Blood Transfusion International (BTI) a partnership ith ... · Blood Transfusion International...

Blood Transfusion International Blood Transfusion International (BTI) a partnership ith the(BTI) a partnership ith the(BTI), a partnership with the (BTI), a partnership with the

developing worlddeveloping worlddeveloping worlddeveloping world

Marcela Contreras MD, Marcela Contreras MD, FRCPathFRCPath, FRCP, , FRCP, FMedSciFMedSci, DBE, DBE

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Global population and blood supplyGlobal population and blood supply

Barcelona 15 - 16 06.2010Dhingra, WHO, 2005

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D l iD l i t it i d dd d hi hhi hDevelopingDeveloping countriescountries dependdepend onon a a highhigh% of % of replacementreplacement oror paidpaid donorsdonors


Replacement or paid donors have a higher % of TTReplacement or paid donors have a higher % of TTReplacement or paid donors have a higher % of TT Replacement or paid donors have a higher % of TT infection than voluntary noninfection than voluntary non--remunerated donorsremunerated donors

HDI: Low Medium High(high % of (high % of (high % of(high % of (high % of (high % of

non-voluntary non-voluntary non-voluntarydonors) donors) donors)

HIV 0 3 14 0 9 0 0 77HIV 0.3 - 14 0 - 9 0 - 0.77HBV 0.1 - 21 0 - 30 0 - 7HCV 0 - 9.2 0 - 13.1 0 - 1.2Prevalence in blood donors (%)Prevalence in blood donors (%)80% of the global population has access to only 20% of a safe blood supply.


HIV HIV seropositivityseropositivity in 2007in 2007

• In the NBS = 4 donations confirmed positive in 2 million or 1 in 0.5 million

• In Chile >71 donations confirmed positive pin approx 200 000 = 1 in 3000

• Peru: 2 public hospitals had 2 positivePeru: 2 public hospitals had 2 positive donations per 3,000 = 1 in 1500M l i d B t 1 i 20• Malawi and Botswana = 1 in 20

• Sri Lanka = 1 in 125 000

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% voluntary blood donations vs wasted% voluntary blood donations vs wasted% voluntary blood donations vs wasted % voluntary blood donations vs wasted units after screening for TTIunits after screening for TTI


Contrast between rich and poorContrast between rich and poorLow HDIConcerns about basic issues:

High HDIConcerns about litigation, media,Concerns about basic issues:

water supply, famine, maternal and child mortality

g , ,potential harm to publichealth authorities

M tl l t dMainly replacement donors and Not enough blood

150 000 women die through

Mostly voluntary donors

NAT for HIV and HCVcosts £ millions150,000 women die through

lack of blood / y

>11 million children die/y, at leastUniversal LD costs £ millions

UK’s programme to avoid100,000 through lack of blood

1/5 of new HIV cases in the ld d t t f i

UK’s programme to avoidnegligible risk of TTvCJDcosts £ millions / y

world due to transfusion

Dengue transmitted by TxUK toying with the idea ofof introducing a “Prion” filteror vCJD assay

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y

Global Maternal MortalityGlobal Maternal MortalityGlobal Maternal Mortality Global Maternal Mortality • One of the MDGs is to improve maternal p

mortality by 66% between 1990 and 2015.• >530,000 deaths/ year during or shortly after

childbirth This has decreased to approxchildbirth. This has decreased to approx. 400,000 recently

• 99% of these preventable deaths in the pdeveloping world

• Leading cause : obstetric haemorrhage, causing >100 000 deaths/ year followed bycausing >100,000 deaths/ year followed by infection and unsafe abortions.

• Rates of national availability of blood forRates of national availability of blood for transfusion in the developing world are inversely proportional to the number of

t l d th i t d ith h hWHO 2009

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maternal deaths associated with haemorrhage. WHO 2009

WHO/PAHOWHO/PAHOEffectiveEffective Blood Services built upon 4 main principles:Blood Services built upon 4 main principles:

Pl i d M t fPl i d M t f N ti l Bl dN ti l Bl d•• Planning and Management of a Planning and Management of a National Blood National Blood ServiceService with a legal framework and sustainable with a legal framework and sustainable fundingfunding

•• Voluntary unpaid donorsVoluntary unpaid donors•• Voluntary unpaid donorsVoluntary unpaid donors

•• Testing/screeningTesting/screening of all blood donationsof all blood donations

•• Appropriate use Appropriate use (including (including haemovigilancehaemovigilance))

All activities within a All activities within a Quality frameworkQuality framework

(WHA Resolution 28.72 signed by most countries; re(WHA Resolution 28.72 signed by most countries; re--

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(WHA Resolution 28.72 signed by most countries; re(WHA Resolution 28.72 signed by most countries; reaffirmed in 2005 and now again in 2010)affirmed in 2005 and now again in 2010)

WHA28 72 R l ti dd dWHA28 72 R l ti dd dWHA28.72 Resolution addressedWHA28.72 Resolution addressed

•• blood safety:voluntary donorsblood safety:voluntary donors•• equitable access to safe blood andequitable access to safe blood andequitable access to safe blood and equitable access to safe blood and

blood productsblood products•• rational and safe use of bloodrational and safe use of blood

However, However, 38 years later, in 2010, the world is 38 years later, in 2010, the world is a long way from achieving universal access a long way from achieving universal access g y gg y gto safe blood for transfusion.to safe blood for transfusion.

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Blood Ser ices in the De eloping WorldBlood Ser ices in the De eloping WorldBlood Services in the Developing WorldBlood Services in the Developing World

• Very atomized, mostly hospital – based, with pockets of “acceptable” practice in some private p p p pblood banks or services that cover only part of those countries’ needs for blood.

• Many are looking at the USA as a model, but the USA is not following WHO recommendatios.

• Some exceptional blood banks within a country have a false sense of security because they are

bb dit d h ISO tifi tiaabb accredited or have ISO certification

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Support for Developing CountriesSupport for Developing CountriesSupport for Developing CountriesSupport for Developing Countries

•• Solutions Solutions mustmust match local conditionsmatch local conditionsSolutions Solutions mustmust match local conditionsmatch local conditions-- economiceconomic-- culturalcultural-- culturalcultural-- politicalpolitical

•• Improvements should be based on an Improvements should be based on an assessment of sustainable changeassessment of sustainable changegg

•• Changes should not be driven by where Changes should not be driven by where th t fth t fthe support comes fromthe support comes from

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Th d f t b dTh d f t b dThe need for an assessment bodyThe need for an assessment body

• No assessment body exists for blood services in developing countries

• BT professionals from developing countries would welcome onewelcome one

• An assessment system, with follow-up visits, assess e t syste , t o o up s ts,support and progress reports would help blood services make sustainable improvements

• Professionals can use the standards and reports to lobby governments for appropriate resources

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lobby governments for appropriate resources

What is BTI?What is BTI?

• A scheme of assessment for blood services in the developing worldservices in the developing world

• Purpose: to assist developing• Purpose: to assist developing countries to make sustainable improvements to their blood servicesimprovements to their blood services and ensure sufficient supply of safe bloodblood

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BTI: BTI: Blood Transfusion Blood Transfusion InternationalInternational

F d d i iti ll b ARKAGA dFunded, initially by ARKAGA and supported by ISBT, NHSBT and other pp y ,blood services.

Programme formed by >40 medical, scientific and management volunteers, mainly from Europe mostly from themainly from Europe, mostly from the UK.

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Developing a scheme ofDeveloping a scheme ofDeveloping a scheme of Developing a scheme of assessment for blood servicesassessment for blood services

•• International "accreditation" systems are International "accreditation" systems are unachievable in developing countries.unachievable in developing countries.unachievable in developing countries.unachievable in developing countries.

•• Assessment based on WHO AideAssessment based on WHO Aide--mémoiresmémoires and and recommendatiosrecommendatios for minimum requirements forfor minimum requirements forrecommendatiosrecommendatios for minimum requirements for for minimum requirements for BT services and PAHO Regional PlanBT services and PAHO Regional Plan

•• Targeted towards low and medium HDITargeted towards low and medium HDI•• Targeted towards low and medium HDI Targeted towards low and medium HDI countries (over 100!) countries (over 100!) Diff t l l f tt i t ithi th hDiff t l l f tt i t ithi th h•• Different levels of attainment within the scheme Different levels of attainment within the scheme

•• Has WHO, PAHO and ISBT endorsementHas WHO, PAHO and ISBT endorsement

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The proposalThe proposal

•• To include a preTo include a pre--assessment assessment ti i f ili dititi i f ili ditiquestionnaire of prevailing conditions questionnaire of prevailing conditions

for a for a situation analysissituation analysis

•• To develop a draft To develop a draft set of standards and set of standards and checklist checklist from existing WHO materialfrom existing WHO material

•• To incorporate a series of To incorporate a series of levels of levels of achievementachievement within the standardswithin the standards

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Methodology (Methodology (ii))A t f ll i h kli t b dA t f ll i h kli t b d•• Assessments, following a checklist based on Assessments, following a checklist based on WHO/PAHO recommendations and common sense.WHO/PAHO recommendations and common sense.

•• Checklist ensures consistency of approach and Checklist ensures consistency of approach and completeness of coveragecompleteness of coverage

•• Only undertaken with Only undertaken with agreement and support of local agreement and support of local specialists in BT and the Ministry of Healthspecialists in BT and the Ministry of Healthp yp y

•• Inspectors are experts from different backgrounds Inspectors are experts from different backgrounds andand countries (countries (1 clinical 1 quality /laboratory 11 clinical 1 quality /laboratory 1andand countries (countries (1 clinical, 1 quality /laboratory, 1 1 clinical, 1 quality /laboratory, 1 managermanager))

t d fi i l t i l d dt d fi i l t i l d d•• management and financial arrangements included management and financial arrangements included

•• draft draft reportsreports highlighting areas of conformance, highlighting areas of conformance,

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partial and nonpartial and non--conformanceconformance

Methodology (ii)Methodology (ii)Methodology (ii)Methodology (ii)

R d ti f hi bl i tR d ti f hi bl i t•• Recommendations for achievable improvements Recommendations for achievable improvements that reflect local conditions of that country and to that reflect local conditions of that country and to attain the next level of conformanceattain the next level of conformanceattain the next level of conformanceattain the next level of conformance

•• Reports are finalised and agreed with local Reports are finalised and agreed with local specialists first, as a draftspecialists first, as a draft

•• Agreed final report sent to specialists and healthAgreed final report sent to specialists and healthAgreed final report sent to specialists and health Agreed final report sent to specialists and health officials/ Ministry of Health.officials/ Ministry of Health.

Follow up visit to review progress and assist asFollow up visit to review progress and assist as•• Follow up visit to review progress and assist, as Follow up visit to review progress and assist, as needed/requested by countryneeded/requested by country

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What the scheme covers (What the scheme covers (ii):):

•• National Blood PolicyNational Blood Policy•• National Blood programmeNational Blood programme•• National Blood programmeNational Blood programme•• Blood Service ManagementBlood Service Management•• Quality System Quality System •• Donor Selection and ManagementDonor Selection and ManagementDonor Selection and ManagementDonor Selection and Management•• Blood CollectionBlood Collection

Bl d D ti S i d G iBl d D ti S i d G i•• Blood Donation Screening and GroupingBlood Donation Screening and Grouping•• Blood component preparationBlood component preparation

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What the scheme covers (ii):What the scheme covers (ii):

•• Blood component storage, distribution and Blood component storage, distribution and transportationtransportationtransportationtransportation

•• Blood stocks managementBlood stocks managementBl d t f i t l ti fBl d t f i t l ti f•• Blood transfusion requests, selection of Blood transfusion requests, selection of blood/components and compatibility testingblood/components and compatibility testing

•• Blood issue for transfusionBlood issue for transfusion•• The transfusion process itselfThe transfusion process itselfpp•• Appropriate use of bloodAppropriate use of blood•• Reporting of adverse reactionsReporting of adverse reactions

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•• Reporting of adverse reactionsReporting of adverse reactions

Pil iPil iPilot countriesPilot countries

•• Number of low and medium HDI countries Number of low and medium HDI countries FAR e ceeds a ailable reso rcesFAR e ceeds a ailable reso rcesFAR exceeds available resourcesFAR exceeds available resources

•• Scheme is evolving, therefore working Scheme is evolving, therefore working with a small number of countries to with a small number of countries to ensure:ensure:ensure:ensure:-- the work is done wellthe work is done well-- the inspectors learn from theirthe inspectors learn from their

experiences and from each otherexperiences and from each other

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pp

-- there is the capacity for the follow up there is the capacity for the follow up visits which is essential to encourage visits which is essential to encourage sustainabilitysustainability

-- the methodology is reviewed andthe methodology is reviewed andgygyupdated from the learning processupdated from the learning process

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Pilot Inspections in Chile, Malawi, PeruPilot Inspections in Chile, Malawi, PeruPilot Inspections in Chile, Malawi, Peru Pilot Inspections in Chile, Malawi, Peru and Sri Lanka and Sri Lanka

•• A long way to go for the 4 countries!A long way to go for the 4 countries!

•• National systems in place in Malawi and SriNational systems in place in Malawi and Sri•• National systems in place in Malawi and Sri National systems in place in Malawi and Sri Lanka: a greatLanka: a great--deal of progress made in just deal of progress made in just 2 years in both countries Two most2 years in both countries Two most2 years in both countries. Two most 2 years in both countries. Two most “national” of the 4 countries inspected.“national” of the 4 countries inspected.

•• Malawi: problem with sufficiency and trained Malawi: problem with sufficiency and trained professionals, as well as with sustainability.professionals, as well as with sustainability.p , yp , y

•• Sri Lanka: problem with management Sri Lanka: problem with management s stems finance and trained TM specialistss stems finance and trained TM specialists

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systems, finance and trained TM specialistssystems, finance and trained TM specialists

Pilot InspectionsPilot Inspections ( )( )Pilot Inspections Pilot Inspections (continued) (continued)

•• Chile: 2 very good “regional” centres, but Chile: 2 very good “regional” centres, but y g gy g gthe capital with most of the population, the capital with most of the population, inefficient, fragmented blood service.inefficient, fragmented blood service., g, g

•• Peru: a long way to go! Main lesson: no Peru: a long way to go! Main lesson: no t l d hi d k i i t i lt l d hi d k i i t i lexpert leadership and weak ministerial expert leadership and weak ministerial

support.support.

Main Lesson from 4 pilotsMain Lesson from 4 pilots: expert : expert pp ppleadershipleadership andand sustainedsustained government government supportsupport are crucial to the success of bloodare crucial to the success of blood

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support support are crucial to the success of blood are crucial to the success of blood services.services.

Viña del Mar – Chile September 2007

Constitution of the National Commission for Blood and Tiss es

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Commission for Blood and Tissues

Hacia un Plan nacional de SangreHacia un Plan nacional de Sangregg

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• Chile: 2 Blood Centres, 41 Blood banksd 43 TM it


and 43 TM units

CHILE: Donación altruista de sangre: 2007CHILE: Donación altruista de sangre: 2007

8% 10%

Overall: 8% voluntary with 10% in the public sectorOverall: 8% voluntary, with 10% in the public sector

Barcelona 15 - 16 06.2010Slides/lectures/Chile Awards/Honoris Causa Slides/lectures/Chile Awards/Honoris Causa –– Univ. de Chile, Abr. 09 (Univ. de Chile, Abr. 09 (3131))

Positive markers per 10,000 Positive markers per 10,000 p ,p ,blood donationsblood donations

Chile NBSHIV 2.6 0.13

C *HCV* 2.9 0.25HBsAg 2 5 0 3HBsAg 2.5 0.3Syphilis* 5.4 0.36ypTOTAL 13.4 1.04

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ChileChile CentralisationCentralisation ProcessProcessChile Chile CentralisationCentralisation ProcessProcess

1998 20122007

2 Centres and139 Bl d b k 3 Centres

41 Blood banks139 Blood banks 3 Centres

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Barcelona 15 - 16 06.2010es/Barcelona 16 .06/2010) es/Barcelona 16 .06/2010) CLUB 25CLUB 25

Barcelona 15 - 16 06.2010Chile Awards/Chile Awards/HonorisHonoris CausaCausa –– Univ. de Chile, Abr. 09 (Univ. de Chile, Abr. 09 (3636))

Donation rate / 1000 popnp p

Latin America, 2003.

52,1

29 040

50

60

20,1

4 3

16,110,9 11,4 11,7 8,6 6,2

11,55,7 7,0 11,0 9,0

14,85 0 5,3

29,0

13,1 13,810

20

30

4,3 , 5,7 , 5,0 5,3

0

10

ARGBOLBRA

CHICOLCRICUBDOMECUELS GUAHONMEX

NICPANPARPERURUVEN

ODOS

A B B C C C C D E E G H M P P P U VTOD

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16 000

Mean donation rate per blood bank, per year in Latin America. 2002 - 2003

12.00014.00016.000

2002

6.0008.000

10.000 2003

02.0004.000

0

ARGBOLBRACHICOLCORCUBAECU

ELSGUTHONMEX NIC PANPARPERDORURUVEN

TOTAL

Es una visión indirecta de la eficiencia del sistema transfusional

Great variability / country: Paraguay 606 units / year, Brasil 7,989 units ; Cuba

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y y g y y , , ;13,389

NICARAGUANICARAGUAT pesT pes ofof donorsdonors 20082008TypesTypes of of donorsdonors 20082008

NUMERO DE DONANTES

DONANTES VOLUNTARIOS

DONANTES REPOSICION DONANTES VOLUNTARIOS REPOSICION

CRUZ ROJA NICARAGUENSE

61,338 31,039

30,301 NICARAGUENSE

51%

49%

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VOLUNTARY VS VOLUNTARY VS REPLACEMENT CNS 2007REPLACEMENT CNS 2007

17748

VOLUNTARIO REPOSICION

24953

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CLUB 25CLUB 25

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VOLUNTARIOS VS REPOSICIÓNVOLUNTARIOS VS REPOSICIÓNVOLUNTARIOS VS REPOSICIÓN VOLUNTARIOS VS REPOSICIÓN CNS CNS 20082008

25369

27460VOLUNTARIO REPOSICION

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VOLUNTARIOS VS REPOSICIÓNVOLUNTARIOS VS REPOSICIÓNVOLUNTARIOS VS REPOSICIÓN VOLUNTARIOS VS REPOSICIÓN CNS CNS 20092009

6018

VOLUNTARIO REPOSICION

52225

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MALAWI NBTSMALAWI NBTS

p y p g pp g•The implementation of a comprehensive IT system to cover all key steps in the collection, processing, testing and issue of blood compo•Staff at MBTS should be more aware of the needs of patients, ie that demand for safe blood is not currently met.•It is a pity that the EU project commenced late and that due to bureaucracy it could not be taken to completion by the Project Manager. S



MALAWI NBTSMALAWI NBTS• Staff : well trained, motivated, dedicated and , ,

committed• Major progress made in the 2 - 3 years since its

foundation. Culture of altruistic blood donations,foundation. Culture of altruistic blood donations, with well treated donors and the notion of a national blood service in a country where these were non existentwere non- existent.

• The main elements of quality management system in placeGi th t i t f l k f fi d• Given the constraints of lack of finance and technical support, evidence of good practice and innovation in managing the MBTSg g

• The system of review and appraisal for all staff is as very good..

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•

Main areas for improvementMain areas for improvement• A programme for gathering information to allow an

accurate assessment of the requirements for blood qin Malawi is needed in order to understand the actual requirements for blood.

•• A plan for sustainability of MBTS should be

developed. More training and support should be given to the Finance and Admin Directorgiven to the Finance and Admin Director.

•• The implementation of a comprehensive IT system

t ll k t i th bl d h ito cover all key steps in the blood chain.

• Staff at MBTS should be more aware of the needs of patients, ie that demand for safe blood is not currently met.

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Malawi Malawi December December

20072007


Sri Lankan Blood ServiceSri Lankan Blood Service

• Excellent – purpose-built blood centre in Colombo with Japanese fundingColombo, with Japanese funding

• All volunteer blood donors• Sufficiency in red cellsy• National Blood Service, though gross

inequality between Colombo and rest of th tthe country

• No liaison between centres and hospitals; no clinical guidelines for blood usageno clinical guidelines for blood usage

• Lack of Transfusion Med specialists, managers and IT system

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g y

S i L k A il 2008S i L k A il 2008Sri Lanka April 2008Sri Lanka April 2008


Sri Lanka Sri Lanka April 2008April 2008pp


BotswanaBotswanaBotswanaBotswana

BNBTS: setting the sceneBNBTS: setting the sceneS sett g t e sce eS sett g t e sce e

• Population covered 1.7 millionHIV l i 2002 35 4% f t• HIV prevalence in 2002: 35.4% of pregnant women, with overall prevalence of 17.1%

• Two blood transfusion centres in Gaborone and Francistown

• 100% voluntary blood donations• Blood collections were 13,210 in 2004Blood collections were 13,210 in 2004 • HIV prevalence in blood donors was 9% in 2001-

02• Approximately 30% of demand for blood was met• Approximately 30% of demand for blood was met

in 2002

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Botswana 2010: achievementsBotswana 2010: achievements• Increase in blood collections per annum from

13,210 in 2005 to 23,275 in 2009, with well ti t d bl d dmotivated young blood donors.

• Decrease in HIV seroprevalence in blood donors from 9% to 1.5% in 2009

• Evident interest of MoH in blood service.• Decrease in blood wastage to levels comparable

to Western European countriesto Western European countries• New, purpose-built Gaborone blood centre • Increased staff by 19 • Provision of vehicles and equipment• Provision of vehicles and equipment • Workshops and training for staff • Creation of NCCUB and HTCs

R i i f id li f li i l f bl d i• Revision of guidelines for clinical use of blood in progress

• Availability of funding for Francistown Centre

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y gand Maun facility

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Findings Findings –– critical areas of critical areas of concernconcern

• Not a truly national blood transfusion service.

• No clear management structure or lines of accountabilityaccountability.

• Francistown facilities unsafe and inadequate; not a “centre”inadequate; not a centre

• Chronic unmet demand for blood with regular acute seasonal shortagesN i li t ti i f• No specialist expertise in any area of blood transfusion

• Blood is often labelled incorrectly with• Blood is often labelled incorrectly with blood group due to poor procedures

• Lack of good laboratory practice

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g y p• True cost of the service is unknown

FindingsFindings –– some areas ofsome areas ofFindings Findings some areas of some areas of concernconcern• Sustainabilityy

– Cost of service is unknown– Lack of single autonomous body to run the

serviceservice– Absence of expertise throughout the

serviceservice– Lack of management capacity

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R d tiR d tiRecommendationsRecommendations• Need for a National Policy and legal y g

framework for a single blood transfusion service

• Define a management structure for an autonomous NBTS with clear lines of accountability to the Ministry of Health

• Francistown facilities need to be urgently upgraded according to revised plan

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R d tiR d tiRecommendationsRecommendations• Review remaining plans forReview remaining plans for

infrastructure investment in Maun and Francistown taking into account quality, a c s o a g o accou qua y,patient safety, need, cost and sustainability (see WHO y (recommendations)

• Undertake an urgent costing exercise to g gestablish the true cost and sustainability of the service

• Develop nationally co-ordinated collection plans to meet demand for red

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cells and platelets

RecommendationsRecommendationsRecommendations Recommendations • Develop a programme for long-term development of

specialists starting with Heads of Department

• Develop a learning culture within the organisationDevelop a learning culture within the organisation

• Establish training in Transfusion Medicine for clinical staff in hospitals and empower HTCsstaff in hospitals and empower HTCs

• Implement automation with positive sample ID in all Testing laboratories

• Implement secure national IT system supported 24/7y

• Implement GLP and GMP

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BTI:BTI:PP d hi td hi tProgress Progress and achievementsand achievements

• Defined a core purpose

• Developed a comprehensive checklist derived mainly from WHO and PAHO recommendations

• Undertaken assessments in 6 (7) countries, with follow up visits 2 ; others planned. Improvements shown in 4 countries.

A l 2 f h i i h• At least 2 further countries in the programme

• Formal links with other organisations established, e.g. ISBT, PAHO AITM NATAPAHO, AITM, NATA

• Meeting of international assessors in London April 2008

Ad ti f th BTI l l• Adoption of the name BTI plus logo.

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Benefits of BTIBenefits of BTIBenefits of BTIBenefits of BTI

•• BTS and Transfusion Medicine specialists inBTS and Transfusion Medicine specialists in•• BTS and Transfusion Medicine specialists in BTS and Transfusion Medicine specialists in many developing countries want a targeted and many developing countries want a targeted and practical scheme So this programme satisfiespractical scheme So this programme satisfiespractical scheme. So this programme satisfies practical scheme. So this programme satisfies an unmet need an unmet need It id i d d t t i tIt id i d d t t i t•• It provides an independent assessment against It provides an independent assessment against emerging basic international standardsemerging basic international standardsIt id bj ti b i t l bbIt id bj ti b i t l bb•• It provides an objective basis to lobby It provides an objective basis to lobby governments for funding and relevant structural governments for funding and relevant structural hh i bl bl di bl bl dchanges to ensure changes to ensure sustainable blood sustainable blood

transfusion services and improvementstransfusion services and improvements

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If th d bt th t BTI iIf th d bt th t BTI iIf there are any doubts that BTI is If there are any doubts that BTI is needed….needed….

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Most countries signed at theMost countries signed, at the

World Health Assembly theWorld Health Assembly, the

WHA l ti 28 72WHA resolution 28.72,

ffi d b i i ireaffirmed by ministers in

Geneva in 2007 and 2010, but

they have forgotten they

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