India’s Blood Services in Urgent Need of Life Support
I have been associated with blood transfusion services in India since 1987, when I started India's first factory in Thiruvananthapuram to make modern blood bag systems. That factory was based on the know-how developed at the SCTIMST, a national lab under the DST located in the city. What began as a startup grew to become the largest factory in the world making this essential product, employing more than 1100 skilled people, and with products shipped to more than 50 countries across the globe. Since those small beginnings in 1987, I've had a close ringside view of the changes in the blood services in the country, as healthcare facilities expanded, and the need for safe blood supplies grew. The number of blood banks in the country has grown from less than 500 to over 3000 today, collecting more than 10 million units of blood.
During this long period lasting around three decades, across the world, technology has had a huge impact in making blood collection and processing safer, enabling the production of safe blood components, and helping blood services support modern healthcare delivery. In India too, we can see the impact of technology, with modern diagnostic tools being used to test the collected blood, and better processing methods and equipment to ensure optimal separation and harvesting of blood components. However, unlike in the rest of the world, in India the safety of blood products is far from satisfactory, and this can be traced to several factors that are all related to the system of blood collection and transfusion that prevails in the country.
All efforts to improve the state of affairs in blood services are generally about using 'better' technology which, in turn, means importing and using the 'latest' technology and equipment. There has however been little effort to see whether the 'system' of blood collection has anything to do with the problem. In system theory there is a maxim: structure determines behaviour. In plain language what it means is that the way processes are structured in a system will determine how the system operates. A system consists of processes and these processes are operated by people. If the processes are defective, then it does not matter who is the person operating it; the outcome will always be defective. In the case of blood services in India, the basic issue is that the system consists of hundreds of independent blood banks operating independently, albeit under some degree of regulatory oversight. As is to be expected in a country like India, this regulatory supervision is not only perfunctory and ineffective, but is also the source of much corruption. The result is that nearly 3000 independently-run blood banks are expected to somehow work together to meet the needs of the growing heralthcare system.
Today, the result is there for all to see: the burden of finding donors falls on the patient's family, in the form of having to find 'replacement' donors before administration of blood transfusion is taken up at the hospital. This casts a huge burden on ordinary people, especially those coming to cities from rural areas, as they would not know local people and hence, are unable to arrange replacement donors. However, as usual, another system is at work here to meet such requirements and hence, the old 'professional' donors reappear now as replacement donors, with payment still at the root of the transaction.
The evidence that this is indeed the state of affairs in India can be seen from the fact that the incidence of Transfusion Transmitted Infections (TTI) remains at about the same levels as it was 20 years ago, when older testing methods were used to screen donors, and older processing technologies were employed. Studies across the world have repeatedly shown that the strongest correlation is that between non-remunerated voluntary blood donation and the decline in TTI. Adoption of any technology without changing the system is doomed to failure, as has been proved again by the blood services of India.
What is the solution? It is to set up a National Blood Service on the lines of those working in almost all countries in the world with a reasonable healthcare delivery system. These national blood services are run in some countries by the Red Cross or Red Crescent, and in a few by a National Blood Service Trust. In the US, the centralised model run by the American Red Cross handles about 50 per cent of the blood needs of the country, while the rest is handled by the Community Blood Centers of America, a loose federation of autonomous community blood centers. In all countries there is tough regulation of the work of blood centers to ensure that all blood components collected, processed, stored and administered meet the highest standards of safety. A country like China which is bigger than India has fewer than 500 blood centers that meet the needs of all patients across that country. In Japan, with 130 million people, each province has a blood collection agency that collects blood from donors which is then sent to central processing centers run by the Japanese Red Cross. The UK, with a population of 60 million, had only about a dozen regional blood centers that ensure the collection and availability of adequate blood components. In India, we have over 3000 blood banks, many of which are uneconomic, staffed by poorly trained employees, and managed by commercial interests. It should not surprise anyone that the results of such a poorly designed and run 'system' are far from satisfactory.
In India, we have many examples of poor systems and practices and policies in operation in various fields, despite there being people in the country with the knowledge and expertise to point out what needs to be done to improve matters. Indian experts occupy important positions in many international agencies, and help to improve systems and processes in many developing countries. Why are they unable to have the same impact here in India? It is because of the operation of the 'default' system which ensures that the iron law of systems mentioned earlier, ie structure determines behaviour, will continue to operate. What is astonishing is that despite these facts being known to at least a few leading experts in the field, even a vital field affecting national health and security like the blood services continues to be neglected, and allowed to function in the present way.
What can be done to improve matters? The first thing to do is to understand that blood security is a right of every citizen. The only way to ensure that right is to make the collection and supply of blood and its components a national non-negotiable priority. That would require a national blood service to be set up, which should be regulated and administered centrally. However, a mix of centrally-managed blood centers run by the Red Cross (as in Odisha) and autonomous blood centers managed by the community and even private entities can be envisaged, provided the regulator is effective. Modern IT tools make it easy to centrally coordinate blood component supplies and stocks, and to ensure that the right component is made available where it is required. Given the diversity and size of the country, and the fact that health is on the Concurrent List, I would advocate setting up of State Blood Services in each State. I recall making a presentation at the PMO when Dr. Manmohan Singh was the PM to a small group of senior officials, including the then Health Secretary, Govt. of India at a meeting presided over by the Principal Secretary to the PM. The subject appeared to capture the attention of those present, and that made me hope that some action would follow. More than a decade later, we are still waiting for steps to be taken to ensure blood security for every citizen in India. D D Kosambi famously said: Indians have the infinite capacity to painlessly digest contradictions! I am astounded at the lack of interest in this vital subject among policymakers and the medical community in the country, while all manner of egregious practices are allowed to continue unhindered, putting the lives and safety of patients at risk. In any society concerned with patient outcomes, and the safety and welfare of the citizens, setting up a blood service would be one of the highest national priorities.
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