, health financing, and data use in partnership with the Ministry of Health, National Health Insurance Authority, and other stakeholders.

Before joining R4D, Dr. Amo-Addae served as Resident Advisor and Country Lead for the African Field Epidemiology Network (AFENET) in Liberia, where she established the Liberia Field Epidemiology Training Program which has contributed greatly to public health workforce capacity-building in Liberia. Maame also supported the creation of the One Health Coordination Platform in Liberia. She previously held senior roles within the Ghana Health Service, leading district health systems and pioneering innovative maternal and child health programs.

Dr Amo-Addae is a medical doctor and holds a Masters in Public Health, MPhil in Applied Epidemiology and Disease Control from the University of Ghana, and a PhD in Public Health from Texila American University.

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