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 crossmatching 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$) was $17 976, equivalent to $16.28 per unit of transfusion-ready blood. Transfusion-related tests used 53% of the laboratory's total annual expenditure of $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.

In contrast to the advanced transfusion medicine in developed nations, our findings highlight the persistent and urgent need for life-saving blood transfusions in especially young children and pregnant women in Africa. The results indicate that blood transfusion services adapted to local conditions may be a realistic solution for providing safe blood products in developing countries. Serious challenges, such as HIV transmission and sustainable organization of low-risk blood donations should be addressed to assure access to safe blood products.

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