Year: 2009
Type: article
Abstract: Blood transfusion is an indispensable service of any health system. Blood products are needed to support many medical and surgical cases, and can save lives or improve morbidity. Blood services in many countries started as early as 1940s, and it was mostly hospital-based pattern. Over the decades, it has been realized in many countries that this vital service should be centralized. The reasons are: better quality assurance, more cost-effectiveness, easier to be updated and effective stock management. Egyptian blood transfusion services were recognized as a separate specialty independent from laboratory services as early as 1975. Blood services were separated from laboratory services following the ministerial decree no 171/1975. Hospital blood banks (HBBs) started as early as 1938, when the Egyptian Red Crescent established the first blood bank in Alexandria. The number of blood banks, mainly hospital based, increased to sum out to around 300 by mid-1990s. The personnel who worked in these blood banks were under paid, did not have proper education and had no career prospects. However, these services were very fragmented and primitive till 1996. Ministry of Health (MOH) realized on that year that blood services should be restructured in order to keep up with other health system. Ministry of Health of Egypt planned for major health reform. The main concern of top management is to upgrade the blood services in order to provide safe, effective and readily available blood components to all patients and causalities. In 1996, a project for restructuring the blood transfusion service was signed between Egyptian MOH and Switzerland. This project aimed at centralizing the production of blood components and converting all the HBBs to storage facilities. The objectives of this reform were: establishing adequate facilities for blood components production, capacity building of the different staff categories and implementing the national blood policy. During the first phase of the project, the establishment of the National Blood Transfusion Center (NBTC) and eight Regional Blood Transfusion Centers (RBTCs) was accomplished. The network of new RBTCs worked according to good manufacturing practice concept and gained very good reputation. The blood collection of this network was not enough to meet the needs of the health institutions. Unfortunately, during the first 7 years of implementing this project, two parallel blood systems were created. This conflict added more burden to the existing situation. The nine centres could not cope with the requirements of blood products, the provision of quality control, and could not reach out to the whole country. In 1999, a ministerial decree number 25/1999 to prohibit the professional paid blood donation was issued. Since then the paid blood donation does not exist. This decree led to the increase in the numbers of family replacement donations to compensate the needs. During the implementation of the second phase of the project that started in 2004, the creation of the NBTS as sole provider of blood was achieved. The network of RBTCs was extended to become 17 regional centres and six district centres. The 24 centres are envisaged to cover the medical needs of blood components to all the country (Fig. 1). Regional Blood Centers Network. Conversion of HBBs to become storage blood banks started in 2007. The conversion plan was established to be implemented over 3 years. It aims at reinforcing the capacity of the RBTC in a given governorate to collect the enough blood units to satisfy the needs of all the hospitals. Then one hospital at a time is converted. The conversion means that the blood components stocks are supplied by the RBTC. This process includes intense training for the staff of both: RBTC and HBBs. The conversion includes as well the following: teaching the clinicians the concepts of appropriate use of blood, hospital transfusion committees, and teaching blood banks staff the principles of immunehaematology and stock management, starting the haemovigilance system and managing transfusion adverse effects. Production of the National Blood Policy (NBP) started in 2005. The actual implementation started in March 2007, following ministerial decree number 117/2007. The NBP was established by the NBTS staff in cooperation with representatives from the stakeholders like university hospitals, private hospitals, military and police medical services. The policy document is short (15 pages) and includes 17 chapters and two annexes that cover all aspects needed to be considered by the decision makers (Fig. 2). National Blood Policy Document. The NBP is supplemented by six other documents that have all the detailed protocols for the different activities (Fig. 3). These documents are: National Blood Standards (NBS), National Guidelines for the Appropriate Use of Blood, National Blood Lab Strategy, Blood Safety Manual, Blood Technical annual, and National Guidelines for Donor Counselling. National Blood Standards, Guidelines, and Safety Manual. Due to the fact that some blood donations in remote parts of the country were tested using very poor quality testing kits or even not tested at all, the task force responsible on implementing the conversion plan decided to speed up the part of the plan that incurs blood donations testing. Testing centralization of blood was implemented between April 2007 and October 2007. This activity was very hard and needed extensive training, reallocation of testing equipment, clear plan for different logistics, close follow-up and monitoring, provision of many supplies and materials, introducing special documents, provision of transportation for samples, provision of fax machines for reporting results. The implementation of the conversion plan was faced by resistance of some health institutions and personnel working in HBBs. The reasons of this resistance include: fear of new advanced technology by old staff, worries about income and job position, new role of HBBs, fear of losing power and concern of the laboratory staff. The implementation of the NBP and conversion plan was not easy. The struggle with all the different authorities whether in MOH headquarters or regional health authorities delayed the time schedule of the plan. Not until the crisis of the defective locally manufactured blood bags that all relevant health officials realized the importance of this health aspect, namely, blood services. The blood collection dropped dramatically soon after this crisis in January and February 2007. Within a month time the NBTS gained the support of all the officials including the minister and others like celebrities, businessmen, sports figures and many others. The blood collection was regained, and more importantly the top management support and commitments that lead to several actions that speeded up the process of restructuring the blood services. In March 2007, a ministerial decree number 119/2007 to merge the two blood systems was issued. This decree was son followed by three other decrees: merging the two budgets, adding the extra RBTCs and banning the trade of empty blood collection bags in the private pharmacies. These ministerial decrees increased the credibility of the NBTS among all other health authorities. The support of local health authorities in the governorates was noticeable. The resistance by the individual staff in some HBBs got less. Establishment of the conversion plan over 3 years to implement the national blood policy started in June 2007. The conversion started in the governorates that had already RBTCs from the first phase of the project. Most of the hospitals in nine governorates were converted and following the new policy. The governorates that have new RBTCs started very limited conversion in the form of collection of extra units of blood donation, converting the very small blood banks into storage and establishment of hospital transfusion committees. The establishment of the National Blood Regulatory Authority was taken seriously by the MOH top management. It was decided that the quality department of NBTS will take the responsibility for 2-year period. After this period, part of the quality department personnel will be transferred to an independent body, namely, National Blood Regulatory Authority. This responsibility is being practiced now and include: licensing of blood banks according to the NBS, organized audit system, extensive document control process, defining the staffing model and equipment lists of all levels of RBTCs and HBBs. With the support of the health officials, a positive acceptance of the plan by the initially resisting parties began to manifest, and resistance converted to acceptance due to credibility of the plan's activities and results. This credibility was the fruit of persistent hard work of the dedicated staff, good planning and adaptation of the plan when needed, regular follow-up and monitoring, changing the work style to match the plan, and the organized training programmes. One of the most important elements of the plan is to increase blood donations, and gradually phasing out family replacement donations that should be completed in 5 years. In order to achieve this goal, the donor programme had several activities: increasing the mobile vehicles, increasing the number of different staff categories, starting the blood collection and donor recruitment committees, acquiring more places for blood drives, implementing a public relations programme, and cooperate with non-governmental organizations. To sustain the funding of a robust blood services, a cost-recovery system was studied. Three scenarios were envisaged: full costing by the government, full recovery of cost by insurance and partial subsidy of cost by government were calculated. The scenarios are being under study by ministry of finance. The aim of implementing of a new funding system is to make sure that the level of the new blood service is sustained and capable of supporting new necessities of safe blood. Quality Management System was established since 2000. The system included the following: appointment of national quality manager, staff of six medical personnel and quality officers in every department and every regional centre; implementation of internal and external audit schedule; major document control process that included creation of quality forms and records, distribution list, numbering and coding, etc.; EQAS system was put in place for transfusion-transmitted infections and red blood cell serology; comprehensive training programmes for all staff categories, and covering all areas. The World Health Organization quality management program was disseminated in 4 years to almost 1000 staff; Helping in establishing the NBP and NBS; and acting as Blood Bank Regulatory Authority for 3 years till 2010. Extensive training programme for all staff categories started at all levels: regional centres, hospital blood banks, anticipated regulatory personnel, administrators in local health authorities, different clinicians who prescribe blood components, etc. The training programmes are conducted in theoretical, practical, on job, and by observation. A group of trainers had a Training of Trainers programme and were assessed for their suitability. This group conducted the training in the HQ and in the RBTCs as well as HBBs. The group was selected from the whole NBTS network. The plan was modified several times during the implementation to adapt for the obstacles and the situations that came across. The implementation and monitoring plan had to be adapted during the course of application. Many unforeseen logistics and unexpected shortcomings faced the management team and the task force groups. The time schedule was delayed twice. Pilot project was implemented first in the most problematic governorate named Gharbeya. This governorate was in the middle of delta and had the challenge of hepatitis B virus and hepatitis C virus high prevalence in an over population situation. The original pilot project was planned to be achieved in 6 months. The plan had to be stretched over 18 months. The model was rolled over other governorates in a time scaled plan that should end in December 2010. Establishment of the Egyptian fellowship in Transfusion Medicine to create career prospects and certification for the medical staff working in the blood network. The fellowship programme is a 4-year curriculum that is delivered in a modular style. The fellowship board includes five of the local blood transfusion medicine experts as board of scientific curriculum. So far, three batches were graduated. The certificate has gained credibility and popularity among medical personnel working in blood banks, more and more candidates are applying for the academic study. The training department of the National Blood Transfusion Center has become very busy and coordinates lots of programmes in all areas of expertise. The trainings are running simultaneously in many governorates, and more trainers are being identified and prepared for doing good job. The centre has gained credibility by World Health Organization and became centre of excellence for education and training for the Eastern Mediterranean Region. High level management commitment is very essential to integrate the blood services into the health system. It has been proven in Egypt that this commitment speeded up the reform process. Planning and determination leads to credibility and acceptance. The shortcomings and resistance that faced the implementation of the reform programme were dealt with by the team positive spirit and dedication. Including all stakeholders in the planning, designing of the policy and standards. The protocols were wel-accepted for implementation due to the partnership of all the health institutions, because they shared in the preparation of the contents. The national blood policy is working well for the Egyptian health system, and supported by the top MOH management. All the local health authorities in the governorates are promoting the principles of the policy and standards in all types of blood banks. Gain more support by the local national partners and international agencies. It is very helpful and supportive to have allies that offer either moral or financial support. Speed up the process of establishing the national blood regulatory authority. This body will lead to better practice and more commitment to the policy. It is expected that HBBs will be encouraged more to implement the role that they should play to help the patients, specially the implementation of haemovigilance. Sustain the human resource development process to cover all the personnel working in NBTS. Appointing the right number and qualification of personnel will help very much the application of all the principles of the blood policy. This process helps create career prospects too, as well as career opportunities. Finalize and implement the cost recovery study in order to sustain the services. The present costing system does not guarantee the sustainability of the anticipated growth. The hope is to adapt the funding system to the new health insurance system that will ensure the provision of descent health services that has reasonable cost to be funded. Look into the prospect of utilizing the recovered plasma to extend the contribution of NBTS to other health aspects. The management teams are planning to qualify the recovered plasma and make it suitable for contract fractionation and mini-pool fractionation. It is anticipated that the plasma products will contribute to the welfare of the needy patients and provide more financial revenue to the NBTS to function even better.
Source: ISBT Science Series
Author: F. M. Moftah
Language: English
Subfield: Hematology
Field: Medicine
Domain: Health Sciences
Open Access status: bronze
OpenAlex ID: W2005343375