C. J. F. Mundy

Laboratory costs of a hospital-based blood transfusion service in Malawi

Background: Despite policies advocating centralised transfusion services based on voluntary donors, the hospital-based replacement donor system is widespread in sub-Saharan Africa. Aims: To evaluate the cost of all laboratory resources needed to provide a unit of safe blood in rural Malawi using the family replacement donor system Methods: Full economic costs of all laboratory tests used to screen potential donors and to perform cross-matching were documented in a prospective, observational study in Ntcheu district hospital laboratory. Results: 1729 potential donors were screened and 11 008 tests were performed to ensure that 1104 units of safe blood were available for transfusion. The annual cost of all transfusion-related tests (in 2005 US

The operation, quality and costs of a district hospital laboratory service in Malawi.

) was

Evaluation and costs of different haemoglobin methods for use in district hospitals in Malawi

17 976, equivalent to

Use of clinical judgement to guide administration of blood transfusions in Malawi

16.28 per unit of transfusion-ready blood. Transfusion-related tests used 53% of the laboratory’s total annual expenditure of

Lost smear-positive pulmonary tuberculosis cases: where are they and why did we lose them?

33 608. Conclusions: This is the first study to provide prospective economic costs of all laboratory tests associated with the family replacement donor system in a district hospital in Africa. Results show that despite potential economies of scale, a unit of blood from the centralised system costs about three times as much as one from the hospital-based “replacement” system. Factors affecting these relative costs are complex but are in part due to the cost of donor recruitment in centralised systems. In the replacement system the cost of donor recruitment is entirely borne by families of patients needing a blood transfusion.

Screening tuberculosis suspects using two sputum smears

Laboratory services are run down in many low-income countries, severely constraining their input to patient care and disease surveillance. There are few data about the quality and cost of individual components of the laboratory service in poorer countries, yet this information is essential if optimal use is to be made of scarce resources. Staff time, range of tests, workload, and safety procedures were monitored over 12 months (1997-98) in a typical district hospital laboratory in Malawi. Data were collected to calculate the total economic cost of these services. Of the 31203 tests performed, 84% were to support blood transfusion and diagnosis of malaria and tuberculosis (TB). Test quality was reasonable for malaria and TB microscopy and blood transfusion, but poor for haemoglobin estimation. The cost per test ranged from US dollars 0.35 for haemoglobin to US dollars 11.7 per unit of blood issued and the total annual cost of the laboratory service was US dollars 32618. Blood transfusion and microscopy for malaria and TB comprised the majority of tests. Ensuring that these tests are of the highest quality will therefore have the most impact in reducing wastage of laboratory resources. Inadequate quality of haemoglobin estimations is a particular problem. The findings of this study are likely to be relevant to other low-income countries with similar disease burdens.

Evaluation of microscope condition in Malawi

Aims: To evaluate the characteristics of manual haemoglobin methods in use in Malawi and provide evidence for the Ministry of Health in Malawi to enable them to choose a suitable method for district hospitals. Methods: Criteria on accuracy, clinical usefulness, user friendliness, speed, training time, and economic costs were determined by local health professionals and used to compare six different manual haemoglobin methods. These were introduced sequentially into use in a district hospital in Malawi alongside the reference method. Results: HemoCue was the optimal method based on most of the outcome measures but was also the most expensive (US

Serological and molecular screening for viruses in blood donors from Ntcheu, Malawi: High prevalence of HIV-1 subtype C and of markers of hepatitis B and C viruses

0.75/test). DHT meter and Jenway colorimeter were the second choice because they were cheaper (US

Quality assessment of sputum transportation, smear preparation and AFB microscopy in a rural district in Malawi

0.20–0.35/test), but they were not as accurate or user friendly as HemoCue. Conclusions: The process for choosing appropriate laboratory methods is complex and very little guidance is available for health managers in poorer countries. This paper describes the development and testing of a practical model for gathering evidence about test efficiency that could be adapted for use in other resource poor settings.

Safety in laboratories carrying out sputum smear microscopy: a dilemma for resource-poor countries.

The aim of this study was to investigate whether clinicians in Malawi could use clinical judgement alone to administer blood transfusions in accordance with guidelines. Clinicians at a district hospital did not use the Lovibond Comparator haemoglobin results provided by their laboratory as they felt them to be unreliable, preferring instead to rely on their clinical judgement alone to guide transfusion practice. Their transfusion practice and the Lovibond haemoglobin results were monitored against the World Health Organization recommended haemiglobincyanide method for haemoglobin measurement without the clinicians having access to this result. The Lovibond Comparator method was shown to have a sensitivity of only 21% to detect trigger haemoglobin values for transfusion published in local guidelines. Without access to a useful haemoglobin result, clinicians gave 67% of transfusions in accordance with the haemoglobin trigger values in the guidelines. This study shows that clinical features alone can provide a reasonable guide about the need for transfusion, and that poor quality laboratory tests limit the effectiveness of transfusion guidelines.