Improving Education and Research in Haematology and Blood Transfusion in Africa: Panacea to Improving the Health and Wellbeing of Patients in the Region

Africa bears a heavy burden of diverse diseases which includes blood diseases that overwhelm the healthcare system. A multitude of factors were believed to be responsible for this burden and it includes a lack of trained healthcare workforce, multi-disciplinary research on diseases facing the region, and a dearth of advanced diagnostic and clinical services for haematologic disorders. Measures taken to improve the situation includes increased health budgetary spending which had marginally improved. The improvement thus far achieved in haematology and blood transfusion education and research need to


INTRODUCTION
Africa bears a heavy burden of diverse diseases (Gouda et al., 2017). Blood diseases are theoretically similar however, their burden on societies is inseparable from socio-economic and cultural factors. Hence, their distribution varies significantly between different parts of the world with Sub-Saharan Africa bearing the largest burden . An increase in disease burden affects not just individuals and families but can over-stretch the healthcare system (Tluway and Makani, 2017). A multitude of factors are believed to be responsible for this skewed distribution. In addition to socio-economic and environmental factors, the lack of multi-disciplinary research on diseases facing the region and poor/inadequate training of healthcare workers have also contributed to the problem (Aikins et al., 2010;Brown et al., 2016).
Further compounding the problem is the dearth of advanced diagnostic and clinical services for haematologic disorders despite the high disease burden in the region contributed by haemoglobinopathies (Lancet Haematology, 2021). Diverse measures were taken to tackle healthcare challenges facing the region and these include increased health budget, improving education and research, doctor-patient ratio, collaboration, and advocacy Roberts et al., 2017). Low-and middle-income countries of Africa commit to increased health budgetary expenditure of 15% to achieve universal health coverage by 2030. Although some countries had failed in their commitment, others had attained the target with the remaining countries struggling at various levels to fulfil their pledge (WHO, 2013).
An increase in health spending can translate to improved education/training and research and thus improve patient wellbeing (Bein et al., 2017;Hahn & Truman, 2015). More so, medical education has a direct impact on the healthcare system as it resolves workforce crises and improves the quality of services delivered (Greysen et al., 2011). One of Africa's biggest health challenges is blood diseases, namely: Sickle cell disease, blood cancers and anaemia (Luzzatto, 2011;Makani & Roberts, 2016;WHO, 2021). This review was aimed at determining the impact of efforts made by some African governments in haematology and blood transfusion education and research to improve the wellbeing of patients.
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Selection Criteria
The selection criteria were based on the PRISMA Statement 2020. The search was focused on the field of biomedical sciences and was narrowed to the literature on haematology education and research. Research and review articles from all sources with no time restrictions that focus on African countries were included. Non-English articles and those focused on countries other than Africa were excluded. haematology, education, and research. However, search filters were applied in all the databases. Hand searching was also conducted during the same time frame using the same keywords. Of the 2616 records generated, a total of 2495 data were excluded and 121 records were extracted for eligibility assessment (see Figure 1).

Quality/Eligibility Assessment
This study was based on original research articles and review papers extracted. The search articles obtained were imported into Mendeley reference management software, where it was then exported to a Microsoft Excel spreadsheet. Duplications and non-English articles were identified and removed.
Using the title and abstract of the selected articles, the quality and eligibility of each article were carefully studied and evaluated for relevance using the criteria stated above ( Table 1). Articles were considered eligible, if Non-experimental, on the development of education and research in the field of haematology and blood transfusion in Africa in the past years and published in the English language. We included papers that report practical interventions in the healthcare challenges faced by the African region and improvement or otherwise witnessed. Articles that did not show these characteristics were all excluded. The quality assessment was not done by automation (software) but rather manually by three independent reviewers. To obviate the risk of bias in the screening process, each article was individually reviewed and scored as 1(relevant) and 0 (irrelevant) and articles with a score of 1/3 were excluded while 3/3 and 2/3 were included. A total of 121 out of the initial 2041 articles were extracted after a thorough eligibility assessment.

Data Extraction
Screening and quality assessment of the articles was followed by data extraction by two independent reviewers. The full-text articles were read independently by the reviewers and their eligibility for use in the review was determined based on the set criteria (Table 1). Disagreements were resolved through discussion.

Study Characteristics
The initial search strategy employed identified a total of 2616 articles, of which 575 were excluded as duplicates and 1920 articles were further excluded as irrelevant. The full-text review further excluded 116 articles leaving only seven articles. The most common reasons for the exclusion were that the studies were largely not directly relevant, non-English articles, and others due to location restrictions and lack of full text. An additional two articles were included from references of the included articles making the total number of eligible articles included for the final review as 7 (Moher et al., 2009).

Characteristics of Included Studies
Articles on the improvement of education and research in haematology and blood transfusion were included. Of the 7 articles included, 6 show advancement in haematology education in terms of workforce, service delivery, infrastructure as well as research in haematology for evidence-based practice, while an article discussed improvement in blood transfusion in terms of human capital development and safety and availability of blood products (Vanitha et al., 2021).

Methodological Assessment
Although the study design of the included articles varied ( Table 2), they were all non-experimental studies. There were three project reports (Tluway & Makani, 2017;Alison et al., 2013;Lubega et al., 2018), a descriptive observational study (Rizh, 2018), two cross-sectional studies (Vanitha et al., 2021;Makani et al., 2017) and a community case study (Buser, 2017). The AXIS Appraisal tool for cross-sectional was found fit to judge the quality and risk of bias of the included studies. The issue of quality common to all the studies was that they lacked clarity in the aim/objectives and findings. Furthermore, with the exception of two studies (Tluway & Makani, 2017;Makani et al., 2017), the study setting and outcome measures were not clearly described.
East African Journal of Health and Science, Volume 6, Issue 1, 2023

Report
To develop home-grown expertise in blood transfusion to produce context-specific evidence for practice and policy making The T-REC partnership programme trained undergraduate and postgraduate students, their supervisors as well as transfusion service professionals in blood transfusion research. Lubega et al., 2018 Uganda Report To build a critical mass of PHO specialists through local training and accreditation in SSA The quality of health service delivery significantly improved. There was decreased mortality and improved prognosis.

Impact of Improving Education and Research
Strengthening haematology and blood transfusion through education, training, and research has a direct impact on patient health and wellbeing. The possible impacts of such interventions were categorised into themes ( Table 3) which could be clearly measured using a modified framework for monitoring health systems performance (WHO, 2010).

Health Service Delivery
Improvement of patient wellbeing can be achieved via the establishment and equitable distribution of healthcare facilities. Although not equitably distributed, the included studies showed an increase in haematology and blood transfusion facilities for routine diagnostic/clinical services in urban areas (Rizh, 2018). An attempt to equitably distribute the facilities to regions with higher patient populations was unfortunately skewed to urban areas . This infrastructural expansion was, though without considering other determinants, claimed to have improved patient quality of life and population growth (Lubegu et al., 2018;Makani et al., 2017). Despite the significant progress in the establishment of routine haematology facilities, with the exception of one (Rizh, 2018), all included articles were silent about specialised facilities such as stem cell transplantation, bleeding disorders, oncology, and genetics centres for advanced clinical and diagnostic services (Rizh, 2018;Vanitha et al., 2021;Makani et al., 2017;Buser, 2017;Tluway and Makani 2017;Alison et al., 2013;Lubega et al., 2018). Blood is an essential therapy for anaemia, for whose quality and safety, a long-term expanded training program was launched for all clinical cadres (PEPFAR). Rizh (2018) showed safety attainment by screening for TTIs using advanced methods. However, Vanitha et al. (2021) reported training programs for blood bank staff, but no impact of such a series of training was reported.
Clinical practice has now shifted to evidencebased and data generated through research from a patient population are nowadays used for the same patient population (Izet et al., 2008). Research culture, capacity, and profile of the region have sharply improved with overseeing partnership (Rizh, 2018;Vanitha et al., 2021;Makani et al., 2017;Buser, 2017;Tluway & Makani, 2017;Alison et al., 2013;Lubega et al., 2018). Highquality researches in the included article were usually externally funded and were principally led by postgraduate students as part of their programmes (Rizh, 2018Tluway & Makani, 2017. The increase in research culture has raised the publication status of the region (Rizh, 2018). Despite a commitment to universal health coverage by African countries, visible improvements in haematology and blood transfusion were only made possible with the assistance of international partnerships. Local effort in strengthening research and education has attracted foreign sponsorship , and as a result, many oversee partners are assisting in haematology education and research (Lubegu et al., 2018;Vanitha et al., 2021, Bursa 2017. Partnership and collaboration

DISCUSSION
Following thorough screening and eligibility assessment, 7 articles were finally included for the review. Of these, very few articles explicitly explored education and research in blood transfusion. There were articles on multinational studies, but they were usually restricted to a few numbers of nations, and that could make the result un-generalisable. Most of the included studies do not report in explicit terms (measurable) the impact of education and research improvement. This review summarised the status and impact of haematology and blood transfusion education and research on healthcare and patient wellbeing. Improving haematology education had yielded a significant impact on the health workforce, and that translates to quality service and, ultimately, patient wellbeing. However, most of the programs that produced the workforce were unsustainable short-term partnership programs and largely concentrated in urban centres. It should have been fairly distributed to the other primary and secondary healthcare, at least for early identification and referral of blood diseases and avoidance of case mutilation. The treatment plan for any disease is based on proper diagnosis; there was noticeably less preference for certain segments of the workforce responsible for laboratory diagnosis. Furthermore, the trained workforce needs facilities to work in, and less reference was also made to this issue in the included articles, but an inequitable distribution of advanced clinical and diagnostic centres in urban areas was reported by a study by Rizk (2018).
There were a few high-quality haematology research works as part of postgraduate programmes, but its replica outside the academic programme was not reported.
Improving blood transfusion knowledge and skills results in preventing avoidable human errors that may cause serious consequences. There were diverse training programmes reported on blood transfusion across the region. The programmes were designed by Blood Services and Blood Bank, unlike the traditional academic setting. However, both short-term on-the-job and longterm training programmes were available for laboratory and other medical staff, with certificates being awarded upon completion of the programme. However, the measurable impact of these programmes was not reported. Research in blood transfusion is essential for practice and policy-making. The capacity and culture of research had received a boost through a partnership which trained and funded high-quality research addressing the high-priority needs of transfusion services. The research cut across cadres conducted by students, professional workers, as well as institutions. There has been a significant advancement in haematology education and research and its consequential improvement in workforce and service delivery. The included articles did not explicitly express these impacts in a quantifiable means so that it can be judged against a standard to determine the level of progress. Moreover, these impacts were largely a result of non-governmental foreign partnerships, which are unsustainable.
Although not quantifiably presented, the outcome of this review corroborated a similar finding that also showed improved workforce and service delivery. However, their outcome was attributed to postgraduate medical education (medicine), which does not include other health professions (Talib et al., 2019). Research has been identified as a priority tool in solving healthcare challenges.
Although this review showed improvement in the research culture, capacity, and profile of all cadres however, Kanmounye et al. (2020) confirmed that these gains are short-lived as they are largely under short-term foreign-funded partnership programmes.

CONCLUSION
This review analysed the literature on the improvement of haematology and blood transfusion education and research, an area infrequently explored in medical research. The review identified two broad themes in relation to the outcomes of education and research in haematology and blood transfusion. Advancement has been made in these two areas, which has resulted in improved service delivery and workforce. However, haematology and blood transfusion services are very limited in many countries of the region, and many countries in the region could not meet the WHO target of one haematologist per 100,000 population. In addition, there are a few centres that provide specialised care, like stem cell transplantation, haemato-oncology, and blood transfusion. To fully understand the gaps, a comprehensive, multifaceted, and multinational study that explicitly explores the intervention and its consequential impact is required.

Limitations
The present review systematically summarises the improvement in haematology and blood transfusion education and research. The main limitation of this review was that gray literature and African databases were excluded and as a result of which, most relevant articles might have been missed. Articles found in the indexed databases were mostly on medical education and research, generally with little reference to haematology and blood transfusion. With the language restriction filter employed, potentially relevant articles might have been missed. Very few of the included articles explicitly explored the outcome of the improvements in a quantifiable way.