Countries with low and medium human development index (least developed and developing countries) represent 82% of the human population but use only 39% of the global blood supply. Additional funding for blood services is needed in these countries, but that alone does not level out this unfair balance. Political will of the decision makers to acknowledge the existence blood transfusions and blood banks and to create an organization for them is a prerequisite for development. Acceptance of blood transfusion as a specialty in medicine and national coordination of the blood services provide better service even with the already existing financial input given to blood transfusion. Different models for blood service operations exist; a centralized national blood service is not the only alternative and may not be feasible in large countries, but national coordination is beneficial even for them. Education of the public for voluntary, non-remunerated blood donation and training of the personnel can be achieved even with limited resources, and guidance as well as training material is available, e.g. from the World Health Organization. Regulation of blood services helps in improving the safety of blood transfusion, but lack of laws and regulations must not be accepted as an excuse for not organizing the blood services. International assistance may be necessary after decisions of a nationally organized or coordinated blood service system have been reached, and implementation is planned. However, without local commitment at all levels – national, regional and local – sustainability cannot be expected.