title: The global blood supply: a literature review.
abstract: BACKGROUND
  A safe and sufficient blood supply is requisite for a functional surgical system. Although the disparity in blood donation rates between low-income and middle-income countries (LMICs) and high-income countries is well documented, less is known about the reasons for this inequity, which compromises efforts to remedy it. We aimed to review the state of the blood supply and elucidate unique country-specific challenges in each of the world's 196 countries.
  
  
  METHODS
  We searched PubMed, MEDLINE, Google Scholar, and WHO reports using the search terms "blood donor", "blood donation","blood safety", "blood bank", "transfusion safety", and "blood services". After an initial review of existing literature, we did a comprehensive country-by-country search of the aforementioned electronic databases, WHO regional reports, Ministry of Health websites, and National Blood Transfusion Services data for specific indicators and data points used to compare blood supply and safety across countries. These included donation rate per 1000 population, percent of donations from voluntary non-remunerated donors, number of blood banks or centres, and national blood policies. Both quantitative and descriptive data are included in a summary table in the appendix of the Lancet Commission on Global Surgery.
  
  
  RESULTS
  Our review yielded 117 publications with data for 188 countries: 101 peer-reviewed manuscripts with 13 reporting data for high-income countries and 88 for LMICs, 16 WHO publications, and a subsequent search of select websites to collect additional country-specific indicator data. Generally, blood donation is limited because of poor health infrastructure (28 LMIC and four high-income country manuscripts), low public awareness of donation practices and safety (22 LMIC manuscripts), and stigmas surrounding voluntary blood donations, especially in LMICs. Most blood banks and donation centres are located in urban centres, inaccessible to those in rural areas. The prevalence of transfusion-transmissible infections in the blood supply is higher in LMICs (30 LMIC manuscripts), resulting in high discard rates and increased transfusion risks. Two-thirds of countries have a national blood policy in place, but are often unable to efficiently coordinate and regulate blood services nationwide. To overcome these barriers, some countries have developed innovative solutions.
  
  
  CONCLUSIONS
  The blood supply in LMICs is of insufficient quantity and safety, and the reasons for these deficits are multifactorial. Addressing blood supply inadequacies requires focused attention at both local and global levels. Political prioritisation and innovative solutions to the blood crisis will be necessary to improve this situation and will require a culturally cognizant, pro-poor, pro-equity approach. Reviewing successful approaches to this crisis employed by some countries can be helpful in charting a way forward.
  
  
  BACKGROUND
  None.
authors: Eck Institute for Global Health, University of Notre Dame, Notre Dame, IN, USA. Electronic address: kkraliev@nd.edu.
authors: Katherine E
authors: KE
authors: Kralievits
authors: Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA; Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA.
authors: Nakul P
authors: NP
authors: Raykar
authors: Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA; Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA.
authors: Sarah L M
authors: SL
authors: Greenberg
authors: Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA; Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MA, USA.
authors: John G
authors: JG
authors: Meara