In Europe, donor management faces several challenges, some of them with considerable political weight. At least three factors, different by nature, are responsible for that.
1 Demographic changes
2 Commercial activities
3 Competition in the blood product supply chain
This paper discusses these factors, including some data on remuneration of donors. It builds on the efforts made in the Donor MAnagement IN Europe (DOMAINE) project. This project was co-funded by the European Community. Altogether 18 countries, the patient-driven Thalassaemia International Federation and the South-Eastern Europe Health Network worked together in producing a survey report on donor management in Europe. While writing this paper, a manual on Good Donor Management is being finalized. Parts of the survey report and of the manual have been incorporated here.
Migration throughout Europe and ageing effects in its population have enormous consequences on blood product supply and demand (see Table 1). One statistic that reflects the proportion of migration is the percentage of foreigners in European countries, which in the 27 EU-member states on average is 6·2% and varies form 0·1% in Romania to 42·6% in Luxembourg . Migrant populations show different disease patterns with different demands, while available data suggests that migrants tend not to be a blood donor in their new country. For example, in the Netherlands, the percentage of the blood donors who are so-called ‘originally non-Dutch citizens’ is less than a tenth of the percentage of the general population who are ‘originally non-Dutch citizens’ (Atsma F, Veldhuizen I, de Kort W, unpublished data).
Table 1. Demographic data
aPercentage of foreigners, including citizens of other EU Member States and non-EU citizens, usually resident in the reporting country. ‘Citizenship’ denotes the particular legal bond between individuals and their State, acquired by birth or naturalization, whether by declaration, choice, marriage or other means according to national legislation. ‘Citizenship’ is, therefore, not synonymous with ‘ethnicity’.
bThis indicator is the ratio between the total number of elderly persons of an age when they are generally economically inactive (aged 65 and over) and the number of persons of working age (from 15 to 64).
European Union (27 countries)
10 666 866
7 640 238
10 381 130
5 475 791
82 217 837
1 340 935
4 401 335
11 213 785
45 283 259
63 982 881
59 619 290
2 270 894
3 366 357
10 045 401
16 405 399
8 318 592
38 115 641
10 617 575
21 528 627
2 010 269
5 400 998
5 300 484
9 182 927
61 179 256
4 737 171
7 593 494
An important type of migrant diseases that have an impact on the demand for blood products are haemoglobin disorders, such as thalassaemia and sickle cell disease. Globally, it is estimated that more than 500 000 children with haemoglobin disorders are born every year . Of these children, 40% are born with thalassaemia and 60% with sickle cell anaemia. In Europe, it is estimated that about 20 000 living transfusion-dependent patients reside, and an additional 1500–2000 babies with these disorders are born each year . As a result, the blood supply needs to increase each year, to cover the needs of these patients.
The ageing of the European population, reflected in an increasing Old-Age-Dependent-Ratio (OADR, see Table 1), has a double negative effect on the blood supply. First, the demand for blood products is likely to increase with age. Second, an increasing OADR entails a relative decrease in the part of the population that is eligible to donate, implying an imminent decrease in available donors. Unchanged age-adjusted blood demand, therefore, requires a vigorous change in donor recruitment and retention, because the percentage of donors in the eligible population has to rise steeply to keep fulfilling the blood demand.
DOMAINE survey findings
The DOMAINE project performed a survey on current blood donor management practices throughout Europe in 2007. Using a questionnaire, European blood establishments were asked to provide information on their donor management practices. Relevant for this paper are the results on remuneration and compensation.
Remuneration and compensation
In six of the 35 countries involved in the DOMAINE survey, donors might be given an expense allowance in cash, based on the incurred expenditure and the particular type of donation. Not all six countries are EU member states. Expense allowance mainly relates to plasma or platelet apheresis donations, and in only one country all donors are offered an amount of money. The sum, given to donors, ranges from €12 to €25 per donation.
The principle of voluntary and unpaid donations does not exclude compensation for donors, if it is limited to reimbursing the expenses and inconveniences related to the donation. These expense allowances can be given in different ways. In some blood establishments, such compensation is limited to travelling costs reimbursement or a food voucher. The DOMAINE survey showed that donors are allowed free time off work in fourteen countries. In most of these countries, this time is capped to the time needed for the entire donation process or to a limited amount of time (e.g. 2 or 4 h). However, some blood establishments continue to allow donors to get a full day off work and this obviously is closer to real remuneration. Most countries have discontinued such practice.
Figure 1 shows the percentages of European blood establishments that did or did not remunerate their donors for their donation. Figure 2 illustrates the kind of compensation (other than remuneration) that donors received for time or expenses.
Commercial establishments now operate in 20% of the European countries, mainly on collecting and processing plasma. In the plasma-derived pharmaceutical business, paid donors do occur throughout the world, including the Americas and Europe. Although in most cases, the commercial establishments only collect plasma for fractionation, in some countries they also collect whole blood. This introduces competition for both donor recruitment and blood product selling. Together with the phenomenon of paid donors, this may impact on donor retention, donor safety and patient safety.
Notably, among all the actors in the blood transfusion chain, recipients, volunteers and donors are the ones who do not make money. Recipients of blood products (patients, or ‘clients’) can, in fact, be expected to pay for blood products, either themselves or through their insurance, or in whatever way, depending on a country’s health care financing system. Their gain for this payment is extra life expectancy and quality of life. Because, by definition, volunteers decline payment, this situation leaves the blood donor as the only person breaking the common rules of economics in the entire transfusion chain. This works out well, as long as no shortages arise . All the others in the blood transfusion chain, such as blood establishment staff, suppliers to blood establishments and health care workers, do make money, not uncommonly, even for a living.
There is probably nothing wrong with that, as long as market principles are considered a socially acceptable elaboration in accordance with distributive justice . Subsequently, these ‘paid actors’ in the transfusion chain must guarantee individual rights and well-being.
Blood as tradable good?
All of this may imply that blood is some kind of tradable commodity or good [6,7]. However, from a legal point of view, the question arises as to whether blood or blood products can actually be considered a good . The European Commission did not exclude the possibility that blood may be considered a ‘good’ for the following reasons.
1 Although international treaties prohibit financial gain of blood, these treaties are not binding.
2 In the European Community, blood is subject to normal customs tariff.
The question as to whether or not blood is a ‘good’ has not yet been decided and could become a matter before the European Court of Justice.
An important reason remains for not wanting blood to be commercialized: the safety of the recipient. It is a proven fact that donors paid in cash show a much higher risk of having a transfusion transmittable infectious disease . But also other types of payment, including vouchers or free tickets and time off work, could imply an increased risk .
Competition and donor management
In general, the supply of blood products for direct use in patients through blood establishments is not a market-oriented activity. Most European countries have blood establishments that are organized on a regional or on a national level. In those countries, regionally or national self-supporting systems exist, and competition between blood establishments does not yet occur, or only so on an occasional basis.
However, the debate on introducing competition in the field of blood supply for direct use in patients is growing throughout Europe. For example, compare the point of view of the European Blood Alliance (EBA) see the reference for that . Pricing of blood components and access to donors are the major arguments for starting this debate. For example, prices for blood components differ to a great extent between European countries. Insurers and hospital managers ask questions on how these differences are to be explained or could be diminished. In addition, pharmaceutical industries want to have equal access to (plasma) donors, which is not yet allowed in many countries.
Given the mere fact that there is a demand for products or services, competition is likely to occur. This is true for commercial enterprises and non-profit-making enterprises. Until now it has been felt that commercialization of body parts, such as organs, tissues and blood has a strong moral implication that needs to be approached with great caution. Therefore, non-remuneration of donors – the suppliers of these products – still is the written basic principle handled throughout Europe. However, in the plasma-derived pharmaceutical business, paid donors do occur throughout the world, including the Americas and Europe. Competition for donors is rife between blood establishments, in relation to collecting blood (components) for direct use in patients, on the one hand, and organizations collecting plasma as a raw material for the pharmaceutical industries on the other.
Of course, it is not necessarily the case that a new player will aim to provide the whole range of services or products. An organization could decide to collect and produce profitable components, leaving out products that are too expensive to produce, e.g. Human Leucocyte Antigen (HLA)-typed platelet concentrates or red blood cell concentrates from donors having rare blood groups (‘cherry picking’) .
Competition in a not-for-profit environment is not uncommon. An important example is the competition that exists between charity organizations. The charity-market is huge, but there are limits to the amount of money people are willing to donate for charity purposes. Depending on many factors, people decide to donate money to one or some aid organizations. Consequently, aid organizations try to attract as many benefactors as possible. True competition exists there.
Competing for blood donors is not a common feature yet. Although similarities between the profile of blood donors and of charity fund contributors exist, differences are known as well . In addition, large, self-explanatory differences exist regarding the act of donating either parts of your own body or ‘just’ money. Giving money does not entail intrusion of one’s body; it can be done at home, and there are no fears to be overcome.
Where competition on blood donors occurs, donor management is likely to change. Some aspects for donor management need special attention. Two of these aspects are the following.
Requested/potential donor base
To a certain extent, hospital and industry demand together determine the donor base needed to fulfill the total demand for blood products. However, only the product range and market share of the blood establishment determine the qualitative and quantitative requirements of the donor base needed. For example, if a blood establishment decides to produce only apheresis plasma and only non-sub typed blood group A, B, or O-red cell and platelet concentrates for the lowest possible price, then the donor base will be essentially different from the donor base needed to produce the full range of blood products and blood components. In addition, one may expect that pricing of blood products between the two blood establishments is likely to be different. Blood establishments producing only certain commodities probably will be able to set lower prices compared to blood establishments that produce the full range of blood products.
Minimum quality and safety standards are laid down in European Directives and must be met by each blood establishment. However, a rise in quality assurance inevitably has its price. The precautionary principle, by definition, confronts blood establishments with possibly large costs. Therefore, in straightened economic circumstances, the precautionary principle  will, likely, be the first to be attacked with a subsequent potential rise in patient risk.
A special feature arises regarding donor safety, when donors decide to go shopping among blood establishments. The only sure way to prevent any adverse reactions, e.g. caused by frequent donations in different blood establishments, will be data exchange on donors between different blood establishments, when operating in border regions.
The introduction of competition in donor management will bring about great changes, enhanced by commercialization of the transfusion chain. These changes will be felt by hospitals/doctors, and donors. Both groups will experience advantages, as well as disadvantages. Hospitals (doctors) are likely to get commodity blood products at lower prices; however, the cost will be much higher prices for specialties. Donors might experience an increased level of service. However, a change in attitude or motivation cannot be excluded. Blood establishments must anticipate more or less fluctuations in both their client base (shopping hospitals) and donor base (shopping donors). Expected changes in demographic relations further stress the need for rationalizing donor management.