Blood donation in sub-Saharan Africa is a vitally important topic at the intersection of public health, ethics and public policy. Recent studies on blood transfusion practices show that blood transfusion safety remains a challenge in Nigeria (and most African countries) due to the presence of commercial blood donors. While the activities of commercial blood donors pose ethical concerns for the safety of the healthcare system, they appear to fill a gap in medical delivery because of blood shortage. This ostensible benefit, however, should not obscure the imperative of removing economic challenges that promote donating blood for remuneration.
From a survey by blood bank personnel, it was discovered that a good number of Nigerian healthcare institutions depend largely on commercial blood donors as against voluntary non-remunerated blood donors. Two major factors propelling the reliance on paid-donors are the wide gap between blood demand and supply as well as the increasing decline in voluntary blood donors relative to the increasing rise in commercial blood donors. A survey carried out by Ahmed et al and referenced by Aneke and Okocha, reveals a progressive decrease in the percentage of voluntary blood donation from 31% to 5%, against an increase from 20% to 63% in the frequency of commercial blood donation.” According to Nigeria’s National Blood Transfusion Services (NBTS) Manual, citing the national baseline data survey on blood transfusion, 25% and 75% constitute commercial and replacement donors respectively in public healthcare institutions in Nigeria. When this figure is compared with the private healthcare institutions according to the baseline data, there exists a remarkable switch of figures. It discovered that 75% and 25% make up commercial and replacement donors respectively. Replacement donors here represent those family members or friends who would donate blood for a patient with a view to replacing the volume of blood expended on their sick loved ones.
What this latter switch in data shows is that private medical facilities largely depend on blood sourced from commercial blood donors. It is also important to note that, although government healthcare institutions rely less on for-profit blood donors, they are not left out in the patronage of commercial blood donors. In some public health institutions for instance, commercial blood donors organize themselves into powerful associations to protect their business interests in the supply of blood. Highlighting further the crisis in the blood supply chain in the Nigeria healthcare system, the National Coordinator of the National Blood Transfusion Service, Dr. Joseph Amedu, disclosed that Nigeria needs at least two million units of blood annually. However, only 500,000 units of blood are donated yearly. While 95 per cent of them are from paid donors, only 5 per cent are from voluntary donors. Blood shortage in the Nigerian healthcare system and indeed in sub-Saharan Africa has serious health consequences. Take for example maternal health: according to Chukwuma Muanya, “everyday, 537 women in Sub-Saharan Africa die from pregnancy-related complications. Many of these deaths are due to lack of blood. Half of the maternal deaths from severe bleeding in the world occur in Sub-Saharan Africa. About 65 per cent of these deaths occur in the post-partum period, according to reports.” Sulaiman Akanmu, a professor of Hematology and Blood Transfusion, reported that, “in Nigeria, 80-90 per cent of maternal mortality is as a result of bleeding complications that we are not able to manage due to shortage of blood.” Because many healthcare providers have sworn to save lives, they would not mind procuring blood from paid donors even though the blood from this category of donors are known to be less safe.
Despite the important gap paid-donors fill, the safety of blood remains a serious concern in the Nigerian healthcare sector, because, as most scholars hold, paid-donors all over the world have higher incidence of Transfusion Transmission Infections (TTIs) [i.e. they are high-risk donors]. This is because, apart from infecting the blood system with their diseases, they are also exposed to the risk of infection with constant donation of blood. According to a study conducted by Safe Blood for Africa Foundation, about 2 million transfusions are given to children annually and at least 200,000 are infected with HIV through blood transfusion. This rate is gradually rising because there is a general lack of interest in Nigeria to voluntarily donate blood, hence blood donation is left to the high-risk paid-donors. Drawing from demographic studies carried out by Jean-Pierre Allain in Sub-Saharan Africa, Aneke and Okocha observed that commercial blood donors were mostly young adult males, which unfortunately were also associated with highest carriage rates of TTIs. As a result, safe blood for transfusion is not readily available in the country.
Apart from the risks associated with TTIs, attention to income and how it impacts blood safety is imperative. In a study carried out among the Ebonyi people of South Eastern Nigeria, respondents mentioned “not being strong enough” and “not having enough blood” as the two major reasons for declining blood donation. Viewed critically, these responses may point to underlining income and health issues. In a society where most people spend a greater part of their day toiling and where most people do not make enough money to pay for medical treatment, it should not come as a surprise when people show aversion to the idea of donating their blood for free.
Those who could donate, particularly those who donate blood for gain tend to conceal information about the frequency of donation and are more likely to donate blood at different vendor centers to make more money, even if it becomes unsafe to do so, as one thing the donors have in common is the lack of the financial wherewithal to take care of themselves.  This situation may be linked to the unjust and unequal economic structures, which have rendered them financially dependent. This situation makes it possible for a substantial number of paid donors to come from the lower class as well. The natural response of these people will be to exchange their blood for cash. Because the fundamental interest of these commercial donors is financial in nature, many of them hide information regarding their health condition, which can endanger other peoples’ lives. They generally avoid voluntary donation of blood with the argument that the majority of those who donate blood are usually not sufficiently nourished nor well off. As such, demanding financial remuneration is justified by the fact that the donors provide a source of nourishment.
Studies have shown that the more people are economically well off, the more they are likely to donate blood without remuneration. A published study reported that, in Brazil and Denmark, blood donation “increased with the economic level of the respondents” and that those who were in the middle and high income groups “had a fourfold higher blood donor prevalence compared to the lowest income group.” One possible explanation for this could be that, those on the higher economic ladder feel medically and economically secure compared to those on the lower income ladder who may be worried about what to do to recover their health should anything go wrong as a result of donating blood. Considering the role socio-economic conditions play in how people respond to blood donation, the fact that most people do not see blood donation as a social responsibility, governments and blood transfusion agencies should focus on creating and encouraging conditions that could put money in people’s pockets, thereby reducing the need to need to ask for money for blood donation.
Thus, one possible way to diminish commercial blood donation is for government to provide the enabling environment for people to have medical insurance. Rooting out the activities of commercial blood donors and ensuring safety of blood transfusion will require that citizens enroll in health insurance. For decades the Nigerian governments, politicians and technocrats have talked about the need to have a nationwide health coverage but have failed to make significant progress. In a country, as reported by the Nigerian Bureau of Statistics in its 2022 report, where 133 million people live in multidimensional poverty, the Nigerian Health Insurance Scheme (NHIS) was established in 1999 to alleviate huge out-of-pocket healthcare spending. However, recent reports by Al Jazeera state that enrollment has been low, in fact, less than 10 percent of Nigerians are enrolled in the Nigerian Health Insurance Scheme (NHIS), and most of these are federal employees and their families, according to Nasir Sambo, the executive secretary of NHIS. The implication is that many Nigerians are uninsured and will either have to pay out of pocket for their medical expenses or succumb to inadequate medical treatment. “More than 70% of Nigerians are still uninsured, especially those in the informal sector and rural dwellers, for whom paying out of pocket for their health needs seems like the only option available.”
Though it may true, as some have argued, that people’s faith and trust in God to heal them of any ailment may be driving low health insurance enrollment, but more important is the reality that most ordinary people do not have enough income to enroll in health insurance. Although private insurance companies were meant to supplement the efforts of the governments, especially in the coverage of the informal sector, they tend to focus on large and profitable companies whom they believe have the resources to pay the premiums. Hence, those who fall under the low-income bracket are priced out of the health insurance markets. Therefore, from the point of view of economic justice, governments at all levels should ensure that citizens and residents are adequately insured. This is not a privilege but a right that belongs to every person.
Considering that in Africa the single most important ethical concern is the preservation of life, governments and businesses should ensure that employees and citizens are medically insured. Doing so will attenuate if not eradicate the need to donate blood for a fee. Furthermore, in light of Africa’s understanding of solidarity in terms of a community that comprises the ancestors, the living, the dead and the unborn, it is imperative that governments and businesses look beyond the profit-mindset to consider how economic solidarity might support people. Assisting indigent citizens to improve their economic standing can discourage them from selling their blood, encourage safety in blood transfusion, promote public health and economic wellbeing for many.
 John Aneke and Chide Okocha, “Blood Transfusion Safety; Current Status and Challenges in Nigeria,” Asian Journal of Transfusion Science 11 no. 1 (2017): 1-5. https://www.ajts.org/text.asp?2017/11/1/1/200781
 Federal Ministry of Health, National Blood Transfusion Service, Nigerian National Blood Policy, Abuja, May 2006, p. 1.
 Chukwuma Muanya, “95% of donor blood units used in Nigeria ‘unsafe,’ experts warn,” The Guardian, June 2021, https://guardian.ng/news/95-of-donor-blood-units-used-in-nigeria-unsafe-experts-warn/.
 Chioma Obinna, “Nigeria far from achieving 100% voluntary blood donation — NBTS,” Vanguard. February 2023. https://www.vanguardngr.com/2022/06/nigeria-far-from-achieving-100-voluntary-blood-donation-nbts/#:~:text=According%20to%20the%20NBTS%2C%20about,donate%20blood%20for%20monetary%20gains.
 Federal Ministry of Health, National Blood Transfusion Service, Nigerian National Blood Policy, Abuja, May 2006, p. 1.
 The study was conducted by Jeff Busch, project chairman of Safe Blood for Africa Foundation.
 Aneke and Okocha. “Blood Transfusion Safety; Current Status and Challenges in Nigeria.”
 Odidika Ugochukwu Umeora, Sunday Omale Onuh, MaryJoanne Chinyem Umeora, “Socio-cultural barriers to voluntary blood donation for obstetric use in a rural Nigerian village,” African Journal of Reproductive Health 9 no. 3 (December 2005):72-76.
 Benedict Nwogoh, Augustina Awodu Omolade, and Nosakhare Bazuaye Godwin, “Blood Donation in Nigeria: Standard of the Donated Blood.” Journal of Laboratory Physicians 4 no. 2 (2012): 94-97.
 Olalere Dawood, Interview by the Author.
 Edmund Ndudi Ossai, Nelson C Eze, Okwudiri Chukwu, Ugochinyere A Uguru, Ezinne C Ukpai and Ezeogo Ihere, “Determinants of practice of blood donation among undergraduate students of Ebonyi State University Abakaliki, Southeast Nigeria,” Archives of Community Medicine and Public Health 4 no. 1 (2018): 1-7.
 Mariam Adetona, “Two decades later, Nigeria’s health insurance is still flailing,” Aljazeera. May 11, 2022. https://www.aljazeera.com/features/2022/5/11/two-decades-after-nigerias-health-insurance-is-still-flailing
 Adetona, “Two decades later, Nigeria’s health insurance is still flailing,”