Road blocks in achieving a 100% voluntary blood donation rate in the South Asian region.

Voluntary blood donation rates are not high in the South Asian region, except in a few countries. The reasons for this are outlined and the roadblocks for improvement of the situation noted. The need for increased planning, both regionally and nationally, is emphasized and some factors that inhibit voluntary blood donation are mentioned. There is a real need to move from a system of reliance on 'replacement' donors to a fully nonremunerated voluntary blood donation system, and the examples and lessons from successful countries should be carefully studied.

Roadblocks often have to be surmounted in real life. A road map to find alternative routes may act as a temporary measure. Then follows the development of a plan by the authorities to repair the roadblocks. Action must follow, that is adequately financed and has the involvement of many persons, both planners and workers. Once the obstructions have been resolved, there must then be adequate maintenance to avoid the problem developing again.

This analogy is a good one to in thinking about the problems of voluntary blood donation in the region.

What is a Voluntary Blood Donation?

The definitions of what is a voluntary nonremunerated blood donation have been outlined in a Council of Europe publication[1] as well as by the International Federation of the Red Cross and Red Crescent Societies. Both definitions are very similar.

The Council of Europe definition states, ‘Voluntary unpaid donation shall mean the donation of blood or blood components by a person of his/her free will and without receiving payment in cash or in kind in return which could be considered a substitute for money. This also includes time off work reasonably required for donation and travel. Small tokens, gratuities, refreshments and the reimbursement of direct costs and direct travel expenses are compatible with the voluntary and unpaid donation of blood.’

This definition should also be considered in the context of the International Society of Blood Transfusion (ISBT) Code of Ethics. It states, ‘blood donation including hematopoietic tissues for transplantation shall, in all circumstances, be voluntary and non-remunerated: no coercion should be brought to bear on the donor …’[2]

A recent international forum[3] on paidvs.unpaid donors clearly shows the range of interpretations that occur between countries. Even in developed countries there are variations in procedures, although most now are almost entirely dependent on unpaid voluntary blood donors.

In Asia, a volunteer donor may be simply one who gives blood voluntarily and may still be remunerated in some way, either directly or indirectly. Direct ways include the provision of a substantial meal, supply of a carton of goods, various items of sometimes quite reasonable value, free tickets for entertainment, assistance with transport or a payment for ‘diet.’ Indirect ways include time off work, extra holidays, ‘free’ blood when the donor or their relatives should be in need of it, preference for admission to hospital or other health benefits. The borderline between an incentive and a payment is often blurred.

Many persons give a ‘voluntary’ donation when blood donor camps or mobile collects are organized. At these times there may be considerable peer, competitive and emotional pressure to donate and although the donation may be voluntary, it is not common for such donors to return. In some countries even ‘replacement’ donors, i.e., persons giving blood to supply the transfusion needs of a designated patient, are classified as voluntary donors. Armed Forces personnel donors are often classed as ‘voluntary’ even though some degree of coercion is not uncommon.

Thus statistics for the percentage of voluntary donors often do not provide full data that can be relied on. If the ISBT criteria are observed, there are few countries that have a high percentage of truly voluntary nonremunerated (unpaid) blood donors and perhaps fewer still that have a blood supply system based on ‘repeat’ donors. The latter reflect a key performance indicator (KPI) for blood services, and generally only blood services with a very high volunteer rate have a high percentage of these repeat donors.

It should be the aim of all blood services in South Asia to aim to achieve a 100% voluntary nonremunerated blood donor panel. This is the objective, but in countries with limitations in finance, education and expertise, this is not easy to achieve although some countries such as Nepal[4] and Thailand[4] have been able to get close to this desired objective.

How Bad are the Roadblocks in South Asia?

Despite the unreliability and incompleteness of statistical information and the broad range of interpretations of what is a ‘voluntary’ donor, there has been a gradual improvement in the percentage of ‘voluntary’ donations over the past 10 years. One of the indications of progress in the SE Asian area is summarized in the Proceedings of the Tri-annual Symposia sponsored by the Japanese and Thai Red Cross Societies.[45] Recently collected statistical data[6] indicates that the number of voluntary donations collected varies greatly between countries, with the average being 60% for 10 countries but with a range of 27-94%. Replacement donors still make up a very significant proportion of the blood intake, ranging from 5-80%. Regular donors are estimated to be less than 10%.

Roadblocks to Voluntary Blood Donation

Expectations of a financial or health benefit from donating blood

The attitude of ‘what's in it for me?’ applies to the blood donation process and is understandable. It is a concept common in Asia and in many other countries of the world, particularly those with low per capita incomes. Donating blood without a recognizable return is not easy to understand in an increasingly commercial world.

Blood has an inherent value and therefore why should individuals give a nonremunerated voluntary donation of blood to a Government-funded or other organization? The same individual may then have to pay for any blood transfusion that he/she may subsequently need if he/she is taken ill. The logic of this is clearly a hindrance to voluntary blood donation, and efforts to explain the reasons for this situation usually fall on deaf ears. Furthermore, the idea of a ‘gift for a gift’ is deeply ingrained in some Asian countries.

This roadblock is a difficult one; so some Asian countries have systems to enable ‘volunteer’ blood donors to have free access to any blood needed for themselves or their close relatives. This is not unlike the system first evolved in the USA, whereby any blood donations were credited to the individual, their family or often to a company. This credit system required a complex computer arrangement to ensure all donations were designated appropriately and fairly.

However, some Asian countries have been able to develop good voluntary systems despite these restraints and without crossing the boundaries of what can be considered as an ‘incentive’ rather than a ‘payment.’ Hong Kong, Singapore and Japan are classic examples, and there are others.

Ideally, if blood is donated freely, there should be no cost to the recipient. Such a system encourages voluntary blood donation; however, as health services have become increasingly commercialized with a ‘user-pay’ mentality, this is probably not feasible in many Asian countries at this stage. Countries such as New Zealand, Australia and Great Britain, that have fully nonremunerated blood donor systems, do have arrangements whereby the costs of the clinical blood services are met out of taxation revenue and there is normally no charge made to the patient for the costs of any blood supplied.

Lack of policy and planning

One of the great roadblocks preventing the development of an effective voluntary blood donor service is lack of sufficient forward planning by the relevant political authorities. For the development of a blood donor system, there should be a general agreement and a framework for overall regional or national donor policies. Essentially this is the responsibility of the government. Blood Transfusion Medicine and Science, along with blood donation, is part of the health services, over which the government should have substantial input. Governments may delegate that responsibility to organizations such as the Red Cross Society or a formal independent body but usually require adequate feedback to ensure all obligations are met. Governments must take a real interest in blood transfusion and develop relevant planning and legal controls. In turn, the government should provide financial support to the organization responsible for blood collecting procedures.

Without this type of arrangement, development of blood services often proceeds in a haphazard fashion, with little or no coordination and with frustration to all concerned. New hospitals form new blood banks without adequate coordination with other blood banks, and competition for recruiting donors takes place. There is commonly no liaison between adjacent blood banks regarding supply and overall policies. Unfortunately, this is a fundamental problem in some Asian countries as even when there are formulated systems, there is often no follow-up, finance is not available and regulations are not followed. An adequate supply of blood donations is thus not assured.

Part of the solution is for local transfusion medical experts, who understand the need for coordinated regional or national planning for blood transfusion services, to find ways to approach those in political control and make them aware of the need for adequate planning procedures. However, most medical personnel understandably often avoid such involvement with political processes. Sometimes an outside consultant is required to enable transfusion needs to be presented at the highest possible political level.

Nevertheless, leadership is important and unless somebody takes the effort to inform and advise politicians of the community needs, little progress can be made. It is in the national interest to have a high quality blood transfusion service in a country. Having available the informed help and resources of the government can greatly facilitate development. For instance, the development of legislation to facilitate voluntary blood donation and proscribe against other forms of blood donation is very useful. These political roadblocks must be overcome in some way if a voluntary blood donor service is to develop. Another way is to work through agencies such as the World Health Organization (WHO), the Red Cross or Red Crescent Society or other international organizations such as the ISBT, as governments may more easily pay attention to their statements.

Part of this planning is to set goals and objectives. It is clearly impossible in most countries to move to a 100% voluntary nonremunerated blood donor system; so interim aims need to be clarified with realistic dates. This provides a focus for action and allows a phased program of development that is attainable.

Inadequate leadership

Most blood services in Asia are directed by medical doctors who have had training in hematology or pathology and who are often skilled in laboratory aspects of these specialties. Unfortunately, their training in transfusion medicine is often lacking, as this subject is not emphasized in their specialties, unless they have taken special interest in the subject. Most have never worked for a prolonged period in a modern transfusion center, and few have had direct experience or training in blood donor recruitment. Fewer still will have an advanced qualification in transfusion medicine.

This can result in a situation of ‘the blind leading the blind.’ Unless the Director has had special experience and training in transfusion medicine, it is unlikely that they will be able to have the vision necessary to specifically lead and inspire a donor recruitment team. There is thus a real need for improved training and certification of blood transfusion directors to ensure they have the required skill base to lead a blood service. Although many have good insights into the problems of a blood service, unless they have had adequate experience in a first class blood transfusion service, they may not be able to provide the solutions to problems.

Attracting and retaining voluntary blood donors is a specialty that requires good knowledge of many aspects of a society. As it is one of the prime responsibilities of a blood service, much more effort needs to be directed to ensure that leadership is fully informed in different methods of donor recruitment and motivation to enable this roadblock towards voluntary donation to be removed.

Poor staff training

In some Asian countries, the staff of blood services have had only limited specialized training in blood donor matters, and often very little outside their own country.

Staff of a blood donor service are actually selling a product. This product is ‘life’ achieved by donating blood. They must be able to ‘sell’ their ideas and concepts to the general population and thus motivate them to donate blood. To do this they need training, not unlike that given to their commercial counterparts. They need to understand the philosophy and psychology of the population they are working with. Encouraging a population to donate blood voluntarily and without a physical reward requires considerable skill and leadership. Classic examples of how this can be done are provided from Singapore and Japan.

Those involved in blood donor recruitment should have special training and experience, but seldom do. This can be achieved by visits to successful blood services in other countries, attendance at international forums, contacts with the commercial world to understand techniques of marketing, and in-service training perhaps by an outside transfusion consultant. Unfortunately, there are few places where specific training in blood donor recruitment methodologies can be obtained. An intelligent approach to this matter is provided by the West Bengal Blood Donors Association[7] that has managed through motivational methods to develop ways to involve many classes of people in volunteer work and blood donation. Another example is the Blood Donors Association of Nepal.[8]

Nevertheless, there is still a deficiency in the provision of training systems for blood donor organizers and insufficient recognition of the strategic importance of these persons.

On many occasions, the work of donor recruitment is devolved to laboratory workers who may be very competent at their technical work but lack the personal skills to attract and retain volunteer blood donors. This lack of training of the persons required to carry out blood donor recruitment is a major roadblock in the development of voluntary blood donor systems.

Problems of literacy and community education

The low standards of community education in South Asian countries are a roadblock in achieving a voluntary blood donor system. Where there are low literacy rates, people are not always able to understand the deeper significance of the call for volunteer blood donors. Their understanding of procedures is limited, which restricts their ability to answer questions and fully take part in the procedures. Good educational levels can also help dispel misconceptions that many people have about giving blood. Fears of harm to their health are common, ranging from fear of needles to loss of potency in males. Real efforts to alter these views are needed if blood donation is to be well accepted as a part of the role of a citizen of a country.

However, a low literacy rate may not prevent a voluntary blood donor system from being developed. For instance, in Papua New Guinea, despite a relatively low literacy rate, volunteer donors provide all blood. In this country, communication is adequately achieved by oral explanations, resulting in good response from the public. In addition, other techniques of motivation are used successfully.[9]

A high level of education in a country can of course enhance voluntary blood donation, as it allows the wider use of printed material, better teaching on aspects of transfusion in schools, and interaction with a donor population more likely to understand the overall needs of their community. Roadblocks to community education are present in most populations, and blood donor recruitment organizations have to find alternative ways to get heir message across to communities and individuals.

Inadequate financing

All blood services have problems in this area. However, it is not always a problem of finance that prevents the development of a voluntary blood donor service. Very often it is the inappropriate allocation of available resources within a blood transfusion system. Sometimes more attention is paid to buying sophisticated technical equipment rather than using finance to employ top class people in the blood donor recruitment area.

Commonly, the blood donor recruitment area is financed quite inadequately, while the laboratory gets the lion's share of resources. Although at times this may be appropriate, the big challenge in South Asia is to place more finance in the donor recruitment area, not only for staff but for printed, electronic and other items required for blood donor recruitment. The biggest problem facing Asia in blood transfusion is the ‘epidemic of empty blood shelves,’ and this can only be solved by channeling available funds into areas of blood donor recruitment.

The roadblock in doing this is often the administrator of the blood transfusion service. Such persons may not have had enough experience to understand the full needs of a blood donor system. It is easier to understand the needs of the laboratory, as it is really much simpler to buy equipment than to spend finance on upgrading and adequately staffing a donor system. Such attitudes are common, as few administrators appear to have a clear idea of the real financial needs of a growing blood donor system.

Blood transfusion services need blood donors. Inadequate financing will generally result in poor blood donor systems. All blood services need to watch carefully to ensure that their donor systems are proportionately well funded and that they are not bewitched by the blandishments of commercial entrepreneurs keen to sell sophisticated equipment.

Staffing problems

The selection of suitable staff for a blood donor recruitment program is of prime importance. Experience has shown that the most effective donor recruiters may not always be the persons who are technically or academically qualified. As a general rule, donor recruiters are best obtained from those among the target donor population who have become motivated by their own involvement as blood donors and who understand the human need for blood in hospitals. They need to be ‘people persons’ who are able to relate easily to others and possess an ability to lead and persuade. They need not have great medical or technical expertise but must be enthusiastic and competent.

Selection of such persons may not be easy. Often donor recruitment positions are not regarded highly by administrators, the selection of staff in this area is considered to be of low priority and salaries for such staff poor. They are seldom given the respect and recognition they deserve. There is a need to upgrade the status and salaries of those involved in the donor recruitment areas as this will help achieve the aim of increasing the number of volunteer blood donors.

Lack of use of community volunteers in blood donor recruitment

Many blood services incorporate volunteer workers in their staffing. This is common when the Red Cross Society manages the national service. Such volunteers can be of great value as they often carry out duties beyond their obligations and are highly effective in donor recruiting and management. Blood services need to increasingly use volunteers in their organizational structure - not only to save costs but also to make the blood service into a more community-based organization. So often, for donor recruitment, full use of organizations such as Rotary Clubs, Lions Clubs and other community groups is not made. Such groups can provide considerable support to a developing blood service and may be able to help remove roadblocks in a developing blood donor organization.

In some countries, e.g., Nepal and West Bengal, the formation of a blood donors association has proved very useful. Volunteers in these organizations have been able to do a great deal to encourage blood donation, and this is an excellent model that could be followed elsewhere.

Insufficient use of mobile blood collections

One aim of a blood collection service should be ‘to take the bed to the donor rather than expecting the donor’ to visit a fixed blood donor site. Although there is always a place for the latter, the use of a mobile team to visit widely throughout a country and offer the opportunity for all citizens to give blood is an important part of the strategy of a blood donor service. In the developing Asian countries, transport is not always easy and is often expensive for the poor; so expecting donors to come to a donor center is often wishful thinking.

Commonly, when mobile collects are done in some parts of Asia, they are not well resourced or organized. Insufficient emphasis is laid on staff training; donor screening is less than adequate; and a competitive spirit is often present, such as ‘let's see just how many donors we can get.’ So often the result is that a large number of blood donations are collected from poorly screened donors, often by staff under pressure.

The result is a poor quality system that does not always encourage donors to return for repeat donations. It should be the aim of mobile collects to have the same quality standards as those for established static sites, with careful attention to all aspects of donor screening, selection, handling and comfort. It is only in this way that quality blood can be obtained that meets safety standards. The encouragement to voluntary donations is enhanced when the blood donation service is careful about these matters, as the donation of blood basically depends on the goodwill of the population served. A poor performance by a blood collecting team may permanently discourage donors from ever attending again.

One attractive form of mobile collect is the use of dedicated buses or caravans. These can be designed to meet excellent standards of quality performance and can be parked in areas of major population traffic. They also are very useful for advertising blood donation. However, they are expensive to build and administer but are used in many countries. The limitation is the number of donors they can handle at any one time.

Lack of quality assurance

It is not commonly recognized that quality assurance methods need to be applied to the blood donor systems just as much as to laboratory systems. Few blood transfusion services in the South Asian area have dedicated quality assurance officers. Because of this and a general lack of insight for the need of quality assurance in donor work, activity in this area is neglected frequently. But if a blood service wants to recruit and retain blood donors, it is essential that more attention is paid to quality assurance in every aspect of the donor systems. Each part of the blood donor work needs critical systematic evaluation to ensure that it is providing a service to the donor that is acceptable and which meets high standards of performance. This results in a blood donor system that can gain a high reputation, which in turn will attract blood donors.

Lack of donor recognition

A roadblock to achieving a high percentage of blood donors is often the lack of giving due recognition to donors for their contribution. It is essential that every regular voluntary blood donor is shown respect and honored in some way. There are many ways to do this.

Blood donors are very special people, and care at all stages of their processing and handling is part of the key to success in developing a voluntary blood donation system. All donors like to feel that their donation is of help to the community, and in return they wish to have the respect of their community. It is part of the role of the blood donor recruitment department to ensure this is done in some significant way.

So often in Asia this is not done well, with a consequent loss of motivated donors from the system. Donors who come back to give blood again and again will do so only if they have been given due recognition for their continued contribution. Such donors should be the basis of all blood donor services, but sadly in Asia the emphasis is so often on recruiting new donors rather than retaining the donors already recruited.

Discussion

In the past, the immediate need for blood in the Asian region was initially so urgent that authorities often took the line of least resistance and set up systems that quickly provided blood donors. This resulted in the establishment of commercial blood donor systems which now have been shown to provide only sub-optimally safe blood and in limited quantities. Most countries have now ceased or legislated against such systems of blood donation.

The next step was to place the onus of donor recruitment on the patient in an effort to meet his/her blood requirements. This resulted in friends and relatives being under pressure to give blood at the request of the patient, i.e., replacement donors. These were often relatively unwilling donors who gave blood under a form of coercion. It can result in people coming forward to give blood who had been recruited financially by the patient or his/her family, concealing the fact that they were in reality very much like commercial donors. Many abuses result from such a system, and scientifically there are good reasons why blood from close relatives should not be used routinely for blood transfusion. Unfortunately this system is perpetuated in many hospitals today.

It is too easy for countries to continue with a system that places the onus of recruitment of blood donors on the patient, who is therefore saddled with a double load of problems, i.e., the disease process and a need to obtain blood donors. Such a system is easy for hospitals but is less safe than a volunteer system, as much data demonstrates that infectious marker rates are nearly always higher in such donors than in truly voluntary donors. Blood donor arrangements of this type need to be phased out as quickly as possible in favor of the development of a truly voluntary donor system. This will be initially more expensive for a hospital as it requires improved staffing and facilities but in the long run will produce a system that has committed regular high quality volunteer blood donors.

Although voluntary blood donations were encouraged in many hospitals, they were often commenced without a thoughtfully planned program that incorporated what was really required. Emphasis was often placed on the rewards of becoming a blood donor, and major incentives were offered, such as time off work, extra holidays and improved health access plus commonly a host of other physical incentives but not money. Little effort was made to improve donor facilities or to treat voluntary donors with the respect they deserved. The result was a poor response, viz., donors more interested in rewards rather than being of assistance to their community. The problem is that once such a reward system is commenced, it is quite difficult to reduce the offered benefits without affecting the blood supply. Without an understanding of the basic motivating factors that underlie a society and the altruistic factors that can be used to influence prospective donors to donate blood, voluntary donor recruitment programs can be ineffective.

The roadblocks to achieving a 100% voluntary blood donor service are thus many. Perhaps the main one is the lack of planning by politicians and the lack of national policies on blood transfusion. Until governments take a real interest in this subject and provide at least basic funding, blood services are greatly handicapped in trying to achieve their goals. Certainly, this was one of the important problems identified by Asian participants at the Thai-Japanese Symposium.[4]

What are the strategies that can be put in place to encourage governments to remove the roadblocks in this special field of transfusion medicine? There is no simple answer as each country has different circumstances. Certainly, the government, politicians and administrators need to be made aware of the comparative country statistics on blood transfusion that are available, as national pride can encourage action. In some situations, the need for a national evaluation report of blood transfusion matters by an independent expert can facilitate new developments. In others, publicity based on human clinical needs is useful. It is hard to always get the ear of politicians as transfusion medicine is a relatively small part of a country's health budget; even in developed countries, expenditure is rarely more than 1% of all health costs and thus transfusion medicine attracts less attention of financial bureaucrats. Another strategy is to make use of the expertise of international organizations. For instance, Viet Nam has had the assistance of the World Bank; Bangladesh, the UNDP; and other countries have used the Red Cross or Crescent Societies or WHO.

Sometimes it is better to appeal to the heart rather than the intellect as although some notice is taken of statistics and data, action often only comes when emotions are touched. Most of our major decisions in life are made not on logic but on feelings, and the same can also apply to government policies. Some countries have had the good fortune to have available a motivated and enthusiastic individual or group that has the perseverance to agitate for change in transfusion-related policies and work issues. Such persons are very valuable and need to be encouraged and supported as sometimes they can obtain better access to governmental, political and administrative procedures than those employed by the blood services. There is also a responsibility for trained and experienced senior workers in the blood services – to keep providing accurate and updated information to their political and administrative leaders to ensure that all the responsible persons are aware of the problems and what could be done to solve them. Where this is done regularly and positively, progress can be sometimes be made. But it is not easy and the transfusion medicine workers in many countries often experience great frustration as they see time passing by and little action by their politicians who have other objectives and aims.

The most satisfactory way to attract and retain blood donors is to appeal to their altruistic motivation. Donors who give blood because they really desire to help their community need little by way of physical rewards. The downside of such a recruitment drive is that it requires additional financial input and considerable effort by all concerned to present a campaign that will appeal to the hearts and intellects of the population. For this reason, there has been considerable reluctance on the part of authorities in some countries to have the courage to rely on the goodwill of a community to provide blood. Countries such as Korea, Hong Kong, Singapore, Macau and Thailand and others have faced this problem successfully, with the result that each has now good functioning voluntary blood services. India has commenced but still has some way to go, although progress has been made. Some of its publications[10] on donor recruitment are excellent and would be relevant to the donor programs of several countries too. The pathway to success in this area of health services is reasonably clear; the problem for countries is to plan ahead for the journey and avoid the many roadblocks on the way. Volunteer donors eventually can provide the safest and surest supply of blood, but for such a program to be successful, good regional and national planning in all aspects of blood transfusion service is required to ensure that all needs of the donor are met.

It is easy to be pessimistic regarding the low rates of voluntary blood donation in some Asian countries, but it is clear that most people - of whatever race or religion - will respond to an obvious humanitarian need. This is clearly seen during major disasters, when blood services are commonly embarrassed by the number of blood donors available! The challenge is to present the human needs regularly and clearly and to have a blood donor system that can give recognition and good service to the ordinary person who volunteers to give blood. This can only come about when advance planning has been made and thoughtful consideration given to the needs of the hospitals and donors.

Volunteer blood donation roadblocks can be removed, and this is well demonstrated in some Asian countries that have achieved the goal of establishing successful systems. We all need to learn the secrets of success from each other and adapt them to meet our own requirements. This is not impossible but does require motivated and responsible leadership, coupled with planning and education. We can then be optimistic about the future of a volunteer blood donor system in South Asian countries as we head towards a 100% voluntary blood donation system.