The State of Transfusion Medicine in Low- and Middle-income Countries: A Critical Narrative Review.

An annual global shortfall of over 100 million blood units is borne almost entirely by low- and middle-income countries (LMICs), with measurable consequences for patient survival. Despite sustained advocacy, the evidence on transfusion medicine across these settings has not been systematically and critically reviewed. A narrative review was conducted across 9 electronic databases, applying strict LMIC-specific, date-bound eligibility criteria. Studies conducted in LMIC settings addressing any aspect of transfusion medicine and published within the preceding 15 years were eligible. Seven studies met the inclusion criteria; this scarcity reflects a genuinely thin peer-reviewed evidence base and is itself reported as a finding. The reviewed literature identifies substantial deficiencies across transfusion systems in LMIC settings, spanning regulatory frameworks, hemovigilance, voluntary donation, infection screening, and infrastructure. The evidence base is geographically narrow and predominantly descriptive: it documents what is lacking but offers limited explanatory or evaluative reach. All 7 studies were rated as moderate quality. The most significant evidential gap is the near-total absence of outcome-level data: only 1 study examines the relationship between system performance and patient survival, finding that 1 in 5 children in Kenya who were prescribed a blood transfusion died before receiving it. Transfusion medicine in LMICs is characterized by substantial and consistent deficiencies attributable to shared structural determinants, whose specific expression in each setting is nonetheless shaped by local institutional and political conditions. The evidence base documents these deficiencies but cannot explain their origins or determine what would change them. Transfusion system reform in LMICs requires legislative and regulatory engagement, not only technical assistance; voluntary donation programs require sustained governance commitment to remain stable; and outcome-level research across diverse LMIC settings is the most urgent research priority.