P-PBM Blog: From Scarcity to Strategy: Reshaping Blood Care in Africa Through PBM

This blog examines the practical implementation of PBM in African healthcare settings, highlighting strategies to improve perioperative outcomes, optimise blood use, and strengthen health-system resilience.

By Françoise Nizeyimana, Alexander Akowuah, and Fredy Ariza

Across Africa, healthcare systems face a paradox: a high burden of anaemia, bleeding, trauma, and obstetric haemorrhage on one hand, and on the other, limited access to blood components, diagnostics, and advanced haemostatic technologies. Despite scarcity, perioperative transfusion remains variable and sometimes avoidable, exposing patients to preventable complications and straining fragile blood supplies.

Poorly justified blood requisition practices further exacerbate shortages in sub-Saharan Africa, particularly where donation systems and logistics are already constrained.¹ Moreover, perioperative red blood cell (RBC) transfusion is consistently associated with increased postoperative morbidity and mortality across major surgical cohorts, reinforcing that “more transfusion” does not equal “better outcomes”. ^2,3 Patient Blood Management (PBM) is therefore not aspirational but a pragmatic, patient-centred strategy suited to African realities.

Endorsed by the World Health Organization (WHO) and supported by the World Federation of Societies of Anaesthesiologists (WFSA), PBM is explicitly positioned as a health-system intervention that prioritises education, governance, and multiprofessional collaboration, rather than technology-dependent solutions.^4,5

Why Sub-Saharan Africa cannot afford to delay PBM implementation

Sub-Saharan African surgical and obstetric populations differ substantially from those in Europe or North America, where much of the perioperative evidence concerning blood and transfusion practice was first generated. However, emerging data suggest that the risks PBM addresses may be even more pronounced in African settings, including among children.

In sub-Saharan Africa, paediatric anaemia remains highly prevalent, leaving many children physiologically vulnerable before surgery.⁶ At the same time, children represent a substantial proportion of the population and carry a major surgical burden, with outcomes after surgery in African settings reported to be significantly worse than global benchmarks.⁷

A secondary analysis of the South African Surgical Outcomes Study (SASOS) demonstrated that almost 50% of adult surgical patients in public hospitals presented with preoperative anaemia, which was independently associated with increased in-hospital mortality (OR 1.66), and higher rates of critical care admission (OR 1.49).⁸

Crucially, these findings were observed in a young surgical population, underscoring preventable perioperative risk and the urgent need for structured quality-improvement programmes targeting anaemia and bleeding. Longer elective surgery waiting times should be viewed as opportunities for anaemia detection and treatment.

PBM works because it focuses on people, not products

A persistent misconception is that PBM depends on advanced diagnostics or costly therapies. Evidence from South Africa clearly refutes this. A five-year PBM-oriented change programme in a regional hospital reduced RBC use by over 40%, with parallel reductions in plasma and platelet utilisation, without additional staff, infrastructure, or budget. ⁹

Success was driven by:

• Education and engagement across clinical disciplines,
• Simple, evidence-based transfusion criteria,
• Revitalised transfusion committees, and
• Continuous audit and feedback.

This model demonstrates that PBM is achievable and sustainable in resource-constrained environments when the focus is on behaviour, accountability, and teamwork rather than technology.⁹

Addressing inequity: PBM as a system-level solution

National data from South Africa reveal profound disparities in blood utilisation between public and private healthcare sectors. Public hospitals serving most of the population, operate with lower pre-transfusion haemoglobin thresholds, higher anaemia prevalence, and greater reliance on transfusion in obstetrics, general surgery, and medical admissions.¹⁰

These differences are driven not only by disease burden, but also by practice variation and system fragmentation. Authors conclude that nationally coordinated PBM programmes are essential to ensure equity, sustainability, and blood security. PBM thus becomes not only a clinical strategy, but a health-system equaliser, aligning patient safety with responsible stewardship of scarce resources.

Education as the cornerstone: the WFSA perioperative PBM initiative in Africa

Appreciating these realities, WFSA, through its perioperative PBM (P-PBM) Working Group, has prioritised context-adapted education as the foundation for implementation.

The following have been done as part of this strategy:

• Two preparatory regional webinars addressing anaemia, major bleeding, transfusion risk, and PBM feasibility in low-resource environments. 
• A P-PBM course tailored to Sub-Saharan African settings was piloted in Addis Ababa under the stewardship of seven regional leaders:  Alexander Akowuah (Ghana), Fitsum Kifle (Ethiopia), Françoise Nizeyimana (Rwanda), Amos Zacharia (Tanzania), Tirunesh Busha (Ethiopia), Biruk Dires (Ethiopia), and Lemi Bayisa (Ethiopia).

All activities were aligned with the WFSA P-PBM Course Manual for Facilitators, emphasising multiprofessional learning, local adaptation, and stepwise implementation. Both initiatives were deliberate steps towards building a shared PBM agenda for Africa.

This work was made possible through grant support from Global Health Partnerships (formerly THET), funded by the UK Department of Health and Social Care (DHSC), and through close collaboration with the National Perioperative Quality Initiative in Ethiopia. These partnerships enabled an education-first approach aligned with African priorities and global PBM guidance.

What a structured PBM agenda for Sub-Saharan Africa should prioritise

Drawing on WHO guidance, data from Sub-Saharan Africa, and recent WFSA experience, a pragmatic PBM implementation agenda should focus on:

1. Anaemia as a diagnosis, not a number:  Routine screening, basic diagnostics, and early treatment especially in major surgery, obstetric, and trauma patients.
2. Multiprofessional ownership:  P-PBM must involve anaesthesiologists, surgeons, obstetricians, nurses, midwives, laboratory teams, pharmacists, and hospital leadership.
3. Simple, standardised pathways: Context-adapted algorithms for anaemia management, bleeding control, and restrictive transfusion practice.
4. Education before technology: Faculty development, case-based learning, and continuous professional education as primary drivers of change.
5. Governance and measurement: Active transfusion committees, basic indicators, and audit-feedback loops to sustain progress.

A collective opportunity

Sub-Saharan health systems do not need to replicate high-income PBM models. They require ownership, collaboration, and continuity. PBM improves outcomes, reduces harm, and preserves resources, which is critical where resources are scarce.

Encouragingly, this collective vision is already taking shape. The Ethiopian Ministry of Health has demonstrated commitment to PBM by convening clinicians, professional societies, and policymakers in a truly multiprofessional national effort.

This work has resulted in the near finalisation of the first draft of the National PBM Clinical Guidelines and the development of a National PBM Manifesto. Potential PBM champion sites have been identified to support early testing of the guidelines.

These activities lay the foundation for a phased national PBM scale-up, including the initiation of a national policy and regulatory pathway aimed at improving universal access to safer therapeutic alternatives and enabling technologies across the country. This effort will be undertaken in collaboration with the Ethiopian Blood Bank and key stakeholders. Next steps include developing a national PBM dashboard, using a minimal core dataset to support monitoring and quality improvement at hospital and national levels.

The challenge ahead is collective. By aligning education, governance, global guidance and local circumstances, healthcare systems in Sub-Saharan Africa or similar contexts can move from transfusion-dependency to patient-centred blood care.

The potential benefits of PBM in the region are immense and this should spur efforts to provide safe perioperative care for all.

Recommended Readings

• ¹ Mauka WI, Mtuy TB, Mahande MJ, Msuya SE, Mboya IB, Juma A, Philemon RN. Risk factors for inappropriate blood requisition among hospitals in Tanzania. PLoS One. 2018 May 17;13(5):e0196453.
  
• ² Gupta P, Kang KK, Pasternack JB, Klein E, Feierman DE. Perioperative Transfusion Associated With Increased Morbidity and Mortality in Geriatric Patients Undergoing Hip Fracture Surgery. Geriatr Orthop Surg Rehabil. 2021 May 16;12:21514593211015118.
  
• ³ Obi AT, Park YJ, Bove P, Cuff R, Kazmers A, Gurm HS, Grossman PM, Henke PK. The association of perioperative transfusion with 30-day morbidity and mortality in patients undergoing major vascular surgery. J Vasc Surg. 2015 Apr;61(4):1000-9.e1.
  
• ⁴ Guidance on implementing patient blood management to improve global blood health status. Geneva: World Health Organization; 2024. Licence: CC BY-NC-SA 3.0 IGO. Available in:  https://www.who.int/publications/i/item/9789240104662
  
• ⁵  https://wfsahq.org/our-work/safety-quality/perioperative-patient-blood-management-p-pbm/
  
• ⁶ Tesema GA, Worku MG, Tessema ZT, Teshale AB, Alem AZ, Yeshaw Y, Alamneh TS, Liyew AM. Prevalence and determinants of severity levels of anemia among children aged 6-59 months in sub-Saharan Africa: A multilevel ordinal logistic regression analysis. PLoS One. 2021 Apr 23;16(4):e0249978.
  
• ⁷ ASOS-Paeds Investigators. Outcomes after surgery for children in Africa (ASOS-Paeds): a 14-day prospective observational cohort study. Lancet. 2024 Apr 13;403(10435):1482-1492.
  
• ⁸ Wise R, Hood K, Bishop D, Sharp G, Rodseth R; Saving Blood Saving Lives Working Group. Analysis of a 5-year, evidenced-based, rational blood utilisation project in a South African regional hospital. Transfus Med. 2024 Apr;34(2):154-164. doi: 10.1111/tme.13025. Epub 2023 Dec 28. PMID: 38152867.
  
• ⁹ Thomson J, Hofmann A, Barrett CA, Beeton A, Bellairs GRM, Boretti L, Coetzee MJ, Farmer S, Gibbs MW, H Gombotz H, Hilton C, Kassianides C, Louw VJ, Lundgren C, Mahlangu JN, Noel CB, Rambiritch V, Schneider F, Verburgh E, Wessels PL, Wessels P, Wise R, Shander On Behalf Of The South African Patient Blood Management Group A. Patient blood management: A solution for South Africa. S Afr Med J. 2019 Jun 28;109(7):471-476. doi:10.7196/SAMJ.2019.v109i7.13859. PMID: 31266571; PMCID: PMC10414180.
  
• ¹⁰ Bolton L, van den Berg K, Swanevelder R, Pulliam JRC. Characterising differences in red blood cell usage patterns between healthcare sectors in South Africa: 2014-2019. Blood Transfus. 2022 Jul;20(4):299-309. doi: 10.2450/2021.0209-21. Epub 2021 Nov 29. PMID: 34967724; PMCID: PMC9256512.