Perioperative Patient Blood Management (PBM) in Africa: a multicentre mixed-methods assessment of health system readiness and clinical practice in Ethiopia

Abstract

Abstract Background Perioperative Patient Blood Management (PBM), a patient-centred, evidence-based approach to improve outcomes by preserving and optimising a patient’s own blood, remains unimplemented in most low- and middle-income countries. Few studies have assessed health-system readiness for PBM implementation, anaemia management, or transfusion practices in sub-Saharan Africa. This study provides a pre-implementation baseline assessment of perioperative PBM readiness in Ethiopia. Materials and Method A mixed-methods approach evaluated 12 public hospitals in Addis Ababa, with the PBM Facility Assessment Tool to determine readiness scores. Data from 1,236 surgical patients assessed anaemia, transfusions, and predictors. Interviews with clinicians, blood bank staff, and policymakers explored decision-making and barriers. Findings were integrated through triangulation. Results The composite PBM-FAT score was 6.6 ± 0.7 (range 5.5–7.5); however, this reflects general perioperative and transfusion-service infrastructure rather than PBM-specific capability. Domain analysis revealed critical gaps: 75% of facilities lacked intravenous iron, viscoelastic testing was absent in all, and 66.7% lacked point-of-care haemoglobin testing. Fibrinogen and haematinic tests were rarely available (66–92% never tested). Preoperative anaemia was documented in 7.1% of patients, a minimum estimate reflecting detection failure due to non-systematic haemoglobin testing, and perioperative transfusion occurred in 2.4%, more consistent with supply rationing than with optimised clinical practice. Independent transfusion predictors included cancer surgery (AOR 11.28, 95% CI 3.00–42.36) and blood loss ≥500 mL (AOR 9.76, 95% CI 3.94–24.17). Interviews revealed blood shortages, the absence of national PBM governance, transfusion as the default treatment for anaemia, and highly variable thresholds. Conclusion Ethiopian hospitals have functional transfusion services but lack the anaemia management pathways, diagnostics, therapeutics, and governance structures required for Patient Blood Management. PBM is not yet operationalised as a patient-centred, preventive care strategy. Priority implementation steps, aligned with the WHO 2024 PBM guidance, include systematic preoperative haemoglobin screening, access to intravenous iron, blood utilisation governance, and a national PBM framework to improve patient outcomes. Visual summary Highlights Ethiopian public hospitals have functional transfusion and perioperative infrastructure (composite PBM-FAT score 6.6/10) but lack the PBM-specific capabilities, systematic anaemia management, intravenous iron, and haemostatic diagnostics required for patient-centred blood optimisation. Systemic barriers, including blood shortages, the absence of national PBM governance, and inconsistent practices, highlight the urgent need for national guidelines and utilisation monitoring to strengthen surgical safety. Blood shortages coexist with inefficient utilisation practices, indicating that governance gaps compound supply constraints.