Blood Transfusion services

1. Blood Transfusion services Government Monopoly Versus NGO/Private Competition Magdy El Ekiaby, MD Egypt

2. Government commitment and support • Unit or department within ministry of health for the national blood programme, with designated national blood programme manager • Adequate, specific and sustainable finances for national blood programme • Provision of suitable infrastructure and facilities • Adequate number of qualified and trained staff • National policy and standards • National blood policy • Legislative framework • National standards • Regulation • National blood commission • Representatives of major stakeholders • Technical expert advisory groups • National strategic planning • Advice on medical, scientific and ethical issues relating to blood transfusion

3. National blood transfusion service • National, coordinated service with responsibility for the national supply of safe blood and blood products • Effective organizational structure for blood supply system • Effective BTS leadership and management • Quality systems • Human resource and career development • National information management system • Standardized procurement and supply systems • Collaboration with hospitals for the development of systems for the rational use of blood and blood products

4. Fact I: • Global Blood Collection: Around 92 million blood donations are collected annually : • Approximately half of these blood donations are collected in high-income countries, home to 15% of the world’s population. • Infrastructure: About 8 000 blood centers in 159 countries report on their collections • The average annual collection per blood center: • 30 000 in high-income countries • 7 500 in middle-income countries • 3700 in low-income countries • Blood Screening: In 39 countries, blood donations are still not routinely tested for transfusion-transmissible infections • Blood Processing: • Only 31%of the blood collected in low income countries is separated into blood components • The capacity to provide patients with the different blood components they require is thus still limited in these countries.

5. Geographic disparity in blood collection

6. Fact II: 69% of blood collected in low income countries is not processed into components • 45 million units of blood are collected in developing world • These donations need to be: • Tested according to international standards • Processed into components • Plasma further processed into safe plasma products • If this can become true, then probably plasma from these 45 million donations can become additional source for fractionation and production of plasma products • With realities mentioned in WHO report, it looks that a lot of work need to be done to process these blood donations and qualify its plasma for fractionation

7. Fact III: geographic disparity in plasma products consumption Source: P. Robert, Market Research Bureau 2009

8. Fact IV: Access to blood products is bound to GDP Per capita FVIII use by gross domestic product group for countries: <US$ 2,000 US$ 2,000-10,000 Worldwide Source: WFH Global Survey 2001-2010

9. Fact V: Health priorities in low income countries • In low income countries governments strive to commit to public health challenges: • Vaccination programs • Prevention of maternal and child mortality • High prevalence diseases • Government health budget usually covers 20 – 40% of actual health expenditure • This means that around 70% of health expenditure in these countries is actually out of pocket

10. Fact VI: Safe blood self sufficiency is mandatory • Blood components are vital for management of many health problems, most of which are critical medical situations • Lack of self sufficiency of safe blood components may lead to: • Morbid or even fatal situations in case of failure to secure the needs • Securing unsafe blood which may lead to health disasters and scandals • Securing safe blood with actual cost against subsidized cost from government services which may leave a public impression of blood black market

11. Fact VII: Public impression AS I DONATE MY BLOOD FREE, BLOOD SHOULD BE SECURED FREE

12. The dilemma • WHO and most international organizations advocate for state monopoly of BTS • Low income countries that initiated a NBTS, in many situation can not achieve self sufficiency of safe blood • Multiple price strategies for securing blood components; FOC, subsidized or at cost prices for patients under different health care programs • Accordingly public opinion on blood donation is usually fluctuating and in many situations there is negative attitude

13. Is there a way out?!! • Facts finding • Suggest complimentary approaches that comply with the national blood programme • Transparency: • Telling the society the truth • Informing the society about the new approaches • Define the ultimate goal as “Self Sufficiency of Safe Blood Components at Affordable Cost”

14. NGO/Private sector contribution to secure self sufficiency • Increase donor base and number of donations • Increase capacity of blood testing and processing • Actively implement ACUB

15. Increase Donor base • Donor recruitment: • Encourage NGO participation • Liaise to a professional recruitment organization • Participation should be tailored to augment NBTS in a way that will attract more donors and not deviating already existing donors to the other organization

16. Component processing • Encourage private sector to invest in establishing GMP labs for blood testing and processing • The capacity of these labs should be based on cost efficiency and securing high standard blood components to achieve self sufficiency • These labs will be only dedicated to blood processing and testing without being involved in blood collection or distribution • NGOs will be involved in the distribution of the blood components

17. ACUB • Contractual relation between NGO and hospitals • The contract will define the needed quantities of blood components • The contract will define the indications for the use of the blood components according to guidelines • Establishing training program on the guidelines • Joint auditing on the ACUB • Report of adverse events

18. Controls • The NGO/Private sector blood transfusion activities will be a part of the National Blood Programme and comply with relevant legislative framework • It will be licensed and regularly audited by national regulatory authority

19. Can this approach be of help • In Egypt as an example, many NGOs are highly credible to the society • NGOs activities in blood donation currently represents close to 10% of national collections • These NGOs can increase their input in case there are increase of capacity of testing and processing labs • Private investment in these labs will reduce the burden of investment from the government, will improve quality and safety of blood and will eventually reduce the production cost due to increased efficiency

20. Cost reduction to public money • NGOs will subsidize the costs of blood donor recruitment, donor qualification and donation • Large processing and testing labs with high throughput will increase efficiency of production cost • Blood safety and availability will improve due to adding a new stakeholder that can contribute to the blood service and not be only an abuser of the public blood service

21. Examples • SNBS • German Red Cross (Business Organization)

22. Business Model of NBS • UK Blood and Tissue Service • Netherland: Sanquin

23. Conclusion • Private sector contributes with success to various services in health, education, communication, …so why not in blood transfusion • The state should create the legislative and regulatory frameworks that helps to control private blood services • State monopoly should not be the situation, if self sufficiency of safe blood is not achieved