The Financial Toxicity of Anemia Management among Patients on Chronic Hemodialysis: A Cross-Sectional Study on Blood Transfusion Costs and Care Disruption in Douala, Cameroon

Background: Chronic hemodialysis patients frequently require blood transfusions due to persistent anemia. However, in many sub-Saharan African settings, patients face substantial informal costs when sourcing blood products. These hidden, out-of-pocket expenses remain poorly quantified, limiting policymakers’ ability to effectively address financial barriers to safe and timely transfusions. Methods: A cross-sectional survey was conducted among patients undergoing chronic hemodialysis at the two public hemodialysis facilities in Douala, Cameroon. A total of 168 patients were interviewed. Variables assessed included sociodemographic and economic characteristics, anemia management data, estimated cost per blood unit, impact on hemodialysis non-adherence, and perceived quality-of-life effects. Descriptive and bivariate analyses were performed. Results: A total of 168 (males 53%, n = 89) patients were included; the mean age was 49 ± 12 years. Low socio-economic status was prevalent (58.3%, n = 98) and 65.5% (n = 110) had a monthly income < US$200. Erythropoiesis stimulating agents (ESAs) were used by 69% of patients (n = 116), but compliance was suboptimal. Nearly half of the patients received ≥ 1 blood unit during the past 3 months (48.2%, n = 81), with most of them receiving ≥ 2 units per month (n = 46). The use of non-medical intermediaries was common (58%, n = 47), with a median fee of US$20 [IQR: 10 - 40]. Among patients utilizing replacement donors (n = 75), 88% (n = 66) relied on compensated individuals, with a median procurement cost of US$16 [IQR: 10 - 20] per donor. The median total estimated cost per blood unit was US$81.5 [IQR: 60 - 90]. Nonadherence was reported by 30.3% (n = 51) of patients and was mainly due to blood unavailability (43.1%, n = 22). It was significantly higher among patients transfused within the past 3 months compared to non-transfused peers (50.6% n = 41 vs 11.5% n = 10, p < 0.001). Transfusion requirements constituted a massive burden, manifesting as a structural barrier to medical care (44%, n = 74), altered quality of life (51.8%, n = 87), financial distress requiring personal loans (43%, n = 55), and acute psychological stress (37%, n = 62). Conclusion: Transfusion costs constitute a major and under-recognized barrier to timely access to blood among chronic hemodialysis patients in our setting. The combination of high out-of-pocket expenses with intermediary and donor payments is associated with increased socioeconomic vulnerability, hemodialysis nonadherence, and