Building Sustainable Blood Systems in Africa
AABB Helps PEPFAR Focus Countries Meet Challenges
In recognition of World AIDS Day, Dec. 1, 2006, the U.S. State Department released new information on the progress that has been made in the fight against HIV/AIDS through the President’s Emergency Plan for AIDS Relief (PEPFAR) — a five-year, $15 billion, multifaceted approach to combating HIV/AIDS around the world. Since PEPFAR received its initial funding in January 2004, approximately 822,000 people with HIV or AIDS have received antiretroviral therapy, and more than 100,000 infant HIV infections have been prevented.
How are these data related to making Africa’s blood supply safer? While 78 percent of PEPFAR’s funding is used to care for and treat those with HIV/AIDS — which affects 39.5 million people worldwide, according to the World Health Organization, many of whom live in the 15 PEPFAR focus countries — the other 22 percent of the program’s funding is devoted to prevention. Within this category, 2 percent of PEPFAR’s $15 billion budget is set aside for blood safety activities. This is the funding that allows AABB — through a cooperative agreement with the Centers for Disease Control and Prevention — to advise and train transfusion medicine professionals and others in five PEPFAR focus countries in Africa.
Setting Up Sustainable Systems
The national blood services in several of the African nations working with AABB can already point to statistics that illustrate the progress they have made in creating safer blood systems. For example, in Kenya , approximately 80 percent of the blood supply now comes from voluntary donors, in contrast to the 20 percent that came from voluntary donors just several years ago. The increase in voluntary, donors in these countries has resulted in a corresponding decrease in HIV prevalence rates among blood donors — a decrease that the countries want to continue.
While statistics like these are encouraging, they do not begin to tell the story of how far these nations have come in their journey toward a safer blood supply, said Jim Reilly, director of AABB’s global development division. “What we are doing in Africa is building capacity, and that takes time,” he said. “A traditional approach to programs like PEPFAR has been to tackle only those jobs with indicators of success that can be measured fairly quickly — how many people are trained or how many new people are on antiretroviral treatment, for example. While we are seeing some of these types of statistics coming out of PEPFAR, the program is not just focused on short-term achievable goals — it is structured to provide much more than a quick fix.”
The goal of the PEPFAR program is to help countries covered by the plan develop the necessary infrastructure to create long-term, self-perpetuating programs, an approach that allows AABB to help national blood services in its PEPFAR focus countries implement quality systems that can serve as a platform for continuous improvement. “Everyone looks at the President’s Emergency Plan for AIDS Relief and they think, because it is an ‘emergency’ plan, that it is fast,” said AABB CEO Karen Shoos Lipton, JD. “But the blood program is different. What we’re trying to do is build sustainable systems, and that requires us to work with the countries assigned to us on a number of different issues simultaneously.” Each country has its own unique needs, but typical projects could include working to streamline procurement systems, ensuring that physical infrastructure issues are not creating barriers to collecting, testing, storing or distributing blood, working to strengthen transfusion medicine curricula in medical schools, working with professional societies to develop clinician education programs on appropriate blood utilization and working with technical colleges to ensure that they have appropriate training for technologists who will be staffing the blood transfusion services.
Building sustainable systems also means having a set of standards that can be used as a framework for decision-making and a basis for training. “By establishing standards and participating in their development, the countries set goals for their own blood programs,” said Reilly. “To some extent, the standards even set up an opportunity for efficiency to begin to flow into a system, and in the long-term, as countries begin to fund their own blood services, these efficiencies will be important.”
Different Countries with Similar Challenges
Although the five countries AABB is advising under PEPFAR have different histories and experiences, they all must overcome some similar obstacles, with human resource issues topping the list. “In many of our countries there has been a tremendous assault to the infrastructure,” explained Shoos Lipton. “Civil wars and unrest, droughts and flooding have undermined efforts to bring stability to many of the systems. In some countries there is also a tremendous shortage of professionally trained workers, as physicians, nurses and technologists have left the country for better opportunities.” While in many countries the shortage of qualified health care workers is severe, in other countries, there is an adequate supply of applicants. “In these countries, the challenge is getting the qualified applicants into the blood program, and then retaining the staff once they are trained,” said Terri Konstenius, AABB’s international program operations director.
Most of the countries, however, must develop educational materials and training systems as well as a pipeline for bringing new workers into the field. Currently, AABB is involved not only in training but in helping some of the PEPFAR countries customize educational materials for their specific populations. “How we conduct training in each country is different in that we must adapt each set of training materials to meet the needs of the workers,” said Konstenius. “We can’t just create a one-size-fits-all program. What works in one country may not work in another.” Also important to this process is a mechanism that will identify and educate leaders who can then train others when AABB is no longer in the country. Emory University has developed a Visiting Scholars/Visiting Dignitaries program that is designed to train blood bank and transfusion medicine professionals at the highest levels from other countries, but more education will be needed in this area.
Getting necessary equipment and supplies from their own governments is often a challenge for national blood services in many of the PEPFAR focus countries. “Equipment and supplies are typically purchased through the existing government procurement process, which usually has many layers and can be a real barrier to getting the appropriate equipment in a timely manner,” said Konstenius. This is one of the reasons why AABB works directly with the ministries of health in the countries it is advising — to provide them with an understanding of how critical it is that the blood services receive the appropriate financial support.
Another reason for working with the ministries of health is to ensure that they have input into building their own national blood service. “When you are trying to organize such a system, you are not just working with one blood bank — you must also work with the country’s ministry of health and its health care professionals,” said Shoos Lipton. Some of the PEPFAR focus countries already have a national blood service in place, but some do not. “South Africa probably has one of the most sophisticated national blood transfusion services in the world, and, in fact, they surpass things that we are doing in the United States. However, in other places, they are trying to pull regional banks into a system, and that is quite an undertaking,” she added. It can also be difficult to convince hospitals that are collecting blood that it is in their patients’ best interests to have one national system to oversee the process.
Reilly sums up the challenges most of the PEPFAR focus countries face in one word — sustainability. “They have work force and education issues, and they need assistance to develop systems that will generate leaders, good roads, clean water and decent physical structures. All of these are related to sustaining a blood service,” he said.
Celebrating the Successes
Even though there is still a great deal of work to be done, those who have visited the PEPFAR focus countries AABB works with have been a part of some great success stories. “For me, the most exciting thing has been to see AABB take its standards development process to some of the countries, assemble groups of experts in these countries, and have the experts develop their own set of standards on which we could then build training programs,” said Shoos Lipton. “The entire process has been very rewarding, and I believe that if the countries that have written their own sets of standards were to satisfy all of the requirements, they would have an effective operating national blood transfusion service.”
Konstenius has witnessed the impact the standards have had and has been impressed by how quickly transfusion medicine professionals in the countries have embraced the standards. “In some of the countries where the standards have been adopted, they are working fairly well. It is exciting to see the blood bankers and transfusion medicine professionals in these countries recognize how the standards connect to the daily operations within their blood bank and enhance quality. It’s not just another document on the shelf,” she said.
AABB advisers have also seen improvements to facilities that house blood services in the PEPFAR countries and have watched new workers enter the field. “Some of the countries had just one individual trying to manage all aspects of the program. Now that they have received funds from PEPFAR, they have been able to hire more people into the program. Once you reach a certain critical mass, you can make great strides,” said Shoos Lipton.
Donor recruitment initiatives, particularly in Kenya and Tanzania, have also been quite successful. “When we first began working with some of the PEPFAR countries, they really didn’t have many donor recruitment resources. They did commit to expanding their efforts in donor recruitment though, and to see how that commitment has been translated into increased collections has been exciting,” said Shoos Lipton. “In Kenya and Tanzania in particular, people are willing to donate and are coming in to do so. They are really beginning to make inroads into the blood needs in these countries.”
The Greatest Natural Resource
The PEPFAR focus countries still have many obstacles to overcome, but according to Shoos Lipton, they have the willingness to do it. “Although their biggest challenge is human resources, it is also their best asset,” she said. “I have never met people who are as dedicated as the individuals we work with in our PEPFAR countires. They have tremendous pride in their countries and they want to stay there and fix them.”
In her experience, said Konstenius, the greatest surprise has been the enthusiasm that the blood bank and transfusion medicine professionals in the PEPFAR focus countries have for improving the way blood services are performed. “The excitement and willingness of the people we are working with to consider our suggestions and really run with them has been surprising, in a great way. We have encountered a a level of excitement and dedication beyond what we expected,” she said.
How PEPFAR Benefits AABB
AABB’s PEPFAR efforts are expanding the association’s international reach, and Shoos Lipton believes that the organization is already benefiting from its involvement in the program. “PEFAR gives us an opportunity to reach out to other nongovernmental organizations to see where we might be able to collaborate or to identify areas where we can be of assistance,” said Shoos Lipton. “At AABB, we have core competencies of standards setting and accreditation, and I think we have tools and templates that we can offer to other countries and other cultures to see if we can develop standards and accreditation programs to fit their needs.”
On the international level, Shoos Lipton believes that AABB can follow two paths to the future. “One path expands our offerings at the highest levels of science, administration and technology to our members all over the world. The other path offers our expertise and commitment to countries that need our assistance in creating sustainable national blood systems and transfusion practices.”
Reprinted from the January 2007 issue of AABB News