WHO Workshop on the
Management of National Blood Programmes
Workshop Report
3-7 September 2007
Singapore
Jointly Organised by the Centre for Transfusion Medicine/ Health
Sciences Authority, WHO-WPRO, WHO-SEARO, and WHOGeneva with support from the Singapore Government
1
Introduction
Blood transfusion is an essential part of health care. Every country shares the need to
ensure the quality, safety and accessibility of blood transfusion. This is best achieved
though the presence of an effective and coordinated national blood programme that is
responsible for the provision and rational use of adequate supplies of safe and high
quality of blood and blood components. One of the key factors towards a successful
national blood programme is an efficient and well organised national blood service.
It is important that Directors and Programme Managers of national blood services are
equipped with the appropriate management knowledge and skills to enable them to
implement and operationalise the national blood programme. This includes the
necessary skills in human resources, finance, administration and planning within the
blood service that will allow them to manage their available resources and implement
the national blood plans effectively.
To address these needs, a series of Training Workshops in Management of Blood
Services is planned. The first series comprises three training workshops to be held on
an annual basis over three years. During the course of the three years, participants will
be trained in key aspects of management, with emphasis on their application in the
management of the blood service. The second series comprising two workshops over
two years will cover advanced training in specific priority areas that have been
identified during the first series.
2
Objectives of the Workshop
The overall goal of the series of workshops is to strengthen the organization and
management of national blood programmes in order to improve safety and availability
of blood supply in the Region
The specific objectives of the workshops are:
1.
To sensitize national directors/programme managers of national blood services
with contemporary concepts on planning, organisation and management of
national blood programmes
2.
To promote experience sharing and networking among the Member States in
the Region
3.
To identify gaps and challenges in areas involving the management of blood
programmes in the individual countries, and actions to address them.
The first workshop will address organisational models, strategic planning and
implementation, financial management, the introduction of standards for blood safety,
and the management and effective use of the communication media.
3
Expected Outcomes
1.
Focus on the areas that have been identified through various WHO meetings
and workshops, which include strategic planning and implementation;
contingency planning and disaster preparedness; developing and implementing
standards for blood safety; costing and budget management; human resource
development and management; managing communication and media; and
managing partnerships.
2.
Provide opportunities for experience sharing and learning among the
participating countries.
3.
Participants will monitor progress, identify gaps, and propose necessary
actions for developing and implementing the national blood programme in
participating countries.
4
Proceedings of Day 1
Opening Ceremony
The Workshop was formally opened by the Senior Minister of State (Ministry of
Foreign Affairs and Ministry of Information, Communications and the Arts) Dr Balaji
Sadasivan.
Dr Han Tieru, WHO Representative to Malaysia, Brunei Darussalam and Singapore
welcomed facilitators and participants to the workshop on behalf of the WHO and the
Regional Director for the Western Pacific. Dr Han expressed sincere thanks to the
Singapore government for hosting the workshop. He also expressed delight that the
workshop was joined by participants from the South East Asia Region.
Dr Han highlighted that the need to maintain sufficient and equitable supplies of safe
blood and blood products remains a major challenge in many developing countries.
Two key areas that need to be addressed are the gap between supply and demand of a
safe blood supply, and the serious safety concerns associated with inadequately
screened blood. A major constraint is the lack of infrastructure and systems. To
address these, WHO recommends that member states adopt and implement the
following integrated strategies: the establishment of nationally coordinated blood
transfusion services; collection only from voluntary non-remunerated blood donors
from low-risk populations; testing of all donated blood; and minimising unnecessary
transfusions through effective use of blood. Developing contries are organising their
blood programmes based on these objectives, which will involve significant policy
changes and structural reform. This workshop, which is intended to strengthen
leadership and managerial capacity of those responsible for their blood programme
therefore comes at an opportune time. The workshop also provides further opportunity
to further strengthen the networks among country participants and temporary
advisors.
In his keynote address, Dr Balaji welcomed participants, recalling that he had
previously officiated the opening of the WHO Regional Quality Management
Training Course in Singapore in 2002. He commended the WHO Quality
Management Project and Global Blood Safety Initiative, which had through such
courses, helped to train many senior blood bank officials and health officers in the
fundamentals of implementing quality management programmes. This has contributed
towards establishing safe and effective blood transfusion services in the Region, and
the development of an informal regional quality network.
Dr Balaji noted that organisational management is key towards achieving the prerequisites for an effective quality system. Successful blood services must be able to
provide adequate supplies of safe and high quality blood and blood components to
their population, and this requires a good management system with efficient
infrastructure, good corporate governance, adequate allocation of resources and
financial sustainability. This workshop is intended to provide senior management
teams with the practical know-how of organisation management and opportunities for
them to share their experiences and network.
Dr Balaji’s keynote address was followed by the launch of a training CD on Quality
in Blood Collection, developed by the CTM for the WHO Regional Office for the
Western Pacific. A brief demonstration of the contents of the CD was conducted, and
copies of the CD were made available to all workshop participants and also sent to
national blood services in the Region. The ceremony was concluded by the launch of
the Singapore Red Cross Donorweb Regional Resource Centre for Blood Donation
Programmes.
Session I - Introduction of Participants and Objectives of the
Workshop
Dr Yu Junping facilitated the session during which all the participants introduced
themselves. There were 27 participants from 16 member states; namely Bangladesh,
Bhutan, Brunei Darussalam, Cambodia, People’s Republic of China, India, Lao
People’s Democratic Republic, Malaysia, Maldives, Mongolia, Myanmar, Nepal,
Papua New Guinea, Philippines, Sri Lanka, and Vietnam.
Dr Yu proceeded to introduce the participants to the objectives of the workshop. He
dtressed the necessity for such a workshop as blood safety programmes such as the
WHO Quality Management Programmes, Blood Donor Programmes, are a priority in
developing countries and also with funding partners such as the World Fund and
Global Fund. Additionally, the promotion of voluntary non-remunerated blood
donation is a major challenge in many Member States, as is the establishment of
confidence in both blood donors and the general population.
He mentioned the 58th World Health Assembly in May 2005, during which a
resolution was made (WHA 58.13), which urges Member States to support wellorganised, nationally coordinated and sustainable blood programmes. Therefore this
workshop is intended to sensitise participants to current concepts and practices in the
management of blood programmes, and to provide a platform for sharing of
experiences and best practices.
Dr Yu proceeded to inform participants of the goals of the workshop, which was to
enable those working in the health ministries and blood services to share and learn,
and contribute their experiences. They were to develop and bring back to their
countries action plans on improving the blood programmes, to recommend to WHO
and CTM the action plans to be taken, and also to feedback on the improvements
made.
He urged participants over the next three years to apply the learning objectives, advise
the blood centres, and also to keep in touch and network through web portals, and
finally to report on the progress made.
Pre-Workshop Questionnaire
Dr Peter Flanagan presented a summary of the responses obtained from the preworkshop questionnaire circulated earlier. He mentioned that the purpose of the
questionnaire was to enable the facilitators to gain a better understanding of the
background of the participants, as well as to identify the current challenges they
faced.
Based on the responses, the participants are on the whole very experienced (most with
at least 10 years of experience) and come from a broad mixture of backgrounds. The
major challenges came from the areas of donor recruitment, government support,
blood collection, centralisation, and hospital issues. Some other issues included
quality management, IT support, finance, and standards. The major priorities for the
workshop were identified by participants in strategic planning, project planning, and
training and education.
The personal self assessment by the participants on their management skills was
summarised. In general, most participants felt that they were comfortable with
management competence. There was mixed responses of comfortable and weak in the
areas of strategic planning, project planning and financial management. Most
participants felt that they felt discomfort in the areas of human resources and
transfusion knowledge.
Dr Flanagan concluded the session by noting that he would redesign the questionnaire
and content based on the participants’ feedback.
Session 2 – Organisation and Planning
Organisation Models for Blood Transfusion Services (BTS)
Dr Yasmin Ayob gave a presentation of the various organisation models that exist for
blood services. Most blood services are either hospital based or based on centralised
blood collection, processing and distribution activities. There are six types of models
that currently exist for blood services :

Hospital based

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Government owned
Red Cross / Red Crescent
Red Cross / Red Crescent and Government
Private
Mixture
Hospital blood banks are generally able to meet the requirements of a BTS. The
advantages are close proximity to clinical needs, vein to vein activities, and if they are
in university settings greater research orientation. Disadvantages are duplication of
services, inefficient use of resources, lack of donor focus with weak donor recruitment
and retention, lack of national perspectives and objectives, lack of human resources
and skills in some cases, reluctance to share, and presence of conflicts of interest in
distribution of the blood.
Where the blood service is part of pathology departments, there is advantage in the
presence of set standards and quality assurance programmes. However, donor
recruitment and retention is poor and clinical aspects of transfusion are not
emphasised.
In blood services where the government is the sole provider, national needs are
addressed. However, the organisation may be bureaucratic and rigid, and political
aspects dominant in its activities. Donors may also not donate readily to the state.
The Red Cross and Red Crescent Societies are humanitarian organisations, and this
encourages donors to come forward for blood donation. These have the ability to
create national organisations, have flexible set ups and also have the advantage of
international support and links.
Private or commercial blood banks tend to function efficiently as they are normally
profit-driven organisations. They are also able to invest in more product development
and good marketing tools. However, because of the profit motive, marketing
strategies tend to be aimed at creating need.
Partnership organisations within blood transfusion services are advantageous because
they are able to tap the benefits of the different partner organisations, and to have
combination of authority, skills, flexibility and efficiency. Examples of some models
include Malaysia, where the Ministry of Education and some private organisations
contribute to the blood programme run by the Ministry of Health, and Singapore
where there is a partnership between the Ministry of Health and the Singapore Red
Cross.
The BTS organisations in different countires were described, such as those in
Malaysia, Singapore, USA, Australia, New Zealand and Japan. Dr Ayob also
described the experience in Malaysia in developing a more coordinated national blood
programme.
Dr Ayob concluded by recommending that whichever model is used by the BTS, it
should establish proper working standards, develop guidelines, establish policies,
establish regulations, and have relevant legislation in place. All BTSs should have:
standardisation; coordination; clear structure in terms of authority, responsibility and
accountability; clearly defined functions; and adequate resources. In developing
countries, government must be responsible, committed and take the lead. She also
advised that in order to obtain government support, it is important to present the case
with good data, have clear objectives and knowledge, know the appropriate person to
approach, continue to follow up, and be persistent and patient.
Partnership Models for Blood Transfusion Services
Dr Diana Teo gave an overview of the different partnership models involving blood
services. These generally fall into the categories of outsourcing initiatives, suppliercustomer partnerships, and capability strengthening initiatives. Important elements in
a partnership involve choosing the right partner, having clear goals and objectives,
clearly defined roles and responsibilities, set agreed performance indicators, and
regular monitoring and review. Partnerships can be based on contracts, Memorandum
of Understanding, Memorandum of Agreements, or Service Agreements.
The success factors in a partnership include: common goals; win-win situation;
leadership commitment; clear responsibility and accountabilities; achievable and
measurable performance indicators and targets; organisation buy-in and ownership;
and regular dialogue. The importance of regular dialogue, regular review of
performance, and setting of targets and initiatives was emphasised. She illustrated this
with some partnerships involving the Centre for Transfusion Medicine (CTM).
Different arrangements exist with the different partnerships; however all partnerships
had the common aim of strengthening capability.
The partnership between the blood service in Singapore and the Singapore Red Cross
(SRC) was initiated in 1997 with a taskforce studying how to reduce duplication of
roles and activities in blood donor recruitment and collection. An MOU was signed
between the two organisations in 2001. CTM has clear responsibility and
accountability for the blood programme, and in ensuring the quality and safety of the
blood supply. It focuses on its strength in the professional and technical aspects of
collecting, processing and distributing the blood. The SRC focuses on its strength in
developing and implementing appropriate national strategies to increase awareness of
blood donation, donor recruitment, and training and managing volunteers. The CTM
provides SC with a budget to enable it to manage the blood donor programme.
Staff from both organisations form an operations committee, which looks jointly at
planning of donor recruitment and retention strategies and projects, and also ensures
that both sides are kept updated of activities. Through continuous communications
and joint planning, both organisations are able to achieve national goals and key
performance indicators, as well as to develop annual operations plans and budget.
Performance and KPIs are presented regularly at quarterly staff reviews.
The success of this partnership was due to the formal appointment of the SRC as
national blood donor recruiter by the government, sufficient funding and support,
strong governance, staff involvement, and common goals and objectives. The benefits
from the partnership are a focus on organisational strengths of both sides, and
enhanced resources such as volunteers.
Another type of partnership is the outsourcing of warehousing and supplies inventory
to a logistics specialist Sembcorp Logistics in 2001. The company has qualified and
experienced staff able to manage the purchasing, inventory and warehousing of
supplies efficiently. It also provides logistics support to mobile blood collection sites,
delivering supplies and equipment from its warehouses and collecting them after the
mobile. This partnership benefits the blood service, which is able to focus on its core
business and devolve the supplies management functions to be better and more cost
efficiently managed by specialists.
The third type of partnership involved the partnership with hospitals. This is a looser
partnership based on agreed common goals of providing safe and quality blood to
patients. A good partnership ensures that blood and blood products issued to hospitals
are properly stored and managed. Regular meetings are conducted between staff of
both sides to update on changes in policies or processes, and to address problems and
issues. Within such a partnership, it is also possible to determine set performance
indicators, which could include percentage of blood available to meet clinical needs,
haemovigilance, wastage, or financial indicators.
Group Discussion on Appropriate Organisation Models and
Partnerships
Key points arising from these include:


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While the Singapore model of partnership is a useful model to consider, it
would be more difficult to centralise activities in larger countries where there
would be more than one agency collecting blood.
It is important that the government is able to provide financial grants to
support blood collection activities.
In some countries where the Red Cross is responsible for blood collection, it is
difficult to achieve full cost recovery for these activities. These blood services
then have be supported with assistance from sister national societies in more
developed countries like Australia and Spain as it was difficult to obtain grant
support from the government.
Developing and Implementing Strategic Plans
Mr Benjamin Pwee introduced the strategic leadership triangle which consisted of
strategic thinking, strategic planning, and strategic implementation.
It is important for organisations to conduct an assessment of the external and internal
environment. This would enable them to analyse their strengths, weaknesses,
opportunities and threats (SWOT), and develop their strategies. One method of
assessing external environment is the use of the PEST model, which focuses on four
major areas : Political, Economical, Social, and Technological. He also described the
4S model which can be used to assessment the internal environment, based on
Structures, Social, Strategy, and Skills. The use of the PEST and 4S models was
illustrated by using examples from the Hong Kong Red Cross Blood Transfusion
Service.
Mr Pwee stressed that it is important for organisations to set out their mission, values
and vision statements. He also described the Balanced Scorecard concept which is
used in setting out and monitoring strategic action plans. The scorecard encompasses
Vision and Strategy in the centre, which is interconnected on four sides with the 4 key
areas of Financials, Customers, Internal Business Processes, and Learning and
Growth. The application of the Balanced Scorecard in public and non-profit
organisations, and in private organisations was described.
Through strategy maps and the Balanced Scorecard, the organisation can develop its
targets and initiatives which should lead to the desired strategic outcomes. This
approach provides a uniform and consistent way to describe its strategy, so that
objectives and measures can be established and managed. Strategic maps provide the
missing link between strategy formulation and strategy execution. Strategic outcome
indicators should include satisfied donors and financers, delighted custmers, efficient
and effective processes, and motivated and prepared staff.
In implementing one’s strategic plans, one must conduct external and internal
analysis, followed by developing the mission, values and vision statements. This is
then followed by setting out the Balanced Scorecard indicators, followed by setting
and implementing targets and initiatives, and finally identifying and obtaining
sufficient resources and approvals. It is important to conduct regular monitoring and
review of the plan.
Performance Indicators and Targets
Dr Diana Teo described performance indicators as a management tool to monitor and
evaluate success, as part of planning to enable efficient allocation of resources, and
enable ownership and accountability for the programme or project. She stressed the
importance of choosing the appropriate performance indicators and targets, which
should be relevant, measurable, achievable, simple, and enable timely action. This can
be summarised in the acronym SMART, which stands for Specific, Measure,
Achieve, Relevant, and Timely.
Two types of measures are used. Outcome (results) measures come at the end of the
process and happen after the fact. Driver measures or leading indicators are taken
directly within the process and happen before the results.
Examples of performance indicators and targets that could be used in the blood
services were described. These generally fall into measures of volume, quality, or
efficiency. Key performance indicators for the blood service include the number of
whole blood donations, number of apheresis donations, number of blood components,
and daily blood stock levels. Indicators of mobile blood programme performance
include the number of blood drives organised, and comparison of actual blood
collection against projections. Donor satisfaction can be measured by direct indicators
such as donor feedback, and indirect indicators like waiting times for medical
screening, blood donation, etc. Other useful indicators mentioned included failed
phlebotomies, donor haemovigilance, blood supply utilisation, blood component
outdates and rejects, as well as staff satisfaction and training indicators.
Performance indicators must be regularly monitored and reviewed, and this must be
accompanied by timely action. Targets must be regularly evaluated and updated to be
relevant. Assigned owners of the performance indicators should be appropriately
empowered, and given responsibility and accountability. Platforms for monitoring and
review of performance indicators include strategic planning retreats, and results
communicated staff meetings and stakeholder dialogue sessions.
Practical Session on Developing Strategic Plans
The practical session involved participants working either as individuals (if there is
only one country representative) or groups involving all participants from the same
country. Within the session, participants were encouraged to review the organisational
direction and goals of their blood service, identify the key goals to be achieved, and
develop strategic plans to achieve the goals.
At the end of the session, representatives from four countries presented their work for
discussion. A number of issues, constraints and challenges were identified:
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5
In Vietnam any changes in external environment affects the blood services as
new leaders tend to change policies.
In Papua New Guinea, new minister in office has brought about new changes.
The St Johns Brigade is responsible for blood collection and there is a problem
with funding for the blood programme as there is lack of accountability for the
government funds allocated. There is also problem with social aspects, such as
the preference for directed donations amongst the public, and the increased
rate of HIV and Hepatitis infections. Increase in open-heart surgeries has also
led to increased need for blood transfusion, and increase in number of cars on
the road to more accidents and need for blood.
In China, there has been improved organisational structure, blood collection,
and donor recruitment. Quality management training has led to clearer
responsibilities in quality assurance. The MOH has also rationalised blood
centres in China, and established formal contact with the Red Cross and
plasma fractionation organisations. There is also increased efficiency in
communications, and more effective systems to measure and reward staff
performance, and better career development for blood bank staff. The strategy
is to achieve 100% non-remunerated blood collection, centralization of blood
testing and better communication with hospitals transfusion committees. To
improve skills, there is better investigation of corrective actions and
preventive actions for any errors. It is also aimed to improve skills in donor
recruitment and to increase optimal usage of blood by hospitals.
In India, blood collection establishments are very fragmented and many
partnerships exist. As a regulator, one of the measures is to control the
commercial value of the blood to ensure that it is not sold for more than 500
Rupees per bag, and also to ensure that blood is always available to the poor
and needy (participant from India is a regulator).
Proceedings of Day 2
Managing Projects Successfully Through Effective Planning
Mr William Loh shared the experience of the National Library Board in Singapore as
a project-centric organisation. He noted that 70% of work done in most organisations
are project activities. A project is defined as any temporary, organised effort that
creates a unique product, service, process, or plan. It is a unique venture comprising
of interrelated activities with a definite beginning and end, to meet established goals
within parameters of scope, schedule and resources.
A well-managed project is likely to run smoothly and produce consistent, repeatable
and predictable results. It is able to combine the talents of team members and
coordinate their efforts. Project management includes management of scope, time,
cost, quality, human resources, communications, risk, procurement and integration in
the project.
A project is initiated by: defining the problem or opportunity; identifying the project
requirements, stakeholders and their needs; and developing the project strategy.
Project management strategy includes: define and organise the project; plan the
project; track and manage the project; and close and review.
In planning the project, it is important to give understanding of top down goals,
alignmment of expectations of what has to be delivered, and clarity of roles and
responsibilities. The project team (WHO), project scope )WHAT), and project tasks
(HOW) must be defined. Project teams usually comprise the sponsor, project
manager, core team, and extended team, and h roles of each were described in detail.
Project parameters must be defined, and this includes the project objective statement,
flexibility matrix, major deliverables, completion criteria, and success criteria. Mr
Loh explained the characteristics of a good project objective statement, the use of
flexibility matrix, and how to select relevant deliverables and develop good criteria
for completion and success.
He stressed that project tasks should be clearly defined to improve communication,
minimise re-work, improve schedule predictability, and provide visualisation of the
project. Defining tasks involves defining the total project scope, estimating
resources/cost/time, assigning responsibility, and measuring performance and control.
Each task should be described with a verb and a noun, have an owner assigned, and
duration estimated. Elements of task scheduling - including logical dependance of
tasks, milsetones, and logical relationships of tasks - and issue logs was described.
Finally, Mr Loh shared the importance of the first project kick off meeting. Members
of the project management team should also attend project-planning workshops to
familiarize themselves with the tools and processes used for planning.
Practical Session on Project Planning.
Participants broke out into four Working Groups. Each Working Group was
encouraged to identify a suitable project, discuss an appropriate approach and design,
and develop a comprehensive plan to implement the project. The four projects were
selected for the practical session:
(a)
(b)
(c)
(d)
Setting up a Donor Recruitment programme within 3 years
Implementing a new TTI screening test within 1 year
Establishment of a National Blood Programme over 20 years
Developing a quality system within 1 year.
Disaster Preparedness and Planning
The importance of being prepared and planning for disasters was discussed by Dr
Diana Teo. Planning is essential to ensure blood supply continuity and that supplies,
logistics and trained staff would be available during emergency. This is part of risk
management and enhances stakeholder confidence in the blood service, as well as
strengthening the case for assistance by government/funding agencies in providing
resources.
In disaster preparedness planning, the impact of the disaster on critical elements of the
blood programme must first be identified and then appropriate action plans developed.
Coordination plans must be developed with other stakeholders and agencies involved.
Standard operating procedures must be written up and staff training conducted.
Supplies, facility and logistics should be organized. Readiness must be tested, gaps
identified and plans reviewed regularly.
Disasters resulting in physical trauma generally result in the need for large volumes of
blood, and may disrupt communications/transportation and power/water supplies.
Biological disasters are usually associated with drop in donor attendance, donor
deferrals, decreased blood requirements. Pandemic situations may disrupt
infrastructure, result in curfews and quarantine, and lead to staff and supply shortages.
Disasters involving the blood bank may result in disruption of operations, possible
loss of staff and blood/blood components. Disasters will impact on public, blood
donors, blood service staff, volunteers, patients, hospitals, blood bank processes,
logistics and facilities. It is therefore important for blood centers to develop disaster
preparedness plans to tackle such situations.
The elements of disaster plans include: command and control structure; messaging to
public, donors, stakeholders; human resource management; blood inventory
management; supplies and materials; facility integrity, adequacy, security; logistics
(transportation and communications); and coordination with other units, agencies,
countries.
In developing plans to manage disaster scenarios, the blood service must determine
whether such scenarios lead to a need for more blood, and if so, whether there is
sufficient blood available or how much additional is required. If additional blood is
required, then these should be made available before immediate inventory runs out.
Collection, processing, testing and distribution of additional blood needs must be
planned for, and supply adjusted to demand. It is important that appropriate messages
are provided to public and blood donors based on whether more blood is needed, and
that the public are not alarmed unnecessarily as this will lead to long term
disillusionment and loss of confidence in the blood programme.
BTS planning for disasters requiring large amounts of blood must consider the
following when developing its preparedness plan:  Determine policies for management of emergencies
 Command and control system, roles and responsibilities
 Management of blood donors
 Development of communication plans
 Plans for scaling up operations
 Communication and distribution network with hospitals
 Arrangements for additional supplies, transportation, food, water, etc
 Arrangements with all organizational units
 Coordination with other organizations involved
In scaling up operations, additional space needs to be identified, and crowd movement
and security planned. Mobile sites can be identified so that speedy activation is
enabled. Additional staff should be trained and recall systems set up. Spare capacity,
supplies, additional transport and logistics that can be made available in an emergency
should be identified and arrangements made for deployment when required.
It is also critical that disaster preparedness plans are appropriately disseminated,
regularly reviewed and updated. There may be changes to donation criteria, computer
systems, new tests and technologies, process changes, and new volunteers to be
trained. Emergency exercises are also a useful way of testing and validating
emergency plans.
Flu Pandemic Preparedness
Dr Lin Che Kit introduced the purpose of the disaster response plan in the Hong Kong
blood service, which is to coordinate activities in the BTS, and between the BTS and
hospitals or outside bodies to ensure blood supply in the event of emergency due to
either a general disaster where a larger amount of blood supply is needed than normal
or causing sudden influx of donors, or disruption of the service that temporarily
restricts or eliminates the ability of the BTS.
He described the SARS outbreak in 2003, which severely affected several countries in
the region. In addition to the human suffering, death, and negative economic impact
on tourism, travel and trade, the blood supply was adversely affected. In Hong Kong,
a reduction of 20% was seen in overall blood collection and 14% reduction in blood
utilization during that period. Lessons were learnt from SARS and infectious disease
outbreaks reveal weaknesses in public health infrastructure. An infectious disease
threat in one country is a threat to all, as contagious infections do not respect national
borders. These infections can be contained with high level government commitment
and international collaboration.
During the SARS experience, BTS in the countries affected learnt many lessons
regarding the vulnerability of the blood supply during such outbreak as donors were
unable to donate due to the fear of transmission of SARS, due to deferrals imposed by
concerns regarding its transmission by blood, and potential outbreak in the BTS.
There was a need to strengthen donor programmes to broaden the donor base, manage
donor perceptions and fears, use of media and communication tools, and staff with
suitable training.
BTS also need to establish systems to ensure donor and blood traceability, which
should include effective product recall systems, patient notification and look-back
studies and patient registries. Contingency plans also need to be developed to address
operational issues, such as setting up blood collection sites at location perceived to be
of lower risks and to have alternative plans in event of disease outbreak amongst staff.
The impact of development of diagnostic tests, and implementation of screening tests
also needs to be considered.
The potential impact of an influenza pandemic on the blood supply includes: impact
on blood safety through collection of blood from infected individuals; blood shortage
due to donor deferral and drop in donor attendance; reduced blood demand from
cancellation of elective surgery; spread of infection among blood donors and staff;
and disruption in blood bank operations due to staff illness.
For consistency of reporting and contingency planning purposes, it is useful to adopt
the WHO system of staging Alert Levels from 1 to 6 ( 1, low - 6,pandemic). Dr Lin
described the different measures that can be developed to address the impact of
disease outbreaks at each stage of an influenza pandemic. One of the measures is the
formation of regional and international collaborative networks, such as the Asia
Pacific Blood Network and WHO.
Contingency Planning, Principles and Practice
Dr Peter Flanagan explained that contingency planning manages the “What if”. It is a
form of risk management, and provides the opportunity to plan without pressure.
Contingency planning aims to identify potential problems in advance, and decide how
to avoid it occurring or how to manage its occurrence.
Contingency planning should form part of the business planning process. The
involvement of cross-functional teams and high level support are essential. The
response developed must be proportionate to the risk and its impact. The steps to be
taken in planning for contingencies involve: starting point; impact assessment;
developing plan; testing plan; personnel training; and monitoring plan.
Impact assessment involves the development of a list of serious incidents that might
occur and have impact on normal business. For each incident, the likelihood and
potential should be assessed, and a matrix should be developed of the likelihood of
the event (low, moderate, high) versus the impact severity (low, moderate, high).
Factors that affect the impact of the incident include the site where it occurs, duration
of the event , and intensity of the event.
Contingency plans must be developed for each identified risk. These include the
following aspects. What organisational functions are critical and must be supported.
For each function, the level of contingency support required. Identify the specific
roles and people for each task. Dr Flanagan illustrated the development of
contingency plans using the example of the risk of loss of electrical supply.
The effectiveness of the plan should be tested where feasible, and the level of support
revised if needed. Personnel training requires documentation of procedures, training
of staff in the activation of emergency plans, and listening to feedback. Maintaining
the plan involves regular review. It should be resilient to staff turnover, modified as
organisational capacity changes, and tested on a regular basis.
Common contingency planning scenarios were discussed in detail – earthquake/flood,
recall of HIV test kits/blood packs, industrial action – and the experience and plans
developed by the New Zealand Blood Service shared with the participants.
Emergency Support Regional Networks
Dr Yasmin Ayob stressed the importance of regional networks during emergencies.
Such networks allow information sharing, provide professional and technical support,
increase awareness of blood supply safety, encourage joint actvities, enable rapid
alert, and effective disaster management.
She described the regional networks currently in place in the region – World Health
Organisation (WHO), Asia Pacific Blood Network (APBN), and the International
Federation of Red Cross and Red Crescent Societies (IFRC). WHO works through its
Western Pacific (WPRO) and South East Asia (SEARO) Regional Offices and the
IFRC through its regional offices and the Global Advisory Panel (GAP). These
regional networks are able to maintain knowledge exchange, close communication
and also good transport systems of blood movement to needed areas. Disasters such as
Tsunami, earthquake, flood and outbreak of an infection are emergency situations,
which require blood banks to be on high alert.
The WHO is looking at future regional collaboration for update of knowledge, sharing
of information, training of staff such as staff secondment to advanced BTS centers,
and also by developing shared regional position, by auditing and also by participating
in research trials. In addition to WHO, the Red Cross has the TRAG and GAP to
provide support to the participating countries. The objective is to advise, share
knowledge, have clear policy, the availability of disaster management and also
checking current facilities and improvement to better facilities.
Some of the regional alliances support shared testing, such as NAT and malaria
testing. These have the advantages of enabling review of test before committing to its
use, better cost effectiveness for small volumes, and as interim measures while
awaiting new technology.
Another area involves knowledge exchange in areas such as emergency planning and
disaster preparedness, blood donor management, and risk management issues
(management approaches, strategy plans, testing algorithms). Regional workshops are
a good platform for development and strengthening of regional networks, e.g. the
Inter-Regional Workshop in Kuala Lumpur in March 2007.
Future regional collaborations could include: expansion of the APBN; staff
secondment between blood services for development and training; shared regional
position for suppliers; auditing; research trials; coordinated humanitarian assistance,
and regional workshops. Emergency assistance between countries could take the form
of resources (people, equipment, reagents, facilities, transport) or blood supply.
Practical Session on Disaster Preparedness Planning
The practical session involved participants working either as individuals (if there is
only one country representative) or groups involving all participants from the same
country. Within the session, participants were encouraged to identify the challenges
and constraints that will be faced in their country in the event of a flu pandemic,
identify strategies the will be effective in overcoming these challenges, and develop a
framework for action plans to secure the blood supply in the event of flu pandemic.
At the end of the session, representatives from four countries presented their work for
discussion. Some key points included:

Public would be educated through media on use of protective clothing and
measures to be taken during a flu pandemic, as well limit travel to affected
areas

In the event of a blood shortage, the media should be used to inform public. In
some countries, blood donors would be encouraged to donate blood through a
liaison with recruitment organization. There could also be recall of healthy
donors from uninfected areas.

Blood donors could be recruited during the early stage of the pandemic to
increase the blood stock. Where available, frozen blood stocks could be used.

Information pamphlets could be developed for public and donors.

The address, home telephone and hand phone number of staff and volunteers
could be kept, so that they could be contacted when and where necessary.

If there is insufficient staff, they could be deployed from other departments,
and trained in blood donor screening and other critical tasks. If there is heavy
donor response to blood shortage call, additional manpower may be deployed
from outside the organisation, e.g. army and police was suggested.

Staff and volunteers should take and record their temperatures regularly. PPE
should be provided, and frequency of cleaning of the facilities should be
increased.

Vaccination for all health care workers should be carried out.

If there is no space for the blood donation, alternate sites such as stadiums or
concert halls could be considered.

Processes may have to be simplified and shortened in some cases. Staff may
also need to be trained on the use of alternative techniques.
6

In the case of logistics, options for managing supplies include maintaining
adequate back-up supplies, listing down the supplier’s hotline number so that
they could be contacted, and sourcing for alternative suppliers.

Hospitals would be informed to reduce elective operations and only handle
emergency situations. Clinicians may also need to be educated on stringent
usage of blood.
Proceedings of Day 3
Session 3 – Ensuring Financial Sustainability
Principles of Financial Planning
Ms Grace Chan introduced the participants to the basic principles and practices of
financial planning in an organisation. She defined accounting as the process of
identifying, measuring, recording and communicating economic transactions; this
measurement is normally made in monetary terms. Such accounting processes
produce records in the form of financial statements such as Profit and Loss Accounts
and Balance Sheets. Accounting can be subdivided into (i) financial accounting reporting to external parties and compliance with external accounting standards such
as audits and taxation; and (ii) management accounting for providing information for
management.
She then went on to describe three key accounting reports in detail with examples and
illustrations: Profit and Loss Account, Balance Sheet, and the Cash Flow Statement.
The Profit and Loss Account is a statement of income, and forms a record in monetary
terms of activities of a business during a stated period of time, usually one year. The
Balance Sheet is a snapshot view produced at the end of this accounting period and
forms a statement of assets and liabilities and ownership of a business at the close of
business on a stated date. The Cash Flow Statement is a statement of sources and uses
of case, and reflects the cash position of a business.
The Balance Sheet Statement provides a summary of the financial position and
business net worth at a specific time period, and is represented by the equation
“Assets = Liabilities + Equity”. Assets include current assets (cash in bank,
inventory, etc) and fixed assets (building, land, equipment, furniture, etc). Liabilities
include current liabilities (accounts payable to creditors, accrued expenses, short term
loans, etc) and long term liabilities (long term loans, lease). Equities include
shareholders equity and retained earnings.
Cash flow is critical to an organisation’s survival, but does not equal profit. It is
determined by 3 components by which cash enters and leaves the organization – core
operations, investing, financing. Examples of cash flow statements were discussed.
All stakeholders need to be able to appreciate how the company is performing and this
can be measured through ratio analysis. These are usually calculated by comparing 2
values in accounts, and must be compared over time or against other ratios to be
meaningful. Different types of ratio analyses include performance ratios, liquidity
ratios, gearing ratios, and shareholder ratios; these were described with illustrations.
Ms Chan discussed some issues in investment analysis and decision making. When
acquiring capital assets such as equipment, options of lease versus purchase may be
available. It is important to consider the pros and cons of each in terms of financial
and business aspects. Issues that should be considered include: length of lease
commitment versus business needs; impact on cash flow/available finance; cost of
finance; whether leasing can be terminated part way through; what happens to the
asset at the end of the lease; security requirement and what happens if there is default
on payment; and type of lease including maintenance and breakdown.
When embarking on key investment projects, 3 questions must be asked. Does the
proposed investment fits the overall business strategy, and if not why consider the
investment? Has the financial implications of the proposed investment and the
associated sensitivities and risks been taken into account? Are there operational
capabilities to manage the investment project and then successfully employ the
investment within the business?
Ms Chan discussed methods of evaluating capital investments such as Discounted
Cash Flow, Net Present Value, Internal Rate of Return and Discounted Payback. She
concluded by describing cost of capital, cost of equity, cost of debt and economic
value, illustrating these with examples.
Budgeting and Budget Management for Blood Programmes
Dr Yasmin Ayob discussed budget management in blood programmes. She noted in
starting that total costs of the blood transfusion service should include all resources –
including those with and without invoices, and those with no market price like
volunteers, facility and electricity. Having a dedicated budget to the BTS provides
more flexibility.
One practical way to allocate costs is by activity, e.g. blood donor recruitment, blood
collection, blood processing, blood storage and distribution. Total costs would
therefore be the sum of the cost of all these activities. Costs are divided into capital
and recurrent costs. Capital costs include infrastructure like building, vehicles,
equipment, furniture and training. Recurrent costs include personnel, utilities,
insurance, transport, supplies, and administration. Costs are also divided into direct
and indirect costs. Direct costs are charges that have a direct relationship to the
service, while indirect costs are computed costs based on a percentage of direct costs.
Dr Ayob defined cost as the estimated expenses from task items developed in the
work break-down structure. Managing cost requires a disciplined approach with
proper estimation and control of expenditure. A budget lists all the planned activities,
and the expenditure of these activities. Any budget developed must be consistent with
cost. Variance between the budget and actual cost will affect any activities planned.
Insufficiency in productivity and new activity introduced will increase cost. Tracking
of expenditure minimises such variations, and awareness of any changes in the budget
is essential.
In conclusion, managing the budget depends on the accuracy of the estimated and
resulting budget. The development and execution of the budget must be a disciplined
process, and it is also important to be aware of any changes.
Principles of Costing in Blood Services
Dr Diana Teo explained the rationale for costing in the blood bank setting. It can be
used as a tool for planning and mobilizing resources needed to sustain blood supply; it
provides information on the cost of the different activities involved in providing
products and services; improves budgeting and budget allocation; enables monitoring
of costs; enables realistic planning for future initiatives or expansion; evaluates cost
effectiveness of the products/services; provide stakeholders with information on the
budget required to produce the product or service; and helps to determine blood
processing fees.
4
In the blood bank setting, classification by activity defines a framework that allows
estimation of costs and outputs of specific activities. Allocation of costs to various
cost centres enables good capture of data without duplication. Each cost centre can be
designed to cover clearly defined areas involved in specific activities, e.g. blood
donor recruitment, blood collection, blood processing, etc.
When costing blood products/services, the purpose of costing has to be defined, the
organizational structure of the blood service determined, and the time frame and
sample size identified for data collection. Sources of data include financial records,
payroll records, output data, and time and motion studies. The costs are then
calculated from the data collected.
Cost categories can be based on time frames or based on involvement in activity.
Time frame based costs are divided into capital and recurrent costs. Costs based on
involvement in activity are divided into direct (stand-alone) costs and indirect
(shared) costs. These were explained in detail with examples of capital and recurrent
costs, direct and indirect costs, and annualisation of capital costs. The total annual
cost of an activity is the sum of the average annualised capital cost (direct + indirect)
and the recurrent cost (direct + indirect). The unit cost of activity is therefore the total
annual cost divided by the total activity output.
The process of costing blood involves the following steps: determine all items
contributing to the activity; determine which are direct and indirect, and compute the
allocation of indirect cost to the activity; determine which are capital and recurrent,
and determine the annualising factor based on the useable shelf life for capital items;
determine output indicators; and calculate the total cost of the activity divided by the
relevant output indicator. This was illustrated using the example for whole blood.
The allocation of source costs in blood components was discussed. The cost of the
blood component must include the portion of cost of the source whole blood unit. The
formula used to determine allocation ratios differs among blood services depending
on the practice and policy; it is often based on distribution of components, disposition
of components, or blood service/MOH costing policy. This was illustrated using the
example for platelets.
Dr Teo went on to discuss product pricing and blood processing fees. She noted that
pricing is not equivalent to costing. Where full cost recovery is expected, product
pricing must include wastage and outdate rates which are often not taken into account
during costing. She concluded by highlighting important considerations in costing
blood products; that whole blood is divided into many components; each component
is processed differently; different equipment are used with varying usage period to
process components; some equipment may be used for different components, each
using it for different time periods.
Financial Models
Dr Lin Che Kit reminded participants that the budget lists all the planned activities of
the blood service, and the expenditure of these activities.
There are many different models by which blood services are funded. These include:
government funding, which is either direct or indirect (through national blood
authorities or through blood supply); parent organisations, e.g. Red Cross or other
agency; and recovery from the blood supply.
He showed examples of the different models that exist in the Region. For example,
Malaysia obtains 100% direct funding from the government, while New Zealand,
Australia and Hong Kong receive 100% funding indirectly from the government
through the national blood authority/blood supply. In Singapore, direct government
funding accounts for about 42% with the remaining recovered from the blood supply
as processing fees. In Thailand and Indonesia, there is partial funding from all the
various sources, while in China mode of funding varies from province to province.
There are also different models of the budgeting process. One model is based on
incremental budgeting process, where the budget for each year takes as its starting
position the budget from previous year, and adds/subtracts from that base. This is
practised in Hong Kong and Malaysia. The other model is based on the rational
budgeting process, which is less concerned with budget base, but more concerned
with using resources to meet currently established objectives. This is practised in
Singapore and Australia. Some blood services may use a mixture of both models.
Dr Lin went on to describe in detail the financial frameworks and models used in
Singapore and Hong Kong as illustration. He concluded that financial and budgeting
models for blood services are variable. However, most involve setting of annual
objectives and targets, usually based on previous years actual figures. The more
competitive economic environment is shifting attention away from levels of service to
income and ratios of cost recovery. Knowledge of costs is therefore important in order
to tender correctly and budget efficiently.
Practical session on Budget Planning and Costing
The practical session involved participants working either as individuals (if there is
only one country representative) or groups involving all participants from the same
country. Within the session, participants were encouraged to identify the key budget
components and a revenue source in their organizational budget, identify challenges
and constraints in managing the budgets, and develop a financial strategy and plan to
ensure sustainability. Participants were also encouraged to review the principles and
methods of costing blood and blood components.
At the end of the session, representatives from four countries presented their work for
discussion. Some key points included:
7

Most of the participants identified the following components as key budget
components: blood donor program; purchase of equipment; purchase of
consumables; utilities; maintenance; training; salaries.

In India, there are 2,300 blood banks, with majority in government hospital
blood banks. There are also private hospital blood banks and some stand-alone
blood banks. Funds are given to the hospital by the government and then
divided to the blood bank. Blood is free to the patient and there is small cost
recovery charge in public hospitals, while recovery fee is high in private
hospitals.

In China, the financial models for blood banks differ amongst provinces. In
one participant’s blood bank, the Government is the main source of funding.
Cost recovery is through the cost of one unit of whole blood, which is same all
over the country. The blood centre recovers the cost from each hospital.
Health insurance cover is established for public. Recurrent budget is generally
high and needs to approved by the health bureau every year.

In Nepal, the main source of funding is through the Nepal Red Cross. Blood is
provided to patient on a cost recovery basis. However, the cost of a blood unit
was determined many years ago and has not been updated since. It is therefore
necessary to perform a costing of blood units so that the MOH can determine
the pricing for blood and its components, and help to fund any deficit.

In Brunei, the government funds the blood service. Budget requirements
should be informed to MOH every year, and additional funding obtained if
necessary. Blood is totally free to patients and there is no cost recovery.

In Bangladesh, the government is the main source of funding and there is no
cost recovery from patients.

In Vietnam, the source of funding varies from province to province. It may be
directly from the government, through authority from the government or from
other organisations.
Proceedings of Day 4
Session 4 - Effective Communication with Stakeholders
Principles of Communication - 7 Sins and 7 Virtues
Mr Peter Lim started the session by stating that principles should be kept simple. In
communications, it is important to keep the message short and simple. Using the
context of 7 sins and 7 virtues, he described the basic principles of communication.
The 7 sins were described as:







Lust: We want, but we don’t connect
Gluttony: We get what we want, but it’s never enough
Greed: We have got our goals but no values
Sloth: We show & tell, but we don’t know enough
Wrath: We don’t like, so we anyhow hit out
Envy: We see, we sigh, but we don’t really see what people are about. No
empathy,
Pride: We know our stuff, but we don’t know how to connect
The 7 virtues were described as :







Faith: Connect with our cause/mission
Hope: Get across our wish to connect
Charity: get it across that we care
Fortitude: Get across our integrity. Takes guts to tell the truth
Justice: Commit to balance and fairness
Temperance: That means self-restraint! So stat relevant, maintain perspective
Prudence: That means good sense, which means good taste. That’s how we
connect.
In all communications, it is important to understand the other person’s needs, desires,
fears and aspirations. Using blood as an example, he added that just as the
components of blood are critical, so content is also important in communications.
Good communications should have Relevance, Accuracy and Clarity. The use of fun
in communication content can sometimes be effective too; however this should only
be used where appropriate and in the correct context.
Managing your communication
Ms Carol Teo discussed how to manage communications through the media, through
outreach programmes, and during crisis. Media is a way of communicating to the
masses using various forms of mediums such as print media (magazines, newspaper),
broadcast media (TV and radio), and digital media/new media (website, blogs, on-line
forums). Relating to the media provides opportunity to raise awareness, mobilize the
public around events or causes, or improve the organisation’s image. It can be used to
present or challenge a particular point of view, or the way the organisation’s issues
are covered. It can also help efforts to recruit more people or volunteers, or to raise
funds, donations and services.
Media relations is a two-way relationship, and the media can be friend or foe. Because
the media has commitment and accountability to the public, media content usually
relates to what the public would like to hear. This can be in the form of hard news
(events happening now, serious information) or soft news (follows hard news, how
the hard news has affected people).
It is important to work with the media based on the relationship of trust and
confidence and also through the support of one’s own communication department as
they are then able to state the facts from a reliable source. Participants were advised
against the following: using terms such as “No comment” and “Off the record”, and
jargon and acronyms; repeat negative questions and phrases; lie and confuse the
media; make demands; and play the blame game. Messages provided to the media
must be more than a “spin”, and must reflect genuine action, practices, commitment
and ethics of the organisation. The CEO or director is primarily responsible for
maintaining corporate reputation, integrity, and professionalism.
The tools of communication include press releases, media advisories, interviews, “oped pieces”, news or press conferences, briefings, seminars, news feature, etc.
Organisations must be prepared to handle queries through the use of holding
statements and FAQs (Frequently Asked Questions). Press releases should have
catchy and concise titles, and the lead paragraph should contain important information
and the objective of the release. The body usually includes one or two paragraphs to
explain the issue, and it should close with the organisation’s position on the issue.
In managing print interviews, the questions and angle of the story must be developed
in advance. It is useful to adopt the practice of using no more than three key
messages. Objectives must be stated at the beginning, and if unrelated questions are
asked, the answers should bridge back to the key messages. Most of the time, the
interview are not live, and therefore it gives one time to summaries one’s thoughts. In
TV and radio interviews, it is important to know the audience and the interviewer,
initiate conversation rather than give a speech, and keep to the point. It is important to
adapt and control behaviours such as fidgeting during a TV interview. In radio
interviews, appearance is not an issue and the voice must be able to deliver the
message. Varying the tone of voice is useful.
Press conferences are difficult and it is important to consider the relevance of a press
conference. The communications during the conference should include the objectives
of the conference, the current situation, facts and figures as support, any repercussions
of the situation, where do we want to be, and call for action if any. If there should be a
call for donors, the target audience and eligibility criteria should be stated.
Ms Teo then discussed the management of media during a crisis. It is important to be
prepared and to have a disaster management plan. During a disaster, assess the
situation and gather the facts. Information should be provided through one central
information centre. A proactive approach should be adopted, and holding statements
used until more information is received to enable specific statements. Events should
be recorded as the crisis evolves, and communication plans updated and implemented.
She concluded by using a recent case study in Singapore to illustrate the management
of media communications during a crisis.
Panel Discussion on Managing Your Communication
Key points arising from these include:

How does one manage the media when somebody dies due to lack of blood ?
It is important that proper systems for blood delivery are in place and that
there is no deviation from standards, as there will always be close scrutiny of
the blood bank processes including blood delivery to the patient in such cases.

In the case of a case involving blood supply deficiency, is it appropriate for
the blood bank director to apologise to the media. Lawyers in several countries
would usually discourage this practice. However, if the blood bank is at fault,
then apologising through the media could be positively perceived by the
public as being supportive.

A new dilemna for blood banks nowadays is how to manage the issue of
donors who may have tested negative for infectious diseases in the past, but
now test positive when new technology with higher sensitivity is used. When
new such tests are introduced, it may result in the need to recall a great
number of donors, and also potentially affect hundreds of patients. The
infectious risk to the general population would need to be studied, and if there
is potential that the public might over-react, then it might be better to share the
information with the media in a diplomatic manner. Such decisions could be
decided through the ethics committee; however, whatever decisions are made
should be made responsibly and with accountability.

In countries with many languages, communications can be a major problem
even with media.

Sometimes the media report the wrong facts, e.g. reporting expiry of blood at
365 days instead of 35 days. In such instances, it is important to approach the
media to make the correction the following day.

It is good practice to periodically provide information and updates to the
media about blood and blood transfusion. This helps to educate them so that
they are more knowledgeable and accurate in their reporting.

Sometimes there are news reporters who may distort information to the public.
It is useful in these cases to ask for corrections and clarifications, or if they
refuse, then to report in another newspaper or use other channels. In countries
with many media, the blood service should ideally approach only media with
good and sound reputation.
Methods of Communication
Dr Peter Flanagan conducted a interactive session involving the use of mind-mapping
technique to discuss the different methods of communication and the influence of the
reason for communication and target audience in selecting the right method.
Participants were able to identify a comprehensive list of communication methods
that included: press release; television; radio; website; newspaper; newsletter; music;
party; teleconference; lectures; seminars; press conference; text messaging; e-mail;
sms; fax; bulletin; road show.
The use of different types of communication was discussed: formal versus informal,
individual versus group, internal versus external, and lateral versus vertical methods.
Some examples of tools used to communicate with stakeholders were also discussed.
In communicating with donors, one-to-one approaches such as writing to them or
sending sms text to them were effective methods. Invitation letters to them 2 weeks
before they were due for their next donation was one example, as well as asking them
to make appointments to donate. Use of websites to provide information was another
good method of communication, including reaching out to the public.
Communications with stakeholders such as hospitals could involve methods such as
the use of electronic links or fax that enabled them to provide updates on their blood
inventory levels.
Social Marketing and Developing Effective Communication Strategies
Dr Lin Che Kit explained the need for effective social marketing strategies for blood
programmes. Social marketing is the application of generic marketing with objective
to change social behaviour primarily to benefit the target audience and general
society. The goal of social marketing is not to market products and services but to
influence social behaviour, e.g. anti-smoking, blood donation.
Different types of social behaviour change programmes exist with increasing
difficulties – one time behaviour vs continuing behaviour, individual decision vs
group decision, low involvement vs high involvement. In blood donation behaviour, it
is common to begin with one time behaviour with continuous behaviour as the goal.
High involvement continuing behaviour change is the most difficult.
There are differences between social and generic marketing. Social marketing is often
under intense public scrutiny, must meet extravagant expectations, influence nonexisting demand, or influence negative demand. It is often required to target the less
literate audience, and requires understanding of highly sensitive issues. It can focus on
many benefits – intangible invisible benefit, benefit to third parties (blood donation
being one), self-reward. Long-term changes are central to planning, and limited
resources are a reality that must be taken into consideration.
Good social marketing begins with philosophy that is deeply rooted in the target
audience. Good social marketing involves many factors. Exchange is central, and
marketing management involves influencing exchange. Consumers make decisions as
choices among alternative behaviours that vary in benefits and costs provided. There
must be willingness by the marketeer to change the product being offered, i.e
behaviour being promoted. Customers may not always agree (e.g because blood
donation is painful), and different strategies (e.g. how to make it less painful) may
have to be considered.
Market research is important to determine customer needs and wants, and should be
conducted at the start of strategy development and constantly assessed. Alternative
strategies may have to be experimented with to determine the most effective. There is
usually diversity in target audience needs/wants/lifestyle/perceptions/preferences and
strategies should be fine-tuned to needs and wants of each subpopulation.
Bottom line orientation is important and marketeers need to be mindful of limited
resources. This requires them to keep evaluating the cost effectiveness of the
marketing plan, with constant attention to efficiency and effectiveness of everything
that they do. There must be commitment to planning and to think systematically
through major steps to be undertaken. There must also be willingness to take
“reasoned risks”, which incorporates formal calculation of inherent risk into decisionmaking processes.
Sustainability and institutionalisation is an important consideration as many social
marketing programmes may be temporary in nature, and may be subsidised by
“outside” organisations. Steps must always be taken to train local staff in critical
marketing skills.
Influencing behaviour is primarily a matter of communication. Communication
involves informing target audiences about alternatives for action, positive
consequences of choosing a particular one, and motivations for acting in a particular
way. Everything about an organisation – products/ employees/ facilities/ actions –
communicates something. Organisations must therefore examine their
communications styles, needs and opportunities, and develop a communications plan
that is influential and cost effective. Communications plans should take into
consideration parties other than the target audience; this includes external parties (e.g.
press, government agencies) and internal parties (e.g. board members, middle
management, employees, volunteers).
Dr Lin concluded by discussing how to develop effective communication, firstly by
setting communication objectives and generating possible messages. Messages could
be rational, emotional or moral in nature. He also emphasised the need to overcome
selective attention and perceptual distortion in the target audience. This requires
careful message evaluation and selection, and advised participants to select one that is
most desirable, exclusive and believable. Finally, message execution is important, e.g.
the difference between “Give blood, save life”, “Be a lifesaver, give blood”, and
“Give blood, give life”.
Developing Communications Plans
Dr Yasmin Ayob described the process of communications. The main elements
include the source (communicator), message (set of symbols), medium (channel),
receiver (target audience), and response.
The message developed must have clear content, and channels could include the mass
media, pamphlets, posters, newspapers. Other means of facilitating communication
could be the use of effective promotion programmers, advertising, and leveraging on
networks. Depending on the need, one could use mass (able to reach large number of
people) versus interpersonal (persuasive, stronger impact) communications.
In developing a message, it is important to know the target audience and the
environment ,e.g. the characteristics of the people in the community and cultural
factors. The objective of the message, e.g. to get more regular blood donors, should
also be kept in mind. Messages could be connotative (essentially feeling and
relationship) or denotative (primarily literal and factual) in form, or rational versus
emotional. In planning delivery of the message, the promotional component (what to
promote) and specific activity (how to promote) must be determined.
Dr Ayob went on to discuss the issues surrounding the communication of blood
donation, such as the health and social issues, building of relationships, the image of
the BTS as receiver and giver, donor management. Usually blood campaigns are
short-term in nature, and public relations management is important to complement the
other activities.
Developing communications plans involve first analysing the situation and
environment, and then setting the promotional objective and defining the target
audience. The message must be defined, appropriate channels selected, budget
prepared, and the promotional mix chosen. Following implementation of the plan,
results should always be evaluated for effectiveness.
Communications involving blood programmes usually involve the following target
audiences:





Public e.g. to encourage blood donation
Govt e.g. to establish a nationally blood program
Media e.g. tainted blood, transmission of disease thru transfusion
Blood donor e.g. reactive for TTI screening
Patient e.g. transfusion of possible tainted blood
When dealing with the public and community, correct facts and information must be
provided and appropriately delivered, in both language and form. The appeal to the
target audience could be based on rational or emotional appeal, e.g. we need blood to
replenish our stock versus a bleeding patient needs blood. The response achieved and
effectiveness of the plan should be monitored.
When communicating with blood donors, Dr Ayob advised participants to tell the
truth, give the facts, gauge response, evaluate understanding of the facts given,
encourage questions, and not to adopt judgemental attitude. In the case of the media,
inform them that certain things cannot be compromised (e.g. safe blood donors, public
trust), be conscious of public sensitivities and clear of role and responsibility. It is
useful to engage the media as partners and to bring them to your side. Finally, when
communicating with the government, have a clear objective, present clear facts with
local data, and provide the assessment of the situation if the proposed intervention is
not carried out.
Group Discussion on Communications Planning
Key points arising from these include:

In some countries such as Hong Kong, television advertisements are free.
Similarly in China, some advertisements are provided free for certain
programmes and blood donation is included in these.
Practical Session on Communications Strategies and Plans
Participants broke out into four Working Groups. Each Working Group was provided
a scenario and encouraged to discuss appropriate strategies to manage the scenario,
and to develop effective communication plans to handle the situation favorably.
Scenarios were developed based on true experiences.
The four scenarios discussed were:
8

Based on studies that show that many female donors in your country are iron
deficient at your current Haemoglobin criteria of 12.0 g/dL, you have decided
to raise the criteria for female donors to 12.5 g/dL. Develop your
communications plans to manage this without causing significant donor loss.

There is a major disaster involving a plane crash overseas. Five casualties
from your country are flown back for treatment for severe burns. The public,
wishing to help, rush in to the blood bank to donate blood. However, the
patients need few transfusions initially, but will need more blood support over
the next few months. The blood bank is flooded with donors beyond the
normal capacity. Develop your communications strategy to manage this event.

Patients are charged blood processing fees to recover the costs of processing
and testing the blood. However, blood is donated voluntarily and freely and
there is no charge for blood. Nevertheless the rumour is circulated around that
the blood bank sells blood, and many donors call in angrily in response.
Develop your communications strategy to manage this event.

A survey has shown that many donors do not donate because some fear that
they will catch a disease during donation, some feel that they are too weak,
and some believe that they will get fat. Develop your communications strategy
to manage these misconceptions.
Proceedings of Day 5
Session 5:
Regulation
Achieving
Quality Through
Standards
and
Standards: Why do we need standards, Who should develop standards
and How do we develop and enforce standards
Dr Peter Flanagan introduced the transfusion paradigm, with the medical model of
clinical service provision that is focused on patients and their needs, or the
pharmaceutical manufacturing model that is focused on products and their “fitness for
purpose”. The regulatory paradigm, with its focus on products, involves quality
(conformance to specifications or standards), safety (risk reduction and avoidance of
harm), and efficacy (achieves intended purpose). He went on to define quality-related
terms. Quality is defined as conformance to specifications. Quality control is the
measurement of parameters to demonstrate that the system is performing correctly.
Quality assurance is the development of a systematic approach that will ensure that
products and services meet stated requirements.
Standards are important as they provide a common goal, enable communication of the
organisation’s requirements to staff and stakeholders. Standards are also a first step in
ensuring production of consistent, safe and effective components. There are internal
standards and external standards. The primary responsibility for internal standards lies
with the blood service. Internal regulation means that a system exists within the blood
service to ensure that the standards are met. This improves management confidence
that the system is working is intended. A local quality system might achieve this.
External standards may be are set either by a competent authority (regulator or
government), puchaser (plasma fractionator or hospitals), or the blood service.
External regulation is the enforcement of standards by an approved body and designed
to improve overall performance and assure quality control. Compliance to the
standards are determined by external inspectors and controls.
Two complementary types of standards exist. The first are technical standards which
identify what needs to be achieved - these include the AABB Standards, the Council
of Europe Guide, and the UKBTS Red Book. The second are quality standards which
identify systems that must be in place to achieve stated goals. Standards must be:
clear and easily understood; measurable; realistic and achievable; appropriate to the
local environment; defensible; and may incremental in nature. HIV antibody testing
was used as an example of incremental standards.
Dr Flanagan went on to describe the quality improvement cycle. Key questions that
must be asked are “What do I want to achieve”, “What do I need to do to achieve it”,
and “How will I know if I have achieved it”.
In the blood service, standards generally include the following categories :
 Donor Acceptance Standards
 Blood Donation Standards
 Blood Processing Standards
 Blood Donation Testing standards
 Blood Component Standards
 Service Standards – donors / hospitals.
He used the New Zealand Blood Service (NZBS) Standards as an example. The
NZBS Standards uses the Council of Europe Guide as the primary reference standard,
as this utilises the benefit of a larger and more experienced group (greater status) and
provides useful justification for practice when challenged (defensible). The NZBS
Standards were then produced based on the Council of Europe Guide; however,
changes must be approved by the regulator (MedSafe) and deviations from the Guide
must be justified.
Reference standards that can be used by blood services include the Council of Europe
Guides, WHO guidelines, AABB Standards, FDA Code of Federal Regulations, and
UKBTS Guidelines (Red Book). It is useful to refer to more than one reference when
defining internal standards as it provides for high level of commonality and clarifies
critical requirements.
Donor selection standards are critical in assuring the safety of blood donor and
recipient, and should ensure careful balance between safety and sufficiency. Standards
must be relevant to the local situation as it is not always appropriate to take another
country’s standards and apply it locally. It is therefore useful to learn from sharing
and understand reasons for differences. Common causes for differences include donor
age, donor haemoglobin, volume of blood collected, and frequency of donation. The
key requirement is to set justifiable limits appropriate to the local situation.
Component specifications defines the product intended for manufacture. Critical
manufacturing requirements usually include volume and content. Specifications
should take into account the intrinsic biological variation in the primary donation. It
should also identify quality monitoring requirements. Dr Flanagan illustrated this with
examples of component specifications used in the NZBS.
In assuring quality, two general approaches are used: control of product (component
monitoring) and control of process (process control). Component monitoring
measures output of manufacturing process and identifies whether components meet
specifications. Process control extends the quality system to include control of
processes with the aim of ensuring that blood components will be manufactured to
specifications. Control of process generally provides greater control of the final
product and leads to a relatively standardised product.
Dr Flanagan concluded that standards are an essential part of any blood programme.
At a minimum, each blood service must define its own internal standard and then put
systems in place to ensure that they are met. Where possible, linkage to acknowledged
international standards should be considered. Regulation and external standards would
need to be undertaken in blood services operating within the pharmaceutical
paradigm.
Group Discussion on Standards
Key points arising from these include:

If existing standards were developed many years ago, they need to be updated.
This can be done by approaching an experienced person to document the
standards and then compare them with standards from other countries and
update accordingly.

It is not always necessary to fully comply with international standards or
standards from other countries, e.g. AABB standards, if there are differences
as a result of local cultural difference for example. In such cases, there should
be good justification for the difference. For example, AABB accreditation
allows variance from its standards if there are good reasons given.

In New Zealand, the components standards are developed by clinical advisory
groups using the UKBTS, Council of Europe, and Australian standards as a
guide.

Internal quality control (e.g. temperature monitoring of fridge) is similar to
IQA but not exactly the same. IQC checks only various points, whereas IQA
involves independant people auditing. While external audit might not be
compulsory, IQA is essential.

WHO is currently developing a set of minimum standards for blood services,
which will be available to all countries.
Regulatory Philosophy and the Role of Regulation in Protecting Public
Health
Dr John Lim described the regulatory challenges now facing regulators. The role of
regulator is changing, from that of controller and regulator, to that of nurturer and
facilitator, to that of convener and aggregator. Finding the correct regulatory balance
is a constant balance of role, policy and resources. This is because no health product
is 100% safe, and “safe” does not equal a risk free product. This is complicated by
changing and unstable external environment, such as infectious disease threats and
natural disasters. Operational challenges include service delivery turn-around time,
product safety monitoring, and cost efficiency (maximising resources and minimising
cost of regulation and operations).
He then went on to describe the conceptual frameworks of risk management in
regulation. The old framework involving a zero failure regime with a one size fits all
approach is not possible or desirable. The alternative is smart regulation with a riskbased approach. This requires collaboration and partnerships, and a consultative
approach to determine the acceptable risk management position.
The regulatory toolkit includes: surveillance (market intelligence, environment
scanning, benchmarking), intervention (legislative controls, system and process redesign, inspection, education, communication), enforcement (warning to legal
actions), and strategic partnerships. Using the right tools is a science and an art.
Dr Lim shared the experience of the Singapore HSA. Strategic partnerships are
important to effective regulation. In Singapore, this is facilitated by a coordinated
biomedical landscape, and the HSA is able to work with many partners. He described
the HSA’s regulatory aims, the risk management partnership in Singapore involving
the regulator, business and consumer, and its role in managing medicinal product risks
to consumers. The risk challenge is to determine acceptable levels of risk in the
societal context, and this involves risk assesssment, risk intervention, and risk
communications. Effective risk management involves facilitating access of the
appropriate product at appropriate dose/level to the appropriate patient in appropriate
manner, considering the requirements and expectations of healthcare community.
He then described the restructuring taking place in HSA, which is necessary to deal
with change, improve public health protection while ensuring timely access to
medicines, enhance regulatory efficiency by minimising duplication and using
resources appropriate to risk, and reduce regulatory costs. Legislative restructuring to
modernise the regulatory framework resulted in introduction of the Health Products
Act in 2007. The Act is intended to consolidate medicines control laws, and is based
on a modular approach, which is more responsive and flexible to deal with products
with different degrees of risk.
Organisation restructuring aims for more efficiency through better integration. The
approach includes: focus on outcomes and risk management; matrix model; whole-ofgovernment approach; and leverage on regulatory partnerships locally and overseas.
Systems and process restructuring is also required. Regulatory cooperation involves
inter-agency cooperation which can cover a range of possible activities:
harmonisation of regulatory technical requirements; exchange of information; mutual
recognition; and joint inspection.
Dr Lim summarised the key actions taken. Firstly to study the regulatory restructuring
options, and apply the risk management approach. Wisely select and use regulatory
tools appropriate to context, and implement matrix structure and coordination. Review
and re-engineer systems and processes, and increase regulatory partnerships to
leverage on other systems.
Group Discussion on Regulatory Philosophy
Key points arising from these include:

As HSA is a regulator as well as the national blood service, how does it ensure
that there is regulatory independance and no conflict of interest ? In this case,
there must be transparency, external audit, and well-defined roles and
responsibilities. The regulators (CDA) and the blood service (CTM) are very
independant, and the regulatory professionals do not involve the CEO or the
Senior Directors in their professional deliberations or decisions. Where
necessary, external evaluators are used. The MOH also licenses the blood
bank; only plasma derivatives are licensed by the CDA.

In New Zealand, all drugs require evaluation, even though the drug is a
subsidised drug and registered elsewhere. In Singapore, drugs coming in for
registration are assessed for quality, clinical efficacy, registration with other
relevant bodies, manufacturer, and relevance to the population. The subsidy is
not a factor.

Cord blood regulation in Singapore falls under the purview of the MOH. HSA
only deals with the clinical trials and drug developments in this area.

Regulators are now under immense pressure to standardise practices. Amongst
participants countries, it is best to have coordination, sharing and collaboration
than starting from scratch.
Country sharing and discussion – Pitfalls and limitations, roadblocks
and how to overcome them
Dr Peter Flanagan conducted a group discussion on the challenges and limitations
they faced in managing their blood programmes. Participants were encouraged to
identify roadblocks and also potential solutions.
A number of constraints and roadblocks were identified:

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Buy in from another country
Lack of government support
National policy
Weak organisational structures
Lack of financial sustainability, weak financial framework
Planning capability (resources for planning)
Duplication
Lack of co-ordination/communication
Lack of oversight
Lack of trained staff - “brain drain”
Staff resistance
Limited facilities
Public awareness of blood donation
Patient expectation of free blood products
Lack of data
Clinical education
Research
Some key issues were discussed and possible approaches to overcome limitations are
roadblocks discussed:

Assistance in costing tools and finance. WHO has developed basic costing
tools for blood banks, but these are not comprehensive. One suggestion is to
collate the various data and information from other countries and make it
available.

Training and supervision of staff – training department to conduct training for
staff, including medical staff, hospital staff, donor management staff. Also
useful to train government staff, auditors to create better awareness.

External support could be in form of technical consultants

Must be ownership of action plans and development of the blood service from
the local staff. External consultants able to provide advice and guidance, but
local blood bank staff often already have good knowledge already present and
are capable of making very significant difference.

Management skills are important and must be developed among blood bank
staff through training

It is also important to have clinical competence within the blood bank, so that
blood bank staff feel comfortable providing clinical advice to clinicians and
nursing staff in hospitals.

WHO Aide-Memoires are available on many areas and topics. These are
useful references and can be obtained from WHO Office.

Staff motivations and attitudes are important. The FISH philosophy from
Seattle Fish Market is one approach where a positive attitude, innovation and
excellence is celebrated in spite of a difficult work environment. Participants
were encouraged to adopt this philosophy.

There are different types of staff and the manager must be able to differentiate
between them and manage each accordingly. Sometimes lack of contribution
and value add from a staff may be due to inadequate opportunity.
Session 6: National Action Plans
Group Discussion on the Development of Action Plans
Dr Yu Junping introduced the session relating to the development of action plans by
participants following the workshop. Participants broke up into country groups to
develop action plans. Action plans were presented from the Maldives, Papua New
Guinea, Nepal, and Lao PDR were presented for discussion.
Participants shared their national action plans with WHO. It was envisaged that
updates on the progress of these action plans would be presented at the Second
Workshop slated for 2008.
Workshop Recommenations
Participants
1. Progress the implementation of the draft action plans developed at this
workshop.
2. Prepare a progress report presentation for the 2008 workshop.
3. Seek possible management development opportunities within one’s own
country.
4. The CTM would work with the Singapore Red Cross to develop a regional
internet-based forum to facilitate regional networking and training initiatives.
World Health Organisaton
1. Improve financial capability of national blood services by development of
tools to support financial management
2. Provide support to enhance training and education systems of national blood
services
3. Assist in provision of external support
Closing Ceremony
Dr Diana Teo thanked the participants and facilitators for their active participation in
making the Workshop a success, and wished them a safe journey back to their
countries. On behalf of WHO, Dr Yu Junping thanked the Singapore Government and
Ministry of Foreign Affairs, the CTM staff, and all the participants. Mr Chua Teck
Hock, representing the Singapore Ministry of Foreign Affairs concluded the
ceremony by presenting participants with their Certificate of Participation.