The roadmap for creating an adequate and safe blood transfusion system in India.
By Madan Gopal
India has been undertaking transformational work to achieve Sustainable Development Goals (SDG) targets, including those under SDG 3 to ensure ‘Good Health and Well-being’ for all. The National Health Policy 2017, too, takes into account universality, equity and affordability as key principles for meeting India’s health targets. While the recently launched Ayushman Bharat aims to offer universal access to healthcare services, measures are still needed to standardise the nature and quality of health services across geographies and types of healthcare centres.
Like in any other reformative process, the foundation must be fortified first. Blood transfusions are a key life-saving intervention as per the World Health Organisation (WHO), being an integral part of most medical procedures. While the National AIDS Control Organisation (NACO) and National Blood Transfusion Council (NBTC) have made substantial strides in achieving the objectives of the National Blood Policy, 2002, there are still gaps to be addressed to improve transfusion services in the country.
Challenges of adequacy, availability and delivery: Access to affordable, adequate and safe blood and blood products becomes more important in Indian context as our blood requirement has heightened owing to a large burden of trauma, communicable and vector-borne diseases, and pregnancy-related complications.
The WHO estimates that blood donation by 1% of the population is generally the minimum needed to meet a country’s most basic blood requirements. In 2016-17, India’s blood collection fell nearly 15%, or 1.9 million units short of this 1% benchmark. The WHO norm, however, is based on global averages and does not take into account India-specific factors and disease burden. Moreover, it is based on population need, assuming universal access to health services, while in reality the actual clinical demand of blood in healthcare facilities is lower.
Ideally, all blood need should be converted into clinical demand by ensuring access, enhancing infrastructure and improving health-seeking behaviour of the population. Even though India has adequate blood banks to cater to its population, these are unevenly spread across geographies. The gap between need and actual demand should instead be met by focusing on efficient functioning and service delivery as well as infrastructure development of existing facilities.
To improve access and availability without additional resource commitments, there is a scope for institutionalising the partially centralised hub-and-spoke model, where a fully equipped centralised blood centre can cater to multiple satellite blood banks or storage centres performing limited functions. Blood delivery within this model can further be strengthened through innovative technologies, and already some start-ups are exploring drone delivery.
It is imperative for national estimates to be updated periodically to accurately estimate need and demand, and compare these against blood utilisation. NACO’s first Blood Requirement Estimation conducted in 2017 was a step in this direction; it pegged blood demand at 26.5 million units. To meet this demand, a ready pool of healthy low-risk donors needs to be maintained through promotion of voluntary non-remunerated blood donations. There is immense scope for mobilising the private sector to encourage blood donation in fulfilment of their social responsibility.
Another means of ensuring adequate blood supply using the existing donor pool is by reducing dependence on whole blood. The WHO recommends a 90:10 ratio for use of blood components and whole blood (only limited clinical interventions require whole blood). Collections of blood components through apheresis or component separation after whole blood collections are means of inching closer to this ratio.
Ensuring blood safety through operational and technological initiatives: Major improvements will have to be made at blood-bank level, as many blood banks don’t have proper standard operating procedures (SOPs), even though these are regulatory requirements. Recently, the NITI Aayog, along with Terumo BCT, conducted a blood bank assessment in Sonbhadra, an aspirational district in Uttar Pradesh, and preliminary results show that focusing on rigid processes and commensurate training of staff can go a long way in improving blood safety.
Model donor selection and donor referral processes are also prescribed by the NBTC to reduce risk of transfusion transmitted infections (TTIs), which endanger patient safety—between 2014 and 2017, 1.58% of the blood collected was discarded due to reactivity for TTIs. Logistical factors like expiry of components or deterioration during storage also contribute to wastage. The risk of infection and quantum of blood wastage can be reduced through maintenance of process integrity, and adoption of advanced, economically-pragmatic technologies. NITI Aayog’s experience with disruptive technologies across sectors has been positive, and even in the blood space, promoting advanced screening like NAT and ELISA along with pathogen reduction technologies can reduce the burden of TTIs.
In 2016, the ministry of health and family welfare launched e-Rakt Kosh, an ICT-enabled Blood Bank Management Information System that interconnects all blood banks in a state into a single network, and there is a scope to scale up its usage. For blood banks, it is a tool to standardise and streamline SOPs and workflow. Its citizen interface assists potential donors and patients, giving real-time information about nearest blood banks, donation camps, and blood availability including of a particular blood group.
India is on the right track to strengthen its existing blood transfusion system, but uniform implementation of policy guidelines, adoption of innovative technology, and collaboration between public and private sector is imperative in ensuring translation of policy objectives into action.
The author is senior consultant (Health), NITI Aayog. Views are personal