# Introduction to the global framework
This global framework for action to achieve 100% voluntary blood donation has been developed jointly by the World Health Organization and the International Federation of Red Cross and Red Crescent Societies. It is designed to provide guidance and support to countries seeking to establish effective voluntary blood donor programmes, phase out family/replacement blood donation and eliminate paid donation.
The vision embodied in this framework is the achievement of 100% voluntary non-remunerated blood donation in every country of the world. It is based on the recognition that voluntary non-remunerated blood donors are the foundation of a safe, sustainable blood supply. Without a system based on voluntary unpaid blood donation, particularly regular voluntary donation, no country can provide sufficient blood for all patients who require transfusion. Most developed countries have a long history of voluntary blood donation, but a number of developing and transitional countries have also achieved this goal. Their experiences demonstrate that this vision can be realized, even when resources are limited.  This vision focuses not only on the importance of voluntary blood donors for blood safety and availability, but also for the enhancement of a country's social capital since voluntary blood donors can be considered as a valuable national asset.
This framework for global action outlines broad goals, strategies and action points that will enable countries to move towards 100% voluntary blood donation. The specific objectives are to:
1 Provide information and guidance on the vital role of voluntary blood donors in assuring the availability of stable and sufficient supplies of safe blood for transfusion.
2 Propose a series of interlinking strategies and suggestions for concrete action at national and community levels to scale up voluntary blood donor programmes with heightened commitment and support from governments, partners and other stakeholders in the following areas:
Creating an enabling environment for 100% voluntary non-remunerated blood donation Fostering a culture of voluntary blood donation Building and maintaining a safe, sustainable voluntary donor base Providing quality donor service and care.

# Target audience
The framework has been developed primarily for use in countries that are still dependent to varying extents on family /replacement and paid blood donation or that do not yet have a sufficient and secure supply of blood. It is designed particularly for use by policy-makers, planners and managers in ministries of health and regional health authorities, ministries of education and other relevant ministries, blood transfusion services, National Red Cross and Red Crescent Societies, blood donor organizations and other partners that are working towards making safe blood available at all levels of the health system where transfusion is performed.
The framework for global action has evolved out of a series of collaborative activities organized by WHO and the IFRC. From 2003, a series of joint regional, sub-regional and national training workshops on developing a voluntary blood donor programme were held in the African, Eastern Mediterranean, South-East Asian and Western Pacific regions. Some of these workshops were also supported by the Safe Blood for Africa Foundation. The workshops brought together blood donor managers, donor recruitment and donor care staff and volunteers from ministries of health, blood transfusion services, National Red Cross and Red Crescent Societies, blood donor organizations, Club 25 societies and other nongovernmental organizations. All workshop participants played leadership roles in their respective national blood programmes and were directly involved in various aspects of donor recruitment and donor care.
These workshops provided valuable opportunities for facilitators and country participants to share their insights and experiences of factors contributing to successes in building effective blood donor programmes. They also led to recognition of common barriers and constraints in augmenting voluntary blood donation. Many of the strategies recommended in this framework emerged from workshop discussions, reports and country action plans.
The framework was further strengthened by extensive consultations between WHO, the IFRC, other organizations and individual experts involved in voluntary blood donation. Biennial International Colloquia on the Recruitment of Voluntary Non-Remunerated Blood Donors are organized by the IFRC and co-sponsored by WHO. With their specific focus on voluntary blood donation, the Colloquia have provided a rich source of information and evaluation data on successful country initiatives.
In 2006, WHO established an expert editorial group to consolidate the information provided by these sources, define goals and develop the strategies contained in this framework. The draft strategies were reviewed and further refined by a working group on "Achieving 100% Voluntary Blood Donation" which was convened during the WHO Global Consultation on Universal Access to Safe Blood Transfusion. 6 The Consultation was held in June 2007 in Ottawa, Canada, and was attended by over 100 experts from all regions of the world. The draft strategies were further refined as a result of feedback from participants in the WHO Workshop for the Training of Global Core Facilitators on "Developing a Voluntary Blood Donor Programme" held in Sharjah, United Arab Emirates, in October 2007.
In June 2009, WHO held a Global Consultation on "100% Voluntary Non-Remunerated Donation of Blood and Blood Components" in Melbourne, Australia, to review barriers to achieving a safe global blood supply based on voluntary blood donation and to identify strategies and systems that will assist in meeting this goal. The Consultation also resulted in the development of the "Melbourne Declaration" which called for action by governments to support the achievement of this goal by 2020 and urged stakeholders to work collaboratively to support governments in this task.
This framework for global action was issued in 2010 and will be considered for review within five years. Any updates to the recommendations in the interim period will be noted on the WHO Blood Transfusion Safety website:
Voluntary blood donation: foundation of a safe and sufficient blood supply Blood transfusion is an indispensable component of health care. It contributes to saving millions of lives each year in both routine and emergency situations, permits increasingly complex medical and surgical interventions and dramatically improves the life expectancy and quality of life of patients with a variety of acute and chronic conditions.
Patients who require transfusion as part of their clinical management have the right to expect that sufficient blood will be available to meet their needs and to receive the safest blood possible. However, many patients still die or suffer unnecessarily because they do not have access to safe blood transfusion. The timely availability of safe blood and blood products is essential in all health facilities in which transfusion is performed, but in many developing and transitional countries there is a widespread shortfall between blood requirements and blood supplies.

# Blood transfusion in health care
Many medical advances that have improved the treatment of serious illness and injuries have increased the need for blood transfusion for patients' survival, to support them through recovery or to maintain their health. Surgery, trauma and cancers, for all of which there is a high probability of the need for blood transfusion, are replacing communicable diseases as leading causes of death. About 234 million major operations are performed worldwide every year, with 63 million people undergoing surgery for traumatic injuries, 31 million more for treating cancers and another 10 million for pregnancy-related complications.  National requirements for blood are, in part, determined by the capacity of the country's health care system and its coverage of the population. In developed countries with advanced health systems, the demand for blood continues to rise to support increasingly sophisticated medical and surgical procedures, trauma care and the management of blood disorders. An increase in ageing populations requiring more medical care has also led to increased requirements for blood.
In countries where diagnostic facilities and treatment options are more limited, the majority of transfusions are prescribed for the treatment of complications during pregnancy and childbirth, severe childhood anaemia, trauma and the management of congenital blood disorders.
Haemorrhage, for example, accounts for over 25% of the 530 000 maternal deaths each year; 99% of these are in the developing world. Access to safe blood could help to prevent up to one quarter of maternal deaths each year and blood transfusion has been identified as one of the eight life-saving functions that should be available in a first-referral level healthcare facility providing comprehensive emergency obstetric and newborn care. 9 Children are particularly vulnerable to shortages of blood in malarious areas because of their high requirement for transfusion arising from severe life-threatening anaemia resulting from malaria, often exacerbated by malnutrition. In 2008, 109 countries were endemic for malaria, 45 within the WHO African region. In 2006, there were an estimated 247 million malaria cases among 3.3 billion people at risk, causing nearly a million deaths; 91% of malaria deaths were in Africa and 85% were of children under five years of age. 10 Road traffic accidents kill 1.2 million people and injure or disable between 20 million and 50 million more a year, a large proportion of whom require transfusion during the first 24 hours of treatment; 90% of deaths occur in developing and transitional countries. Road traffic injuries are predicted to become the third largest contributor to the global burden of disease by 2020, with an anticipated increase of 65% in road traffic deaths globally and 80% in low and medium HDI countries. 11 The timely availability of blood at emergency health care facilities is one of the determinants of patient survival.
About 300 000 infants are born each year with thalassaemia and sickle-cell disease and need regular blood transfusion. 12 While the prevalence of these disorders of haemoglobin is unknown, there is a high requirement for regular transfusion in affected regions, particularly the Mediterranean region, Asia and north Africa.

# Sufficiency and security of national blood supplies
Blood transfusion services face a dual challenge of ensuring both a sufficient supply and the quality and safety of blood and blood products for patients whose lives or wellbeing depend on blood transfusion. Blood supplies need to be constantly replenished since whole blood and blood components have a limited shelf-life. Most countries battle to meet current requirements while at the same time responding to increasing clinical demands for blood.
Developed countries with well-structured health systems and blood transfusion services based on voluntary blood donation are generally able to meet the demand for blood and blood products. They must constantly strive to maintain adequate blood stocks in the face of rising clinical demands, increasingly stringent donor selection criteria and the loss of older donors who are no longer eligible to give blood. Nevertheless, even though there may be periodic or seasonal shortages, access to safe blood for all patients requiring transfusion can generally be taken for granted. Overall, developed countries are likely to have effective blood donor programmes, more voluntary donors, higher donation rates and more available blood.
In contrast, in developing and transitional countries, chronic blood shortages are common. Sophisticated health care provision may be available in major urban centres, but large sectors of the population, particularly those in rural areas, often have access only to more limited health services in which blood transfusion may be unsafe or not available at all.
WHO estimates that blood donation by 1% of the population is generally the minimum needed to meet a nation's most basic requirements for blood; the requirements are higher in countries with more advanced health care systems. However, the average donation rate is 15 times lower in developing countries than in developed countries. Globally, more than 70 countries had a blood donation rate of less than 1% (10 donations per 1000 population) in 2006. 5 In the WHO African region, blood requirements were estimated at about 8 million units in 2006, but only 3.2 million units were collected -about 41.5% of the demand. 13 South-East Asia accounts for about 25% of the world's population, but collects only 9% of the world's blood supply -7 million units a year compared with an estimated requirement for total of 15 million units. 14 Ageing populations and more strict donor selection criteria are further reducing the pool of eligible blood donors. Globally, over 81 million donations of blood are collected annually, but only 45% of these are donated in developed and transitional countries, where 81% of the world's population live. 5 Most countries with low rates of blood donation are largely dependent on blood provided by the families or friends of patients who require transfusion -and even on paid donation. They generally do not have structured blood donor programmes and cannot attract sufficient numbers of donors to meet the need for blood in emergencies, planned surgery and regular transfusion for conditions such as thalassaemia.
Paradoxically, despite a markedly inadequate blood supply in many countries, unnecessary transfusions are often given when the availability and use of simpler, less expensive treatments would provide equal or greater benefit. Not only does this expose patients needlessly to the risk of potentially fatal transfusion reactions, it also widens the gap between supply and demand and contributes to shortages of blood and blood products for patients who really need them.

# Safety of blood and blood products
The HIV/AIDS pandemic focused the world's attention on blood transfusion as a significant route of transmission of HIV/AIDS. It is estimated that blood transfusion accounted for 5-10% of HIV infections in the 1980s and it still contributes to a significant proportion of new infections, particularly in high prevalence countries.
The risk of HIV infection through unsafe blood and blood products is exceptionally high (95-100%) compared to other common routes of HIV exposure: for example, 11-32% for mother-to-child transmission and 0.1%-10% for sexual contact. 15 Sub-Saharan Africa has a particularly high level of transfusion-associated HIV compared with other regions due to a higher risk of infected blood being transfused. In some regions of the world, hepatitis B, hepatitis C and other bloodborne infections such as Chagas disease pose an even greater threat to national blood supplies. In developing countries, pregnant women and children account for a disproportionate number of HIV and hepatitis viral infections through unsafe blood and blood products because they are the main groups of patients requiring transfusion.
Preventing the transmission of infection through unsafe transfusion is one of the core strategies for HIV/AIDS prevention -and is, in fact, the only approach to HIV prevention that is almost 100% effective. In most developed countries, the risk of HIV transmission is very low because of the adoption of an integrated approach based on voluntary blood donation, stringent donor selection procedures, the screening of all donated blood for transfusion-transmissible infections and the use of transfusion only when no suitable alternatives are available. However, varying degrees of risk remain in many parts of the world. The transmission of hepatitis and other bloodborne infections is equally preventable.
The prevalence of infectious markers among donated blood units is not only an indicator of the relative risk of transfusion-transmitted infection, but also directly affects the actual availability of blood. In Latin America and the Caribbean, for example, around 240 000 units of blood were discarded in 2005 because laboratory screening tests showed evidence of infection. At an estimated cost of basic supplies of US$ 56 per unit, this represented a loss of US$ 13.4 million. 16 Why voluntary blood donation?
Blood and blood products are a unique and precious national resource because they are obtainable only from individuals who donate blood or its components. Most countries urgently need a substantial increase in the number of people who are willing and eligible to donate blood in order to ensure a stable supply of safe blood and blood products that is sufficient to meet national requirements.
WHO, the IFRC, the Council of Europe, the International Society of Blood Transfusion, the International Federation of Blood Donor Organizations and a number of other international and national organizations have defined voluntary non-remunerated blood donation as a founding and guiding principle. They recommend that all blood donation should be voluntary and non-remunerated and that no coercion should be brought to bear upon the donor to donate.
A voluntary non-remunerated blood donor gives blood, plasma or cellular components of his or her own free will and receives no payment, either in the form of cash or in kind which could be considered a substitute for money. This would include time off work other than that reasonably needed for the donation and travel. Small tokens, refreshments and reimbursements of direct travel costs are compatible with voluntary, non-remunerated donation.
Family /replacement donors are those who give blood when it is required by a member of their own family or community. In most cases, the patient's relatives are requested by hospital staff to donate blood, but in some settings it is compulsory for every patient who requires transfusion to provide a specified number of replacement donors on emergency admission to hospital or before planned surgery. Although donors are not paid by the blood transfusion service or hospital, there may be a hidden paid donation system in which money or other forms of payment are actually provided by patients' families.
In some countries, patients may prefer direct donation by family members or friends rather than "strangers" because they believe this will eliminate the risk of transfusion-transmissible infection. 17 However, prevalence rates of transfusion-transmissible infections are generally found to be higher among family /replacement donors than voluntary donors. 4,5, Paid or commercial donors give blood in return for payment or other benefits that satisfy a basic need or can be sold, converted into cash or transferred to another person. They often give blood regularly and may even have a contract with a blood bank to supply blood for an agreed fee. Alternatively, they may sell their blood to more than one blood bank or approach patients' families and try to sell their services by posing as family /replacement donors.

# National blood transfusion services based on voluntary blood donations
In 1975, the Twenty-eighth World Health Assembly in resolution WHA28.72 23 called for the development of national blood transfusion services based on voluntary blood donation to ensure safe, adequate and sustainable blood supplies and to protect the health of blood donors and recipients. Thirty years later, this resolution was endorsed in resolution in WHA58.13 1 which reflected evidence in transfusion medicine and science and consideration of economic, ethical and social factors. The resolution urged countries to establish or strengthen systems for the recruitment and retention of voluntary, non-remunerated blood donors in order to ensure safe and adequate blood supplies and equitable access to safe blood and blood products.

# Voluntary blood donation and sufficient, sustainable blood supplies
Countries provide annual data on blood safety and availability to the WHO Global Database on Blood Safety (GCBS). 4,5 These data show that 54 out of 193 countries have achieved 100% voluntary blood donation; the majority of these (68%) are developed countries, while transitional and developing countries account for 23% and 9% respectively. The average donation rate in the countries with 100% voluntary blood donation is 31 per 1000 population compared to countries with 50% or less voluntary blood donations, which have an average donation rate of 9 per 1000 population. 5 Analysis shows that countries with 100% voluntary blood donation have a higher proportion of regular blood donors and that this has been maintained over a number of years. Further, in countries where the percentage of voluntary blood donations has risen, there has also been an upward trend in the percentage of regular blood donations. This shows that voluntary blood donors are more likely to donate on a regular basis than other types of donor. A panel of safe voluntary donors who donate blood regularly enables blood collection to be planned systematically to meet the requirements for blood, by blood groups and components. This enables the blood transfusion service to maintain a constant and reliable supply of safe blood when required in every clinical setting practising transfusion. Building a pool of regular voluntary blood donors is also more cost-effective than recruiting new donors.
In systems based on voluntary blood donation, patients have improved access to safe blood transfusion in routine and emergency situations, without which their survival or quality of life might be threatened. The blood and blood products they receive carry a low risk of infection that might further compromise their health. They are not placed under pressure to find blood donors in order to receive treatment and feel a sense of being cared for by others whom they will never meet. In turn, this may motivate a spirit of generosity and a desire for reciprocal volunteering in the future.
In a well-organized voluntary donor programme, the need for blood in disaster and emergency situations can usually be met through its established donor base. Regular donors tend to be particularly responsive to appeals for donors during periods of blood shortage or in emergency situations because they have already expressed a commitment to voluntary blood donation.
Family /replacement donors cannot meet a community's requirements for blood and blood products because they provide blood only for individual patients when requested. The blood given to patients will not necessarily be replaced by blood group or quantity. Hospitals that are dependent on replacement donors are rarely able to maintain a sufficient stock of blood to meet the transfusion needs of all their patients, particularly in emergency situations or for regular transfusions, or to share their blood supplies with other hospitals.
Paying people to give blood undermines the principle of voluntary non-remunerated blood donation. Where systems of paid and voluntary blood donation co-exist, people who might otherwise donate voluntarily may opt to receive payment for their blood, thus weakening the voluntary blood donor programmes.

# Voluntary blood donation and the safety of blood and blood products
Voluntary blood donors, particularly regular donors, are the first line of defence in preventing the transmission of HIV, hepatitis viruses and other bloodborne infections through the route of transfusion. A number of studies have reported significantly lower prevalence of transfusiontransmissible infection markers among voluntary donors compared with other types of donors, with the lowest rates among regular donors. 5,16 Voluntary donors are recognized to be the safest donors because they are motivated by altruism and the desire to help others and by a sense of moral duty or social responsibility. They have no reasons to withhold information about their lifestyles or medical conditions that may make them unsuitable to donate blood. They are not placed under any pressure by hospital staff, family members or the community to donate blood and they entrust their blood donations to be used as needed, rather than for specific patients. The only reward they receive is personal satisfaction, self-esteem and pride. In a well-organized blood donor programme, voluntary donors, in particular regular donors, are well-informed about donor selection criteria and are more likely to self-defer if they are no longer eligible to donate, thus reducing the need for temporary or permanent deferrals. This also leads to less wastage of donated blood, with all its associated costs, because fewer blood units test positive for infection and need to be discarded.
Family /replacement donors are usually not informed about conditions that may make them unsuitable to donate blood. Even if there is a donor selection process to assess their eligibility to donate, they may be unaware of the significance of some of the questions in the donor interview. In their eagerness to donate blood to save the life of a loved one or their fear of distressing or displeasing their family, replacement donors may conceal information about their health status or lifestyle behaviour. This poses an increased risk of the transmission of infection, often resulting in a higher volume of donated blood that has to be destroyed because of evidence of infectious disease markers.  Paid donors often lead lifestyles that expose them to the risk of HIV and other infections that could be transmitted through their blood. The highest prevalence of transfusion-transmissible infections is generally found among paid or commercial donors.  People who accept payment for their blood are primarily motivated by the prospect of monetary gain rather than a desire to help save lives. The need to protect their income from blood "donation" compromises issues of honesty in the donor interview and they are highly unlikely to reveal reasons why they may be unsuitable to donate blood. Further, they are often undernourished and in poor health and may give blood more frequently than is recommended, resulting in harmful effects on their own health.

# Voluntary blood donation and ethical, economic and social concerns
Meeting the nation's need for safe blood and blood products through the donation of human blood should be based on ethical principles including respect for the individual and his or her worth, the protection of the individual's rights and wellbeing, the avoidance of exploitation and the Hippocratic principle of "primum non nocere" -first do no harm.
Paid donors are vulnerable to exploitation and commercialization of the human body as they usually come from the poorer sectors of society and become paid blood donors due to economic difficulties. Any form of exploitation of blood donors, including payment for blood, coercion and the collection of blood from institutionalized or marginalized communities such as prisoners diminishes the true value of blood donation. A blood donation is a "gift of life" that cannot be valued in monetary terms. The commercialization of blood donation is in breach of the fundamental principle of altruism which voluntary blood donation enshrines.
In systems based on family /replacement donation, the onus of providing blood is placed on the patient's family and friends rather than on the health system. Patients and their families are placed under considerable pressure to find blood donors at a time when they are already stressed because of the patient's illness. Relatives who are unwilling or ineligible to donate blood and who cannot find other suitable replacement donors may resort to paying others to donate, even if this practice is forbidden by the country's legislation. The problem is particularly acute when patients require regular transfusion for conditions such as thalassemia and blood is required every month or even more frequently. Patients are also disadvantaged if they have been referred from distant health facilities and have not been accompanied by relatives or friends.
Out-of-pocket payments for health care, including paying blood donors for giving blood, may contribute to households incurring catastrophic expenditure which can help to push them into poverty. The need to pay out-of-pocket may also mean that patients do not seek care when they need it. Ensuring that a safe and sufficient national blood supply is provided through voluntary blood donation effectively removes one of the main barriers to universal and equitable access to blood transfusion.
The donation of blood on a replacement basis also has an impact on its subsequent use. Patients and their families who have provided blood donors expect that transfusion will be given, even if it is no longer needed because of changes in the patient's clinical condition.
Physicians are placed under pressure to transfuse the number of units provided as replacement by their relatives, irrespective of the clinical need and possible risks associated with transfusion.
Voluntary blood donors themselves benefit from health education and encouragement to maintain healthy lifestyles as well as regular health checks and referral for medical care, if needed. Provided that they receive good donor care when they donate blood, they feel personal satisfaction and self-esteem which provides a sense of social engagement and belonging that is recognized and valued by the community. Voluntary blood donors serve as effective donor educators, recruiters and health promoters. Studies have shown that the influence of active blood donors is one of the most effective strategies for donor recruitment. 30 Voluntary donors also play a valuable role as active agents in health promotion; in addition to practising healthy lifestyles themselves, they help to build healthy communities through their influence among their peers and families. Even donors who are no longer able to donate due to age or medical conditions can still play an important role in promoting voluntary blood donation in their families, workplaces and communities.

# Challenges in achieving 100% voluntary blood donation
Information reported by national health authorities to the WHO Global Database on Blood Safety reveals interesting patterns and some striking differences between countries that have entirely voluntary systems of blood donation and high donation rates and those that still remain a long way from achieving 100% voluntary blood donation.
In 1998-1999, when the first GDBS data were collected, only 26 countries reported that they collected all blood donations from voluntary blood donors. 31 Most of these were countries that had always had a history of voluntary blood donation. However, the number rose to 39 by 2001-2002 and to 50 by 2004-2005. 4 In 2006, an additional four countries achieved 100% voluntary blood donation. 5 GDBS data help to identify the challenges that urgently need to be addressed in countries with low rates of voluntary blood donation. These are outlined below. Likewise, the achievements of countries with successful voluntary donor programmes point to strategies that have been effective in shifting from a dependence on family /replacement and paid donation to truly voluntary systems, even in resource-limited countries.

# Government commitment and support
The commitment and support of the government to an effective national blood programme is a prerequisite for the achievement of 100% voluntary blood donation. Without concrete recognition of blood transfusion as an integral part of the health care system, the infrastructure and the human and financial resources needed to ensure the availability of sufficient supplies of safe blood and blood products are unlikely to be provided.
The development of a national blood policy, as part of the overall national health policy, does not necessarily reflect the extent or quality of implementation, but can often be a prerequisite for effective programme action. Effective plans are needed to demonstrate the direction and steps that the government will take to achieve 100% voluntary blood donation. Countries will not be able to achieve this goal until and unless government commitment and support are demonstrable by the development and implementation of a national blood policy and plan with the allocation of resources for infrastructure strengthening, and human and financial resources.

# Blood donor programme
Fragmented systems for blood banking that lack coordination, particularly in developing countries, rarely have the capacity or resources needed to build effective donor education programmes; without donor education, there are limited opportunities to attract adequate and consistent numbers of voluntary donors to reduce the reliance of the health care system on family /replacement donation. Such fragmented systems also lack the wider infrastructure that enables blood and blood products to be exchanged between hospitals or moved to parts of the country where there are shortages. Studies in 15 countries in the Americas region indicate that poor blood bank infrastructures and operations and poor donor care are major hurdles to both voluntary donation and donor retention. 32

# Financial resources
Like every other element of the healthcare system, the blood transfusion service cannot function effectively without adequate, stable financing. Blood donor programmes are often perceived to incur minimal costs, apart from expenditure on blood collection bags, because blood is donated free of charge by donors. As a result, they often receive lower priority in the allocation of funds than areas such as blood screening. Yet without an identifiable budget, the programme cannot reach out to blood donors. All too often, blood donor programmes report that they do not have sufficient funds for donor recall or to maintain vehicles and operate mobile donor sessions.

# Trained staff
When blood is collected from family /replacement donors in small hospital blood banks, it is not uncommon to find that the venepuncture procedure is performed by a laboratory technician, often because no other staff are available. In order to protect donors and donated blood, blood should not be collected in settings where there are insufficient staff with the required qualifications, training and experience to perform the procedure safely.
A wider problem is the lack of specialist staff with particular skills in marketing and communications that are needed for successful donor information, education and motivation. Donor session nurses may be experienced in giving public talks, but rarely have the time or expertise to design effective posters and leaflets or organize media campaigns. Similarly, donor notification and counselling, particularly for donors who are found to have HIV or hepatitis infections, requires qualified and trained staff with excellent interpersonal communication skills and an ability to provide empathetic support and care.

# Donor communication strategies
The issue of effective donor communication strategies and educational materials is closely linked to the issues of budgets and staffing. Even if a blood centre is attractive and well-located, only the most dedicated donors will attend unless they are encouraged to do so. This requires time and money.
Without information, most people will simply remain unaware of the blood transfusion service and the need for blood donation. Without education and motivational activities, few will be sufficiently self-motivated to find out how they can donate their blood. Communication is at the core of a successful and sustainable voluntary blood donor programme. It transcends all areas, not only donor information and education, including advocacy and relationships with stakeholders.
Communication is often regarded as simply sending messages but is really more related to the giving of meaning to things; for this reason the importance of the message lies not so much in what is sent but how the message is perceived by the receivers. This is why communication requires greater recognition within blood transfusion services as a professional discipline, requiring a dedicated budget and specialist staff to undertake research, planning, donor information and education, and evaluation.

# Public trust in the blood transfusion service
The community must have confidence in its blood transfusion service. Without trust in its integrity and efficiency and the safety of its procedures, few people would choose to donate their blood. This trust is earned over a long period of time but can be undermined very quickly, resulting in a negative effect on the loyalty and continuing support of individual blood donors, the community and partner organizations.
Even when unjustified, negative public perceptions can result in an inability to attract voluntary donors and, in extreme cases, the rapid loss of donors. A number of countries have had to cope with potentially damaging public responses to issues ranging from the actions of a single member of staff to faulty blood collection bags, unpopular policies or new donor selection criteria. The media are usually good friends to blood transfusion services, but their involvement in negative situations can have a major impact, particularly if the service is perceived to compromise the health of its donors or has been responsible for the transmission of infection.

# The global framework for action
This global framework for action proposes four broad goals and 20 well-defined strategies to address the main constraints and challenges in achieving 100% voluntary blood donation. The framework can serve as a guide for developing programmes that can be implemented at community, regional, national and international levels. The strategies and the accompanying action points have been found to be effective in a number of countries that have advanced to 100% voluntary blood donation. However, action points that work well in one country or community may not be appropriate or as effective in others and are therefore presented simply as ideas for consideration and adaptation to the relevant context. Some action points are cross-cutting and appear in more than one strategy. Create an enabling environment for 100% voluntary non-remunerated blood donation
The capacity of a country to meet its requirements for safe blood and blood products largely depends on the strength of its blood donor programme. Even well-established donor programmes have to work constantly to bring in new donors while maintaining contact with existing donors and encouraging them to donate again. Without a coordinated and adequately resourced voluntary blood donor programme, achieving a safe and sufficient blood supply will remain an aspiration rather than a realistic goal.
Government commitment is fundamental to an effective blood donor programme, whether operated by the ministry of health itself or by a not-for-profit non-governmental organization.
A national blood policy, based on 100% voluntary blood donation and supported by a legislative and ethical framework, is an expression of government commitment to the availability and safety of blood and blood products for all patients requiring transfusion.
The implementation of the policy requires the allocation of sufficient financial resources for the appointment of adequate numbers of trained staff, a suitable infrastructure, facilities and equipment for blood collection and donor care, a donor database and information management system and quality systems for all aspects of the blood donor programme.
A blood donor programme cannot operate in isolation and requires active collaboration with partner organizations, including community-based organizations, patient associations, professional societies and other stakeholders to meet the nation's need for blood and blood products at all times.

# a b c d

# Advocate for 100% voluntary blood donation
Advocacy plays a crucial role in securing ongoing commitment and support from government, partners and other stakeholders for establishing or strengthening a blood donor programme based on 100% voluntary blood donation. Efforts to gain support from policy-makers for incorporating voluntary blood donation in national legislation and securing sustainable financing for the donor programme should be supported by clear evidence. Information and data are therefore needed to demonstrate the efficacy and cost-effectiveness of investing in a voluntary blood donor programme and providing quality donor service and care to retain blood donors as regular donors. In addition to blood safety, the wider role of voluntary blood donation in health promotion, community service and good citizenship should be highlighted.
The need for advocacy extends to the media and potential partners at all levels. Their involvement and support will be forthcoming only if they are convinced of common goals and areas of mutual interest for effective collaboration. 33 Well-known personalities who can speak about their own or their families' personal experience of transfusion can be particularly powerful advocates.
Advocacy may even embrace an admission of a blood service's own vulnerability insofar as it cannot do everything on its own: it is part of the community and it needs the support of the media and many key elements in the community as partners in order to carry out its task. The community needs the blood service, the blood service needs the community and in this way the needs of the most vulnerable are managed with an adequate supply of the safest blood possible.

# Action points
Identify the government departments, stakeholders and potential partners whose support is needed to strengthen and expand the blood donor programme:
Assess their information needs and provide up-to-date information and evidence to illustrate the case for support Identify and work with key individuals who can provide internal advocacy in each organization.
Promote an awareness of international standards in blood programmes that have 100% voluntary blood donation as their foundation.
Use guidelines and recommendations from WHO, 34 the IFRC 35 and other international organizations to support proposals for policy and financial support.
Build linkages with patient groups whose members rely on access to safe blood transfusion for their treatment, such as thalassaemia and haemophilia associations.
Gain advocacy support from professional societies representing the main clinical specialties that use blood transfusion in patient management.
Engage prominent public figures such as celebrities, sporting heroes, and political, community and religious leaders as ambassadors for voluntary blood donation.

# Strategy 2

# Establish a national voluntary blood donor programme
In most countries that have achieved 100% voluntary blood donation, the blood donor programme is part of a blood transfusion service that is coordinated at national level, either within the ministry of health or by an autonomous not-for-profit, non-governmental organization. A number of countries have different but equally efficient structures in which some elements of the blood donor programme are delegated to another organization although overall responsibility remains with government. For example, the National Red Cross or Red Crescent Society has formal responsibility for donor recruitment only in some countries.
While many donor recruitment and retention activities necessarily take place at individual blood centre level, coordination of the blood donor programme will help to maximize efficiency and cost-effectiveness. National policies and quality systems ensure uniformity in standards and operations 32 and enable often limited resources to be used to maximum advantage. 36 National criteria for donor selection and standardized procedures for assessing donor suitability, donor counselling, blood collection and donor care protect the health and safety of donors, recipients and staff. National media campaigns can achieve wide coverage and a high profile to support local activities while nationally-produced donor information and education materials provide consistent messages and reduce the need for materials to be developed at local level.
As in any organization, an effective blood donor programme requires effective management.
In large countries, there may be different sections, each with their own managers, for donor communication and recruitment and for blood collection and donor service and care. Regardless of the management structure, however, the blood donor programme requires strong leadership, management, communication and marketing skills. In an organization that is dominated by medical, nursing and laboratory technical staff, the importance of this special mix of skills is sometimes not fully recognized or valued.
The public profile of the blood transfusion service and the blood donor programme, or how they are perceived by the community, is probably the single most manageable and yet intangible asset of the organization. A positive image that demonstrates credibility and integrity is vital in building public confidence and trust. This is built on the professionalism, moral integrity and accountability of the blood transfusion service and its partner organizations. It also rests on the quality of service and care provided to donors and the quality, safety and timeliness of the blood supplied to hospitals. Evaluating the image of the service -as it is perceived by blood donors and the public -is an important step in designing communication strategies to build positive community attitudes towards blood donation.
Risk management is fundamental to building and maintaining public confidence and is an integral part of establishing a blood donor programme. Every blood transfusion service has to respond to threats or unexpected situations, such as an emerging infection or public debate about certain donor selection criteria. The way in which the blood transfusion service responds to such threats can have a profound effect on its image. Governments, blood transfusion services and partner organizations should work together to conduct accurate assessments and develop appropriate responses to threats. Policy decisions should be based on up-to-date scientific, medical and epidemiological evidence, with due consideration of economic, ethical and social factors, rather than being driven by factors such as pressure groups or the emotive weight of individual cases. 37

# Action points
Establish a national blood donor programme as a central department or unit with responsibility for all activities relating to blood donation and with designated staff in each facility involved in the blood donation process.
Clearly define the organizational, management and communications structure at national, regional/provincial and blood centre levels within the blood transfusion service, the blood donor programme and with partner organizations.
Appoint senior managers for the blood donor programme with leadership, management, technical and communication skills.
Define roles and responsibilities at all levels and establish a mechanism for the planning, coordination, monitoring and evaluation of: Donor communication, information, education and recruitment

# Donor selection and counselling

# Blood collection and donor care
Post-donation counselling and follow-up Donor retention and recall.
Establish a system for coordination and joint planning between the blood donor programme and the departments responsible for blood testing, processing, distribution and supply to set blood collection targets throughout the year, including periods such as vacations when collections are likely to be lower.
Set realistic targets for donor recruitment and recall, balancing these targets with blood collection targets and the staff and resources available for blood collection at fixed and mobile donor sessions.
Develop formal contractual relationships between the blood transfusion service and the national Red Cross or Red Crescent Society and any other partner organizations to which any functions in the blood donor programme have been delegated. Contracts should define roles, responsabilities and accountability and ensure common standards.
Establish a mechanism for regular communication with all partner organizations and for planning and coordinating activities.
Engage in public relations to build a public image that provides the blood transfusion service with a reservoir of good-will.
Incorporate 100% voluntary blood donation in the national blood policy and legislative and ethical framework
The responsibility for a safe and sufficient national blood supply lies with government.
In 1975, all countries affirmed their commitment to the principle of voluntary non-remunerated blood donation through the adoption of World Health Assembly resolution WHA28.72 33 and reaffirmed it in World Health Assembly resolution WHA58.13 in 2005. 1 The development and implementation of a national blood policy, as an integral part of the national health policy, is an important expression of government commitment. The blood policy should enshrine the principle of 100% voluntary blood donation and define the organizational, financial and legal measures that will be taken to ensure the safety and sustainability of the national blood supply and its sufficiency to meet transfusion requirements.
A national blood plan should outline the strategies that will be adopted to implement the policy, including augmenting the pool of voluntary blood donors.
The law has a specific role to play in blood transfusion owing to the unique and distinct nature of blood; this should be regarded as a national resource and not as a commercial commodity. The blood transfusion service should operate within a legislative and ethical framework. The law should promote and protect public health by recognizing voluntary blood donation as fundamental to improving the safety and sufficiency of the national blood supply and in protecting the health of blood donors and the recipients of blood and blood products. By prohibiting paid donation and discouraging family /replacement donation, it serves to prevent the commercialization of blood and exploitation of blood donors. The Pan American Health Organization/WHO Regional Office for the Americas has developed a model law that has formed the basis for legislation in a number of countries in the region and can be adapted in other regions. 40 The WHO International Digest of Health Legislation (www.who.int/idhl-rils/index.cfm) includes examples of health legislation relating to blood transfusion.
Legal and ethical issues to be addressed in relation to blood donation include the prohibition of paid donation and the intention to phase out family/replacement donation (where it still exists), donor education, donor selection, informed consent by blood donors, donor confidentiality and donor notification and counselling.

# Action points
Incorporate "100% voluntary blood non-remunerated donation" as an ethical guiding principle in the national blood policy, in accordance with World Health Assembly resolution WHA28.72.
Develop a national blood plan that defines strategies to expand the blood donor programme and work towards the achievement of 100% voluntary blood donation.
Seek support from the political leadership, policy-makers and legislators for the enactment of legislation or, when appropriate, the amendment of existing legislation or regulations to progress the cause of 100% voluntary blood donation.
Provide policy-makers and legislators with examples of legislation and regulations on voluntary blood donation that have been developed and implemented in other countries.

# Secure sustainable financing
The importance of sustainable financing for technical areas such as screening donated blood for transfusion-transmissible infections is generally well-recognized, even when resources are scarce. However, the importance of adequate funding for blood donor education, motivation, retention and donor care is frequently underestimated, often resulting in limited budget allocations. When blood is donated voluntarily and without payment to donors, it is often regarded as a free resource and the real costs of the donor programme are often not fully taken into account. In reality, costs will be incurred for the purchase or rental of venues for donor sessions, vehicles and equipment used specifically for the donor programme as well as staffing and other recurrent costs, such as training, communications, media, fuel, donor refreshments, blood collection bags and other consumables.
In the face of competing priorities for health financing, the value of investing in voluntary blood donation must be demonstrated to the political leadership and health policy-makers as well as to donor agencies and potential in-country and international sources, such as foundations, social and philanthropic organizations, service organizations and embassies.
The government should provide the blood donor programme, as a key component of the blood service, with a designated budget allocation to enable it to operate in a sustainable manner while expanding its activities to bring in more donors. While international funds may be helpful in starting a new programme and in providing vehicles and equipment or specialist training, they cannot become a source of long-term support. Nevertheless, applications for supplementary funding may also be submitted to other healthcare programmes or agencies, such as the national AIDS control programme, the Global Fund to Fight AIDS, Tuberculosis and Malaria and the World Bank.
Since the blood donor programme is the most publicly visible part of the service where partnership is particularly vital, sponsorship may also be sought from private sector donors who may be willing to adopt blood donation as a good cause by providing financial or in-kind support, such as covering the costs of campaigns in their workplaces or among their customers.

# Action points
Develop realistic costings of all elements of the blood donor programme as a basis for budget planning.
Use costing data, epidemiological data and records to demonstrate the value of investing adequate resources in a voluntary blood donor programme.
Advocate for a sustained national budget allocation for the blood donor programme, with a budget line item in the overall budget for the operation of the blood transfusion service.
Allocate an adequate budget for staff recruitment, training and retention.
Identify potential partners and financial donors to support the blood donor programme: for example, by providing vehicles and equipment to expand community outreach programmes and mobile donor sessions.
Build relationships with the business community at national and local levels to encourage them to provide financial sponsorship of blood donor campaigns and activities.

# Provide a suitable infrastructure, facilities and equipment
Protecting the health and safety of donors and staff and the efficacy of donated units of blood is a central responsibility of the blood donor programme. This requires the provision of a suitable, clean, safe environment for each stage of the blood donation process. All venues used for blood donation should be attractive, have good ventilation and lighting and access to clean water and sanitation and be spacious enough to allow efficient operations. Donor beds or chairs should be arranged so that each donor attendant or nurse can take care of more than one donor at a time. Space should be provided for donors to take refreshments and be under supervision for a period of time after donation in case of adverse reactions.
Good telecommunications are fundamental for staff responsible for donor recruitment and retention as well as access to computers for the production of donor information materials.
Centralized procurement systems for equipment simplify maintenance, training and technical support and are generally more cost-effective than selection and procurement at local level.
Similarly, the standardization of procurement systems and, where feasible, bulk procurement helps to ensure reliable and sufficient supplies of essential consumables, such as blood collection bags, needles and tubing.
A reliable blood cold chain should be maintained for donated blood, including blood storage during donor sessions, particularly mobile sessions, and the transportation of blood samples and blood units to the laboratory for testing and processing. The WHO Manual on the Management, Maintenance and Use of Blood Cold Chain Equipment  provides guidance on all aspects of blood cold chain management.

# Action points
Assess both fixed and mobile venues to ensure they have sufficient space, suitable facilities and equipment to provide a safe, quality and donor-friendly environment for blood donation.
Monitor venues on each occasion that they are used to ensure that they meet defined standards of health and environmental safety. Take any preventive and corrective action that may be required.
Establish an efficient, standardized system for the procurement and reliable supply of equipment, spare parts, blood collection sets and other consumables used in blood donation and donor care.
Assess donations of equipment in the context of their integration into existing systems, the expertise to use them and the local availability of spare parts and maintenance services.
Designate and train staff to implement maintenance programmes for vehicles and equipment.
Establish monitoring and maintenance systems to ensure that equipment will function reliably in the particular environment in which it is used, particularly at mobile sessions.
Maintain an efficient blood cold chain to ensure appropriate temperature-controlled conditions for all donated blood units prior to testing and processing.

# Appoint and train an adequate number of staff and volunteers
The delivery of an effective blood donor programme depends on a sufficient number of trained staff with suitable qualifications, skills and competencies for their particular roles and a friendly attitude and donor-oriented approach to their work. In addition to their professional skills, medical, nursing and administrative staff who deal with donors, particularly those who may be apprehensive, need a range of interpersonal skills, together with a culture of donor orientation.
The importance of staff who are responsible for donor communications, education and motivation is often under-estimated, but effective donor recruitment and retention relies on individuals with specialist skills and experience in fields such as public relations, media and marketing and opportunities for ongoing training and professional development.
Staff are the public face of the blood donor programme. The importance of their role needs to be recognized to ensure they are well motivated and ultimately rewarded for their commitment to a service of the highest achievable quality.
Volunteers can play a variety of roles in the blood donor programme, either in communitybased activities organized by organizations to which they belong, or working directly with the blood service in donor recruitment or blood donor sessions. Volunteers are usually enthusiastic and may be highly effective in motivating others to donate blood. The roles of volunteers should be clearly defined and training provided to equip them for any activities in which they are involved.

# Implement quality systems
Blood transfusion services have a responsibility to ensure quality at every stage of the donation process in order to protect blood donors, donated blood units and the recipients of blood.
Well-defined quality systems should be in place for all activities and procedures to ensure the safety and efficacy of the blood supply as well as contribute to the sustainability and costeffectiveness of the programme.
The quality system should include:
Organizational management, including policies on blood donor management and the identification of specific staff requirements Quality standards, including donor selection criteria and guidelines on blood collection and donor care
Training of staff and volunteers for the effective performance of their functions Documentation, including the development and use of standard operating procedures and an efficient donor records system Assessments, including the validation of equipment, materials, procedures and software and the monitoring and evaluation of all activities related to donors and donations.
The establishment of effective quality systems provides clarity and accountability in blood donor management, especially in relation to health and safety. Donors are entitled to quality service and care throughout the blood donation process, from registration to recall. Quality in their interactions with the blood transfusion service is crucial in maintaining donor satisfaction which in turn, leads to donor retention. 43 Bringing in new donors requires a substantial investment of staff and financial resources that should not be wasted. Without quality in donor service and care, the blood transfusion service jeopardizes its credibility, risks losing public trust and will invariably fail to build a pool of loyal, regular voluntary blood donors. Establish a quality system for all activities related to blood donation to ensure the optimal care of donors and donated blood.
Develop standard operating procedures for all stages of the donation process and train staff and volunteers to follow them at all times.
Train staff to use equipment correctly and establish a system for the calibration, maintenance and servicing of all equipment by trained staff on a regular basis.
Assess staff performance on a regular basis and provide any further training needed to develop or maintain their competencies, especially in relation to donor health and safety.
Establish a documentation system that enables complete traceability from the donor to the donation, including complete and accurate donor records, the labeling of donations with a unique donation number, the materials used (e.g. batch number), blood screening records and the identity of staff directly involved in each process.
Maintain the confidentiality of donor records to protect donors and uphold their trust in the blood transfusion service.
Establish a national donor haemovigilance system for the monitoring, reporting and investigation of adverse donor events.
Establish a national donor database and information management system Donor records are vital in maintaining the safety of the blood supply and building a stable base of voluntary blood donors. In many countries, it is already a legal requirement to maintain accurate records to ensure the traceability of donated blood from donors to recipients and from recipients back to donors. Records of individual donors are also required to develop a register or database of blood donors, including rare blood donors, for follow-up, recall and recognition. Donor information should be linked to data on temporary and permanent deferrals, successful donations and the results of blood screening.
The confidentiality of donor information must be maintained at all times to protect donor interests and maintain trust between the donor and the blood transfusion service. Only designated staff should have access to donor records and data.
The widening availability of computers facilitates the recording, retrieval and analysis of donor data. However, whether manual or computerized, donor records systems should be comprehensive, accurate and secure. A standard format for the donor questionnaire and donor records should be developed at national level and used in all centres in which blood is collected. It may not yet be feasible to establish a national or regional computerized donor database, but using standardized formats for donor records will make it easier to develop one in the future. This will enable statistical information to be recorded for monitoring and evaluation and facilitate the sharing of information on donation history and deferrals if donors change their place of residence. In many countries, young people in particular tend to have a high level of mobility. Without a centralized database, it is virtually impossible to call up donors who have moved to other areas and may be lost from the donor pool.
Records of blood donor sessions are also valuable in evaluating donor education strategies and materials, monitoring sessions and planning future activities. Records of temporary and permanent deferrals, for example, can indicate the effectiveness of donor information and education materials and the value of particular locations for mobile donor sessions. Establish a national system to ensure that donor records are kept secure at all times in order to maintain confidentiality.
Involve partners, such as universities or the information technology sector, in developing a donor database.
Use data on blood donors and blood donations as a basis for programme planning, implementation, monitoring and evaluation.

# Develop an emergency preparedness and response plan
Emergency preparedness to avoid blood shortages in times of increased demand or emergencies requires a high level of coordination, planning and preparation by the blood transfusion service. This should be undertaken in conjunction with organizations involved in donor recruitment, with other departments responsible for blood testing, processing and distribution and with clinical services. 44 The safety of blood donors and donated blood units must not be compromised under any circumstances, even in an emergency situation.
Emergency situations may arise from an urgent, unpredictable demand for blood involving mass casualties. In addition to the immediate need for blood supplies in affected areas, the rapid depletion of existing blood stocks may result in a lack of blood for other patients requiring emergency transfusion, including obstetric, surgical and trauma patients. It may also have a direct impact on patients requiring transfusion for elective surgery or regular transfusion for conditions such as sickle cell disease and thalassaemia.
Acute blood shortages may also arise from unpredicted or unavoidable disruptions to blood collection. An epidemic, such as pandemic influenza, or a mass vaccination campaign may result in a sudden but temporary loss of donors and staff, restrictions on the movement of people and operation of blood donor sessions or a temporary inability to move blood stocks to required locations. WHO has developed guidelines on Maintaining a Safe and Adequate Supply of Blood in the Event of Pandemic Influenza. 45 Depending on the scale of the emergency, a well-organized blood donor programme based on regular voluntary blood donation may have a sufficient supply of safe blood to meet unexpected demands. It should have an efficient transportation system to move blood stocks to other parts of the country. It can also mobilize a significant number of regular donors who are familiar with the blood donation process and can be handled more quickly than first-time donors. A hospital-based facility that is dependent on family /replacement donors is less likely to have the capacity to handle large numbers of donors while maintaining standards of quality, safety and care.
The management of donors is a critical part of an emergency response and may have a lasting impact on public perceptions of the blood transfusion service, attitudes towards blood donation and donor loyalty. Donors who receive quality care, even in a difficult situation, may be motivated to become regular voluntary donors in the future.
If blood stocks are adequate to meet emergency needs, over-collection should be avoided; a surplus number of new donors places pressure on facilities, staff and resources and may result in the wastage of donated blood, thus undermining public trust in the blood transfusion service. Urging individuals to register as donors and make appointments to donate in the future can be the first step in promoting a lifelong commitment to blood donation.

# Action points
Ensure the inclusion of the blood transfusion service in the national emergency planning committee and provide regular, up-to-date information on blood availability.
Establish an emergency planning group in the blood transfusion service. This should include the blood donor manager and representatives of partner organizations involved in blood donor recruitment and community mobilization. Assess the need for blood donors and mobilize the community by:
Calling up regular and former voluntary blood donors
Requesting partner organizations to mobilize their members to donate blood Issuing a public appeal through the media.
Following an emergency situation, evaluate the efficiency and effectiveness of the emergency plan and revise the plan and standard operating procedures, as required.

# Strengthen collaboration and partnerships
Collaboration and partnerships are important driving forces for voluntary blood donation.
The most fruitful partnerships are likely to be built with organizations that are founded on the principles of volunteerism and community service. In some countries, the National Red Cross or Red Crescent Society play the principal role in donor recruitment. Many other nongovernmental organizations have structures that reach from national to local levels and large memberships at grass-roots level. While voluntary blood donation may not be part of their mandate, they share similar values; they may therefore recognize involvement in blood donation as an additional opportunity for their members to express their sense of citizenship and social responsibility and contribute to health promotion.
Partnerships can be built in every sector and at every level, from community to national and international level. Opportunities for collaboration beyond traditional community-based partners can be opened up by broadening the public perception of voluntary blood donors as active, valued members of society in addition to being contributors to health care.
The involvement of other sectors can enrich the blood donor programme through skill sharing in such areas as research and marketing, as well as offering access to large numbers of potential donors among employees and customers. Many public and private sector employers adopt a charity or a cause as part of their corporate social responsibility programmes. Some may offer financial sponsorship but others also look for ways in which their staff can become actively involved in supporting the cause. Blood transfusion services in a number of countries have formed partnerships with employers whose staff respond enthusiastically to participating in donor education campaigns and organizing blood donor sessions in the workplace.
On the international level, there are a number of agencies that can provide technical support, including WHO, the IFRC and other organizations committed to voluntary blood donation, such as the International Federation of Blood Donor Organizations. Other agencies provide opportunities for linkages with other sectors with opportunities for funding and technical assistance, including UNAIDS, Safe Blood International, the Global Fund for HIV/AIDS, Tuberculosis and Malaria and the World Bank.

# Action points
Identify all potential stakeholders working at community, national and international level and explore opportunities for collaboration and partnership: Consolidate and formalize partnerships by clearly defining the functional roles, responsibilities, authority and accountability of all partners.
Work with partners to identify the most appropriate approaches to donor information, education and community mobilization among their members.
Establish a mechanism for planning and coordinating activities to ensure consistency, common standards and cost-effectiveness and avoid the duplication of activities.
In conjunction with major partners, jointly set goals, targets and plans for mobilizing blood donors and organizing blood donor sessions and follow-up activities.
Develop a system for recognition of the contribution of partner organizations to the blood donor programme.

# Goal B
Foster a culture of voluntary blood donation
Attracting eligible individuals to donate blood for the first time and, equally importantly, to make a long-term commitment to donate regularly requires the fertile soil of positive community attitudes to voluntary blood donation. The first requirement is public awareness of the need for blood and blood products as an essential component of health care and an understanding that they cannot be obtained by any means except the donation of human blood. This must be accompanied by recognition of the special role that voluntary blood donors play in saving lives and improving health and the need for regular voluntary donation to maintain a safe blood supply for the nation.
Public support must be fostered by confidence that the blood donation process is safe and that the blood transfusion service will respect and protect the health of blood donors. This means evaluating the image and profile of the service and developing communication strategies that are meaningful to different target donor populations. In cultures which have little tradition of blood donation, there may be many concerns, myths and misconceptions ranging from fear of needles or fainting to beliefs that blood donation results in a loss of strength or that HIV can be contracted by donating blood. It is therefore essential to identify public perceptions and address them directly, working in partnership with the media and the community who can reach out to large numbers of people. The public must also be reassured that the service, and the physicians who prescribe blood, will not waste the precious gift provided by blood donors.
Developing a strong blood donation culture requires considerable patience and hard work, but the rewards will be seen in a stable pool of voluntary blood donors and a safe and sustainable blood supply. The IFRC toolkit, Making a difference: Recruiting voluntary non-remunerated blood donors, 46 offers both policy makers and managers in health authorities, blood transfusion services and National Red Cross/Red Crescent Societies a more in-depth guidance and models of good practice. Its "Resources" section contains country case studies that provide a useful source of information on approaches to social marketing that have been effective in other countries.

# a b c d

# Strategy 4
Understand your blood donors Each sector of the population will have different beliefs and attitudes and so it is necessary to find out what the general public and blood donors themselves know, think and do regarding blood donation. Understanding your donors -and potential donors -provides a basis for defining approaches and messages for different audiences and selecting the most effective means of reaching them.
Research is an important tool for understanding donors and potential donors. Research need not be complex or costly, but a systematic approach is needed. One of the first steps is to assess the information that can be obtained from reviewing records that are already available. A high rates of discards, for example, suggests that donor education materials are not sufficiently clear about donor selection criteria. Research studies that have already been undertaken are a useful source of insights and ideas. In addition to in-country research institutions, the internet opens up access to a wide range of published reports. Even if research has been carried out in other regions, the findings may still be relevant elsewhere.
A survey examining knowledge, attitudes and practice (KAP) in relation to blood donation and transfusion can be a simple but effective means of identifying factors that need to be addressed in donor information and education. Basic questions to be answered include: The Pan American Health Organization/WHO Regional Office for the Americas has produced Methodological guidelines for socio-cultural studies on issues related to blood donation 47 which provide a helpful framework for national studies. It has also published a report on studies that were conducted in 15 countries in the Americas using these guidelines. 48 Many of the findings were similar, showing that lack of knowledge, fear, facilities, convenience and the quality of service were common factors in people's decisions on whether to donate blood on a voluntary basis. Studies conducted in a number of other countries similarly provide useful examples of how to conduct a KAP study.  Explore donors' perceptions and expectations, using donor surveys and donor feedback to identify factors that have positive or negative effects on their motivation or have already deterred them from donating blood.
Evaluate the effectiveness of current approaches to public information and donor education by reviewing donor records and research studies. Use the findings to assist in developing communication strategies and materials.
Review research reports or country success stories in journals, conference proceedings and other sources.
Conduct simple knowledge, attitudes and practice (KAP) studies to identify the specific characteristics, values, beliefs and behaviours of the general population or specific target donor populations that may impact on attitudes towards blood donation.
Adapt existing research tools, such as questionnaires to reduce the time and costs associated with research.
Involve partner organizations with expertise and interest in research, such as university departments, research institutions, government departments and nongovernmental organizations as well as individual students and research fellows.
Seek technical or financial support in market research from the business community under their corporate social responsibility programmes.
Exchange information and research data through workshops, conferences, journal articles and the internet.

# Strategy 5

# Identify target blood donor populations
The most important consideration in targeting sectors of the population as potential donors is that they should be healthy and that blood donation will not harm them or the recipients of their blood. Targeting specific donor populations helps to focus information and education campaigns on potential donors who are most likely to meet donor selection criteria. This enables the most effective use of available resources by reducing unnecessary donor deferrals and the discard of unsuitable blood units.
However, targeting potential donors goes beyond identifying safe donor populations. Blood donors come from all walks of life. They vary in their age, education, employment, religion, place of residence and socio-economic status. They also differ in their knowledge, attitudes and experience of the need for blood donation and transfusion. In this sense, there is no "typical" donor. It is for this reason that research is so important.
While some campaigns may be very broad, attempting to reach all who may be interested in blood donation, identifying suitable sub-populations from among the general population enables donor information, education and communication strategies to be tailored to different audiences in order to maximize positive responses. These strategies are more likely to be perceived as relevant if they focus on the particular interests of different sectors of the population, such as school students, family/replacement donors or members of faith-based organizations, and use the channels of communication and messages that are most likely to capture their attention.

# Action points
Categorize the existing and potential donor base to identify different types of donor populations: Analyse donor demographic profiles and patterns of donation and deferral among donors using the records of first-time, regular, temporarily deferred and infrequent donors.
Identify the safest potential donor populations from sources such as data on donor deferrals and donation testing records.
Identify populations that may be unsuitable to donate blood by using epidemiological and socio-demographic data and reviewing behaviour patterns in the community.
Engage people who are not eligible to donate blood because of their age or health status but who can be targeted to act as advocates of voluntary blood donation.

# Strategy 6

# Develop communication strategies for donor education and community involvement
Blood transfusion services must strive to develop positive community attitudes to voluntary blood donation in order to motivate, recruit and retain a sufficient number of safe blood donors. However, bringing donors in is only the first step in fostering donor and community commitment. The longer-term objective must be to create a positive culture of voluntary blood donation and promote it as a normal part of a healthy lifestyle.
The findings of KAP studies commonly show that most people have little or no knowledge or experience of blood donation or transfusion. The first objective is therefore to create wider understanding of the need for blood donation and to promote positive attitudes and beliefs towards it. Many people who have never thought about donating blood before may simply need to be asked -through direct personal contact or via the media -and given a convenient opportunity to donate.
Identifying information gaps and communication failures is essential in building community awareness and confidence in the blood transfusion service. Messages must be devised to overcome cultural constraints and social and psychological fears held by different target populations. Positive values, such as a religious or moral sense of duty to fellow citizens, can be powerful motivating factors when harnessed in communication with audiences who share these values. Negative beliefs, such as misconceptions and superstitions about blood, need to be addressed with information and the support of influential individuals who command widespread respect. The ultimate goal is to promote changes in individual behaviour that are manifested by an initial decision to donate blood followed by a commitment to donate on a regular basis and an undertaking to continue to lead a healthy lifestyle.
Bridging the gap between awareness and the actual act of blood donation requires communication and education strategies that address the specific characteristics, values and concerns of different target donor populations and identify entry points and the channels of communication that they use.

# Action points
Utilize the information obtained from research for developing education and communication strategies for different target donor populations.
Develop donor information and education campaigns and materials that are relevant and appealing to the different target donor populations:
Involve representatives of these populations in reviewing draft materials and suggesting ways of improving them Conduct field tests to assess whether the messages and materials are understood and accepted by potential donor groups.
Select the most suitable channels and forms of communication for different messages and target donor populations; these may include posters and leaflets, newspaper articles, public service broadcasting, radio spots and community theatre. Involve media and community partners to disseminate them.
Seek professional assistance in planning and developing information and education campaigns from universities, advertising agencies and the marketing departments of large businesses as part of their corporate responsibility activities.
Provide training to develop the skills of staff and volunteers involved in donor communications and education.

# Strategy 7
Build partnerships with the media
The print, broadcast and electronic media are among the most powerful allies of the blood donor programme. Their ability to reach large numbers of people is unequalled by any other partners and their support should be nurtured and valued. The media can play a vital role in public information about the importance of blood donation and fostering positive responses to requests for new and regular voluntary blood donors.
Media campaigns need not be expensive. Although newspapers, radio and television may charge for advertisements or regular public service broadcasts, journalists are always looking for good stories, which usually do not involve any costs. They are likely to be most responsive if they are provided with well-presented ideas, information and human interest stories that will emotionally engage their audiences. Public appeals for blood donors, for example, are often most persuasive when they feature interviews with people who talk about the difference that transfusion has made to their lives and personally thank the anonymous donors who made it possible.
Proactive involvement and good relationships with the media help to ensure that journalists are well-informed and do not unwittingly fuel negative attitudes to blood donation by reporting stories inaccurately or in a negative way. The results of a survey by the Pan American Health Organization/WHO Regional Office for the Americas indicated that many journalists have limited access to information related to blood donation. It therefore developed a CD-ROM, Blood: Broadening our knowledge 52 to provide objective, accurate information for the media, including examples of testimonials, radio spots and television public service broadcasts.
Although designed primarily for use in the Americas region, it provides a valuable source of ideas and information that can be used or adapted in other parts of the world.

# Action points
Designate a media liaison officer or official spokesperson to build effective interpersonal relationships with the media and maintain contact on a regular basis.
Select the most appropriate media for reaching different target groups and work with them to develop messages that are relevant and appealing to their particular audiences.
Engage journalists in keeping voluntary blood donation in the public eye by:
Supplying regular reports on blood needs and current blood stocks
Requesting special coverage to support specific campaigns or appeals, particularly in time of blood shortages

# Providing human interest stories and photographs of blood donors and patients who have benefited from transfusion
Inviting journalists to visit blood centres and meet donors and staff
Arranging interviews with donors, such as first-time donors and those with record numbers of donations
Working with patients' organizations to feature transfusion recipients who are willing to tell their stories about blood transfusion.
Urge the broadcast media to include free radio and television spots as part of their public service broadcasting mandate.
Issue media advisories well in advance of special events or campaigns such as World Blood Donor Day to give journalists time to plan and research stories and interviews that will achieve maximum in-depth coverage.
Issue press releases to launch special events and follow up with personal contact to provide any additional information that may be of interest to particular audiences.
Seek volunteer support in media campaigns from university departments and individual students, particularly those following courses in journalism and media studies.
Use local media to advertise the locations and times of blood donor sessions and appeal to infrequent or former donors to return to the blood centre.
Use electronic media for innovative communication campaigns:
Encourage internet service providers and search engines to promote blood donation on their home pages on World Blood Donor Day and other special events Request mobile telephone companies to send SMS/text messages to all subscribers urging them to become blood donors Set up a blood donor blog or add online messages, stories or videos to online communities and social networking sites.
Seek the support of the business community to sponsor advertisements in the media and provide messages of support.
Present ideas to the entertainment industry about story-lines on blood donation that could be included in soap operas and other television programmes, plays and movies.
Monitor the coverage and response achieved by media campaigns to identify the most effective media and ways of improving future campaigns. Involve the media themselves in the evaluation process.

# Strategy 8

# Mobilize community partners and create networks
Communities can be a powerful stimulus for change and blood donor programmes cannot function effectively in isolation from them. A pool of regular, voluntary blood donors evolves from the bond between the blood transfusion service and the community it serves. Media campaigns and donor education programmes may be very extensive, but can rarely reach directly into local communities to engage in interpersonal communication -one of the most effective ways of attracting new donors and building long-term commitment to voluntary blood donation. Community-based institutions and organizations know and understand their members and provide a vital means of communicating with potential donors at local level.
Community outreach is particularly effective through organizations that have substantial local constituencies and can help in overcoming many of the socio-cultural constraints to blood donation. They can stimulate their members to become regular voluntary blood donors and encourage their families and peers to donate as well. They can also assist in donor education activities and blood donor sessions or even take responsibility for organizing local campaigns and community-based donor sessions. They may even wish to adopt voluntary blood donation as a special cause or campaign.
Community networks of blood donor motivators are often started by one or more individuals who have direct experience of the need for safe blood and blood products for transfusion. For some, their own or their relatives' lives have been saved by transfusion or they depend on it as part of their regular treatment regime. For others, their individual commitment to donating blood regularly and the personal rewards that it brings may lead to a desire to involve others within their peer group and community to make a similar commitment. Their intensely personal experience can be a strong motivating force.
Many community-based blood donor networks operate on a local basis, but national blood donor organizations with structured networks of members have been established in over 60 countries, supported by the International Federation of Blood Donor Organizations.
Partnerships must be nurtured and developed at a pace and on a scale that enables the blood transfusion service to match their efforts by providing suitable facilities for blood donation. Generating large numbers of enthusiastic individuals who wish to donate blood but who have no opportunity to do so will undermine goodwill and jeopardize partnerships in the future.

# Action points
Identify and involve organizations and institutions that have credible and easy access to target donor populations, including: Retail and commercial outlets which have access to large numbers of staff and customers.
Contact long-standing donors who have demonstrated their commitment to voluntary blood donation and explore their willingness to be involved in setting up a community-based blood donor network or organization.
Identify key individuals in each organization and institution and invite them to visit a blood centre to discuss ways in which they can support the blood donor programme.
Establish mechanisms for communication and coordination and develop joint targets and plans for educational activities and mobile donor sessions.
Develop a structured orientation and training package for new community partner organizations.
Involve organizations in identifying the characteristics, interests and motivations of their members and in developing suitable messages and materials to encourage them to become regular voluntary blood donors.
Provide support to partner organizations in community mobilization by giving talks to their members and organizing regular blood drives.

# Strategy 9
Maximize the impact of World Blood Donor Day and national blood donor events World Blood Donor Day (WBDD), which is observed annually on 14 June, provides a special opportunity to build a culture of voluntary blood donation. Launched for the first time in 2004, this annual event celebrates and thanks blood donors and highlights the unique life-saving role they play in the health of their community. It is also designed to create wider awareness about the need for sufficient supplies of safe blood and how this need can be met only if many more people throughout the world make a commitment to regular voluntary blood donation.
In 2005, the ministers of health of all WHO Member States unanimously endorsed World Blood Donor Day as an annual event and recommended that it should be an integral part of national blood donor programmes. 1 Each year, an announcement of the theme is sent in advance of World Blood Donor Day to ministries of health, blood transfusion services, Red Cross and Red Crescent Societies, blood donor organizations and professionals. National campaigns and activities are supported by an international media campaign that highlights the theme and a global event that is hosted by a country that has demonstrated major achievements in working towards, or maintaining, 100% voluntary blood donation.
The event on 14 June each year is designed to create awareness that blood is needed every day and to encourage more people to donate blood throughout the year, rather than trying to attract a big influx of new voluntary blood donors on that one day alone. The significance of World Blood Donor Day is that it unites people throughout the world in a global celebration of humanity, volunteerism and solidarity. Heads of state, royalty, ministers of health, celebrities and thousands of ordinary people take part in this remarkable, joyful event that celebrates life -and life-savers.
World Blood Donor Day provides a springboard for longer-term donor education programmes and campaigns throughout the year, as well as wider activities to strengthen the blood transfusion service. It is designed to complement rather than replace the national blood donor days or weeks which are organized in a number of countries. Some are held at the same time as World Blood Donor Day while others take place at different times of the year, particularly when there are expected to be seasonal shortages.
Information and ideas for activities and resources to support national campaigns are provided each year on the WBDD websites: www.who.int/worldblooddonorday and www.wbdd.org

# Action points
Build national and local campaigns and activities around the annual theme of World Blood Donor Day.
Visit the WBDD websites to get ideas from other countries on WBDD events and activities.
Develop special materials and promotional items such as T-shirts, pins, caps, pens and mugs using the globally recognized symbol and other graphic resources on the WBDD websites.
Create a public awareness campaign to encourage individuals to register as blood donors.
Consider designating a week as 'national blood donor week' for an extended, sustained public campaign and donor recruitment drive, either during the week in which World Blood Donor Day falls or at a time of year in which blood shortages can be anticipated.
Build up to 14 June by organizing activities spread over a period of months, such as essay, poster and banner competitions for schools.
Organize a song, jingle, essay or poster competition on the WBDD theme for different agegroups.
Plan a national WBDD media campaign to capture public attention about the need for blood and how they can contribute to saving lives:
Start working with journalists well in advance of WBDD and other national events to develop in-depth stories about individual blood donors and patients as well as data on the country's needs for safe blood Urge newspapers to run special editions and editorials on blood donation

# Request the business community to sponsor features and advertisements
Issue a press release highlighting national issues and events.
Invite prominent politicians, celebrities and sporting heroes to participate in WBDD celebrations to create positive role models. Involve champions or advocates at community level.
Hold a donor recognition awards ceremony to honour individuals and partner organizations who have made significant contributions. Set up a thank-you wall and invite transfusion recipients and their relatives to post up cards expressing their feelings about people who voluntarily donate their blood.
Hold open days at blood centres and invite dignitaries and the general public to discover about blood donation and blood transfusion.
Organize sporting and cultural events to highlight the link between blood donation and healthy lifestyles.
Seek corporate sponsorship for WBDD and longer-term activities to support the blood donor programme.

# Goal C
Build and maintain a safe, sustainable voluntary donor base A country's ability to consistently meet the clinical demands for blood and blood products depends on blood donation by a sufficient number of healthy individuals. Well-informed voluntary donors who are committed to donating blood regularly form the basis of a sustainable pool of blood donors that can provide a safe, reliable and sufficient supply of blood in all situations and at all times.
In countries where a proportion of the blood supply is provided by family /replacement and even paid donors, the major need is to rapidly expand the number of eligible voluntary blood donors to meet national blood requirements. However, the objective is not only to bring in new voluntary donors who are suitable to donate but also to build relationships with individuals who make a long-term commitment to blood donation and return to donate on a regular basis.
Considerable time, effort and resources are required for the recruitment of first-time donors. It is therefore more cost-effective to retain existing or former donors who are aware of the importance of blood donation and are familiar with the donation process. A pool of regular voluntary blood donors also enables blood collection to be planned to meet the requirements for different blood groups and components. Nevertheless, there will always be a continuing need to attract new donors to reduce shortfalls in the blood supply, accommodate increasing clinical demands for blood and compensate for the depletion of the donor pool through ill-health, retirement or relocation. A combination of approaches is therefore needed to reach out to current, former and potential donors.
Research studies in a number of countries indicate that the most common reason why people do not donate blood is that they have never been asked to do so. 48 Without public information and organized campaigns to build awareness of the constant need for blood and the role of voluntary blood donors, it will simply not occur to most people how they can make a personal contribution to the health of the community.
Education, communication and recruitment strategies must be matched by the provision of convenient opportunities to donate blood. This requires careful planning and coordination between the donor recruitment and blood collection departments and with partner organizations. It would be counter-productive and waste resources and goodwill to attract more donors than the blood transfusion service has the capacity to handle safely. Long waiting times, a b c d harassed staff and poor donor care will dampen the enthusiasm of both new and returning donors.
The attainment of 100% voluntary blood donation for any country brings with it sustainable, long-term human development benefits. The relationship between a country's voluntary blood donation programme and the capacity of its government and civil society to meet their broader responsibilities reflects the true value of voluntary blood donors in human development.

# Strategy 10
Educate, motivate and recruit new blood donors
Building a donor base through the recruitment of new donors requires a concerted and coordinated effort in conjunction with community partners and networks and the media. High profile coverage in the media needs to be supported by sustained public health campaigns and grass-roots activities that start the process of building a relationship with donors.
The reasons why individuals decide to donate blood for the first time will be determined by multiple factors including culture, religion, and individual values and beliefs. While altruism and awareness of the need for blood are often the most common reasons given for donating blood, some studies have found that the gap between motivation and the actual act of first donation is most effectively bridged through the direct influence of friends, relatives and peers, particularly those who are already enthusiastic, committed blood donors. Media appeals or advertising through television, radio, newspapers, magazines, leaflets and posters are also found to be important means of bringing in new donors. 53 A website can be particularly effective in sharing information, particularly among young people: the websites of blood donor programmes in other countries may be helpful as a source of ideas. However, there is relatively little research on donor motivation and it is for this reason that simple surveys, such as knowledge, attitudes and practice studies, are important in understanding the motivations and behaviour of donors and potential donors and the most effective means of reaching them.
Donor information and education campaigns and materials should address common myths and fears by providing clear information to allay apprehensions. They should also include information in simple language on who can give blood and who may be unsuitable to donate, either to protect their own health or that of the recipients of their blood. People who are motivated to donate blood should have access to information that enables them to assess whether they are eligible to donate or should self-defer; this will help to reduce deferrals and associated feelings of disappointment or frustration in blood donor sessions.

# Action points
Provide information to potential donors on:
Why blood is needed How it is used

# Current blood stocks
The blood donation process Criteria for donor eligibility

# Stories about donors and recipients
Locations and operating hours of blood centres and mobile donor sessions.
Select channels of communication that are mostly likely to appeal to different target donor populations.
Encourage existing blood donors to bring friends or family members with them the next time they attend to donate; urge them to set personal targets for bringing in new donors.
Organize regular blood drives or mobile donor sessions in settings in which a viable number of donors can be anticipated, such as schools and universities, workplaces and places of worship (see Strategy 17):
Work with local organizing committees in the planning, promotion and operation of mobile blood donor sessions Provide posters and donor education materials Use local contacts and channels of communication to publicize sessions in advance.
Set up stalls or booths at special events, such as religious and community festivals, sporting and cultural events, and organize street recruitment campaigns and blood donor sessions in shopping malls, and sports and social venues.
Encourage donors to join or form voluntary blood donor networks and organizations to promote voluntary donation and organize donor sessions in their educational institutions, workplaces and communities.
Introduce a website with an online donor registration system to enable potential donors to request more information, record their interest in donating blood and make appointments to donate.

# Strategy 11

# Mobilize youth as a new generation of voluntary blood donors
Young people are a special target group because they form a large sector of the population and are generally full of idealism and enthusiasm. They are the foundation of the blood donor base of the future. Even if they are too young to donate, it is never too early to educate them to become blood donors when they reach the legal age of donation. Schools, universities and youth organizations provide cost-effective mechanisms to reach and motivate potential and future donors who can also be effective educators of their families, peers and community.
In some countries with particularly high HIV prevalence rates, young people provide a significant proportion of the blood supply. The focus on young donors, particularly schoolbased donors, has evolved specifically to reach young people who have the lowest prevalence of infection.
The creation of Club 25 or Pledge 25 programmes, which originated in Zimbabwe, has proved to be a particularly effective means of mobilizing young people, particularly after they have left school and are more difficult to reach. Club 25 members make a commitment or formal "pledge" to donate blood regularly and to donate at least 25 times in their lifetime. They also pledge to lead positive, healthy lifestyles to protect themselves from HIV/AIDS and other infections and to prevent the transmission of infection through their blood. Club 25 programmes have been established in a rapidly growing number of countries. Their activities vary, but voluntary blood donation and health promotion are core elements. Membership promotes personal development and leadership skills and also embraces young people who cannot donate blood but who choose to volunteer their services in support of the overall aims of the programme. Young people relate well to people similar to themselves in age, background and interests, and cultural similarities help to ensure that the language and messages used are relevant and appropriate.
Through an international network of Club/Pledge 25 programmes, young blood donors experience social interaction and collaboration at the global level, resulting in the acquisition of leadership skills which can later be of benefit to their own country in wide-ranging activities.
Young blood donors first make a contribution to human development by giving blood. Then, by becoming HIV/AIDS peer educators or participating in other health promotion activities, they extend their community involvement. They forge strong solidarity links, helping to build their capacity to provide leadership for improved health and well-being in their communities over several decades. With Club 25 Programmes now gaining a foothold in numerous countries around the world, it may not be too strong to suggest that voluntary blood donation is a practical and positive step towards a greater understanding between countries and a tolerance of different cultures. "International Club 25, one world... one blood" now links together young blood donors from all countries. Guidance on developing a Club/Pledge 25 programme is provided by the IFRC's Youth programme and by the African Club 25 Society: www.ifrc.org/youth/action/health/club25 www.africanclub25society.org

# Action points
Conduct simple research studies to identify the specific values, beliefs, motivations and communication preferences of young people.
Develop specific communication strategies and information and education materials for young people based on:
Age groups Points of contact, such as schools, university campuses and youth organizations Channels of communication that they use.
Advocate to education authorities for information about blood and blood donation to be integrated into primary and secondary school curricula in subjects such as science, social studies, health education and mathematics.
Involve teachers in donor information and education by encouraging them to include issues related to blood donation and transfusion in their courses.
Invite schools to visit blood centres, provide educational talks and materials and involve donors and recipients of blood in creating awareness about blood donation as a social responsibility. Educate students about healthy lifestyles and risk behaviour.
Encourage young people to donate blood for the first time when they reach the legal age for blood donation.
Involve students in the planning and promotion of community blood drives.
Support schools in creating donor recruitment teams and organizing regular school blood donor sessions for older students who have reached the legal age of donation. Parental consent may be required.
Work with relevant university departments, such as social sciences, medicine, nursing, media studies and journalism to encourage institutional and student involvement in projects to support the blood donor programme.
Conduct regular, well-publicized mobile blood donor sessions at university and college campuses.
Encourage motivated individuals to volunteer as student representatives to promote and organize blood donor sessions at their universities or colleges.
Reach young people through youth organizations, particularly those with established structures and community-based membership, such as the Scouts, Guides and faith-based organizations.
Establish Club 25 peer promotion programmes to encourage a long-term commitment to voluntary blood donation by young people.
Keep abreast of and use new communication technologies such SMS/text messaging, email and the internet, including social networking websites and blogs which are particularly popular with young people.
Seek the support of media that appeal especially to young people, such as music and sport channels.

# Strategy 12
Convert eligible family /replacement donors to voluntary blood donors Despite the risks associated with a dependence on family /replacement donation, replacement donors themselves are an important target population as potential voluntary blood donors or as advocates for blood donation. They understand the importance of the timely availability of safe blood because of their direct experience of the urgent need for donors when transfusion is required for a family member or friend.
The responsibility for the provision of blood and blood products lies with the health system and not patients and their families. Where an adequate blood supply is provided entirely by voluntary donors, families do not need to be requested or instructed to provide replacement donors because blood will be available to meet the patient's transfusion needs, however urgent they may be.
For as long as hospitals require replacement donations, individuals have little motivation to donate voluntarily and will generally prefer to save their blood in case it is needed by a family member. Shifting from a system based on family /replacement donation to voluntary blood donation system requires a change in practice by hospitals as well as a concerted effort by the blood donor programme.

# Strategy 13
Recall infrequent, inactive and temporarily deferred blood donors Donors who donate infrequently or no longer donate constitute an important target donor population. Having gone through the donation process including the donor selection and blood screening processes at least once, they have in the past demonstrated their awareness of the need for blood and their willingness to donate.
Reactivating former donors can be more cost-effective than recruiting new donors. Some infrequent or inactive donors may simply need to be reminded of the importance of their donations and encouraged to return. Others may no longer be eligible to donate due to their age or health status. However, more common reasons are that a previous donation experiences was unpleasant or blood centres are not easily accessible or are only open at inconvenient times. Conducting a simple survey of inactive donors may identify some common deterrents or reasons for not returning that can be addressed relatively easily.
The donor database or donor register is a vital tool for recalling previously active donors. However, it is likely to contain the contact details of people who have relocated or are no longer eligible to donate. It is important to update donor data periodically by contacting donors so that donors who are no longer available can be removed from the register. The next step is to segment the donor data according to variables such as the length of time since last donation, the site at which blood was donated and the total number of donations. This will enable priority lapsed donors to be identified; for example, it will probably be easier to reactivate a donor who last attended a donor session two years ago than one who donated once ten years ago. An analysis of donor data may reveal trends that are not otherwise immediately obvious. Certain fixed or mobile sites could be effective in bringing in new donors but have low rates of return, for example; this might indicate poor quality of care or an inefficient system of donor call-up.

# Strategy 14

# Retain suitable voluntary blood donors
Donor satisfaction is one of the pillars of donor retention. Donor satisfaction is derived from both internal and external influences. Altruism is commonly identified as the primary reason given for blood donation, but awareness of the need for blood, social pressure and perceived personal benefits, such as enhanced self-esteem and recognition, are also important motivators.
As donors become more experienced, their motivation may change. External influences such as family or friends tend to become less important as they develop a self-identity as a blood donor and a habit of donating blood. For many regular donors, blood donation offers a private way of helping society at minimal personal cost.
The ideal blood donor is sufficiently self-motivated to donate blood on a regular basis but most donors, particularly those who have made a small number of donations, need encouragement to build blood donation into their normal routines. Countries with a long tradition of 100% voluntary blood donation have demonstrated that while it is possible to build a stable pool of regular donors, these donors must be provided with information, good service and care and given recognition and appreciation to maintain their loyalty. Regular donors themselves can play a helpful role in identifying factors that motivate regular donors and in designing donor retention strategies and materials.
A good donor records and recall system that enables individual reminders to be sent to donors as well as information about mobile donor sessions is fundamental to donor retention. Some studies suggest that frequent contact with new donors in particular is important in influencing them to donate regularly because the motivation of donors intensifies the more donations they give; they should therefore be encouraged to donate again after the minimum interval between donations. 54 The personal touch through friendly messages, updates and greetings helps to keep the blood centre and the importance of blood donation close to donors.

# Action points
Provide donors with a personal record of their donations that is updated each time they donate blood.
Establish an efficient donor records and recall system to call up donors on a regular basis: Establish an appointments system, encourage donors to make an appointment for their next visit at the time of donation and send a reminder in advance of the appointment Identify and use the donor's preferred method of communication including letter, email and SMS/text messaging Send each donor a birthday card, encouraging them to mark another year of their life by donating blood.
Communicate with donors on an individual basis or through organizations to which they belong to remind them to donate regularly.
Establish a panel of blood donors with rare blood groups and inform them of the importance of their blood group.
Encourage donors to donate their blood when donations are expected to be low during holiday periods or in times of blood shortages.
Encourage donors to join or form blood donor networks and Club 25 programmes and promote voluntary blood donation and organize blood drives in their educational institutions, workplaces or communities.
Monitor the donation patterns of regular and repeat donors and set targets to improve rates of donor retention to match clinical requirements for blood.
Conduct donor satisfaction surveys to assess the extent to which the blood transfusion service is meeting donors' expectations.
Invite donors' suggestions on ways to improve the donor recall system, access to blood donation sessions and the quality of donor care.

# Strategy 15
Recognize blood donors' contribution to society
Voluntary blood donors donate blood for altruistic reasons and receive no reward except personal satisfaction in helping to save lives and improve the health of individuals they will never meet. While they choose to donate their blood out of a sense of social responsibility, recognition of the importance of their individual donations and appreciation by the blood service and wider community help to create a sense of belonging to a special group of people.
Even longstanding donors may need to be reminded of the very tangible difference they have made to other people's lives by donating their blood and through their wider role in society as role models and agents of health promotion.
Donor recognition and awards are important strategy in donor retention but should not undermine the concept of voluntary blood donation. Any tokens of recognition should be of the kind that will be appreciated by donors but have no monetary or exchange value that might serve as an incentive to donate. Benefits that attract individuals who would otherwise not donate blood essentially constitute a paid system with all the attendant dangers of donors withholding information about health or lifestyle issues in order to gain the incentive.

# Action points
Provide small tokens of recognition for donors, such as pens, badges, pins, caps and keyrings that have no monetary value, but that acknowledge their important role as life-savers.
Establish a system of "milestone" awards, such as certificates, for donors who have achieved a specified number of donations: 10, 25, 50, 75 and 100 donations.
Hold awards ceremonies for long-standing voluntary donors and involve them in public events and media campaigns for special events such as National Blood Donor Week and World Blood Donor Day.
Provide opportunities for transfusion recipients to interact with blood donors and potential donors to share their stories about the impact of transfusion on their health.
Recognize and appreciate individuals who have contributed to the blood donor programme even if they are not eligible to donate blood because of their age or health status.

# Goal D
Provide quality donor service and care
The principle "First do no harm" is fundamental to blood donation. While the blood transfusion service is responsible for ensuring the provision of an adequate supply of safe blood and blood products, it is equally responsible for protecting the health and safety of its blood donors who provide its most important resource. This requires a safe environment and service-oriented culture with quality systems and professional, trained and donor-focused staff.
The blood transfusion service is dependent on the goodwill and motivation of its blood donors. Whether they are first-time donors or those who have given blood before, quality in donor service and care starts long before donors enter a blood donation session. Available research on donor motivation commonly indicates that convenience in donating blood is a major factor in donor recruitment and retention and that the accessibility of blood centres, the times at which they are open and waiting times can have a direct impact on donors' ability to donate and their attitudes and behaviour. The introduction of mobile donor sessions to take the service into the community is a key approach to increasing access and making it more convenient for people to donate blood.
Donors should feel safe, valued and reassured that donating blood will not cause them any harm and that their blood will be handled and used carefully to help patients. Once donors enter the blood centre or mobile session, the quality of the donation experience and the personal care and attention given to them has a direct influence on donor satisfaction. This is critical for donor retention and plays an important role in building donor trust and long-term commitment. Investing time and resources in donor recruitment may be largely wasted if the blood transfusion service is unable to provide a professional service and quality care for donors that meet their expectations.

# a b c d

# Strategy 16
Make it convenient for donors to give blood
One of the key factors in attracting both new and repeat donors is how easy it is for them to donate blood with as little disruption to their normal lives as possible. While there are many factors that may act as barriers to donation, inaccessible locations and time constraints are deterrents to all but the most determined and committed donors. Factors that may contribute to donors' perceptions of inconvenience include the distance to a donation venue, the time and expense involved in reaching it, difficulty with transportation and the time needed away from work or social activities. 55 Addressing the problems that donors perceive to be important will go a long way to building donor loyalty and encouraging more regular donation.
A well-publicized fixed blood centre should attract a good number of donors if it is well-sited and is close to the centre of a town with good transport links and parking. Donors can come whenever it suits them and there is generally little peer pressure placed on them to donate. On the other hand, mobile donor sessions (see Strategy 17) can help to overcome many of the problems associated with inaccessible locations, particularly if they take place in the workplaces, educational institutions and communities in which people spend their time.
Even when donation venues are centrally-located and accessible, operating times are an important factor in determining whether they are convenient for donors. Opening hours that coincide with normal school or working hours will mean that many people who are otherwise motivated will be deterred from attending, but extending the hours and opening in the evenings and weekends will enable more people to donate.
Long waiting times and a lengthy donation process will similarly serve as deterrents to those who are faced with time constraints but introducing an appointments system can considerably speed up the flow of donors and enable staffing levels to be planned to match the number of donors who are expected to arrive. Walk-in sessions enable donors to attend whenever it is convenient for them, but an option of making an appointment may appeal to others who wish to plan their days.
Conduct a donor survey to explore the attitudes of donors and potential donors towards the location and operating hours of blood donor sessions.
Extend the opening times of donor sessions, including evenings and weekends, to make them convenient for more donors.
Disseminate information in the local media about the timing and locations of blood donor sessions.
Assign sufficient staff for the expected number of donations to ensure a prompt and efficient service with minimal waiting times for donors.
Streamline the donation process and the flow of donors by making the most effective use of space and time in fixed and mobile sites.
Involve trained volunteers in blood donor sessions to reduce pressure on staff, for example, in dealing with anxious donors, offering refreshments and observing donors during the postdonation period.
Establish an appointments system to prevent delays and promote a steady, manageable flow of donors throughout the session.
Use email or SMS/text messages to contact registered donors and request them to make appointments to donate blood.
Set up a online donor registration system to:
Enable potential donors to request the blood transfusion service to contact them with more information, record their interest in donating blood or make an appointment Enable existing donors to update their personal details, make or change an appointment, check when they are next due to donate or view their donation history.

# Strategy 17
Reach out to donors through mobile donor sessions
The use of mobile donor sessions can dramatically increase the number of donors who are able to attend to donate blood. Blood donation is often not an option for people whose homes or workplaces are not near a blood centre, particularly in small communities and rural areas.
Mobile sessions enable the blood transfusion service to reach out into the communities where people live, work and socialize. Bringing the opportunity to donate blood as close as possible to donors reduces their time and travel costs and makes it easier for them to build blood donation into their regular routines. Blood collection through mobiles may go a long way in attracting new donors and regaining the interest and commitment of infrequent and inactive donors.
Mobile donor sessions can be held in many types of location, from shopping malls and community centres to schools, workplaces and rural communities. An important part of the planning process is to estimate the number of people who are likely to donate in order to decide how far it is worth travelling and to assess the time and costs that will be involved.
Estimates of the number of donors are also needed to plan the allocation of staff and the equipment and consumables that must be taken.
Maintaining a suitable environment at mobile sessions presents specific logistical challenges because of the need for the transportation of staff and equipment, the assurance of safe and hygienic conditions and the maintenance of temperature-controlled conditions for the care of the donated blood. Wherever donors go to donate blood in a mobile session they should be able to experience the same high level of courtesy, safety and care as in a blood centre. Special vehicles with donor beds and blood storage equipment are desirable, but are certainly not essential for effective mobile sessions.
Mobile sessions require particularly careful planning and preparation. The facilities used should be of sufficient size and in a suitable location to allow proper operation. They must be clean and maintained in accordance with accepted health and safety requirements. All potential mobile collection sites should be evaluated to assess their suitability, including the availability of water, sanitation and power supplies as well as facilities in which confidentiality can be maintained, particularly during the donor selection process.
Planning should begin well in advance. Once a programme of mobile collections has become established, it is preferable to plan sessions for several months or a year ahead and, where possible, to schedule repeat visits to the same location every four to six months to enable donors to donate on a predictable, regular basis. The involvement of local partners can often make a major difference to the success of mobile collections. Partner organizations can play an important role in publicizing the donor session, motivating friends and colleagues to attend to donate blood and preparing the facilities. Where sessions are taking place in workplaces, employers can be requested to grant time for donors to attend the donor session and give blood without loss of wages or other benefits.
Since mobile sessions require a high level of organization, monitoring their effectiveness plays an important role in planning future schedules. One of the most important tasks is to select suitable venues that result in good donor turnout and blood collection figures. Venues that attract small numbers of donors or where there is a high rate of donor deferrals or seropositive donations divert resources from more productive locations and may not be cost-effective.

# Strategy 18
Assess donors' suitability to donate blood Donor selection is one of the most important steps in the blood donation process. Its main purposes are to:
Protect donor safety by identifying and deferring donors whose health might be adversely affected by donating blood Identify donors who are eligible to donate and reduce unnecessary donor deferrals Enhance patient safety by minimizing the collection of blood from unsafe donors, such as those with a history of travel to defined areas or practising high-risk behaviour.
The donor selection process also provides reassurance to donors that it is safe for them to donate and minimizes the wastage of resources resulting from the discard of donations that test positive following blood screening.
National, standardized criteria for donor selection should be developed. These should be based on international best practice, national and local epidemiological data on infectious diseases, prevalent risk behaviours, the nutritional and health status of the general population, medical conditions, medications and vaccinations, surgical interventions and local customs, such as tattooing or scarification.
The decision to accept or defer a donor, either temporarily or permanently, is made on the basis of the knowledge and experience of the individual physician or nurse who conducts donor selection. However, the assessment of donors' suitability to donate blood should be made on the basis of the national donor selection criteria and in accordance with standard operating procedures.
The assessment of donor suitability should be undertaken on each occasion that a donor attends to donate blood.
A standardized questionnaire that is designed to obtain information about the donor's health status, medical and travel history and possible risk behaviour should be completed by each donor before donation. The questionnaire should reflect the donor selection criteria and be provided in local languages. Assistance should be provided to any donor who has difficulty in completing the questionnaire. The questionnaire should be used as a basis for pre-donation counselling to make an initial assessment of the donor's eligibility to donate and to provide information on the blood donation process. Pre-donation counselling should also include taking a medical history, including current medications, to assess health factors of importance to the donor and to the recipients of the blood. This should be followed by a simple physical health check, including blood pressure and weight. The estimation of the donor's haemoglobin or haematocrit is an invasive procedure and should be undertaken when all other eligibility criteria have been satisfied.
Donors who do not meet the donor selection criteria should be deferred from donating blood.
Donor deferral may be temporary when the donor is generally healthy but donation has to be postponed to a later date because of current circumstances, such as convalescence from illness, short courses of medication or travel history.
Deferral may be permanent when:
The donor's own health might be adversely affected by donating blood
The donor has a transfusion-transmissible infection or their lifestyle and behaviour expose them to the risk of infection.
Deferral may be indefinite when there is a possible risk of an infection for which no screening test is yet available, such as variant Creutzfeldt-Jakob disease (vCJD).

# Action points
Develop national criteria for blood donor selection to assess the suitability of individuals to donate blood.
Regularly review and, when necessary, update the criteria for donor selection and deferral on the basis of any changes in the epidemiology of infections, haemovigilance data, advances in technology and international best practice. Develop a standardized national donor questionnaire, based on national donor selection criteria and in different languages, as required, to record the donor's medical history, health check, risk factors, if any, and informed consent at each donation.
Train staff to use the donor questionnaire and follow standard operating procedures throughout the donor selection process.
Widely disseminate information about the criteria for donor selection in donor information and education materials and in media and public information campaigns to encourage self-deferral by unsuitable donors and reduce the need for donor deferral at the blood donor session.
Provide written or verbal information to donors before donation in order that they can make an informed decision on whether or not to donate.
Maintain donor confidentiality throughout the donor selection process:
Provide suitable facilities to ensure auditory and visual privacy during interviews with donors Treat all donor information as confidential and reassure donors that the information they provide and the results of any tests on their blood will be kept confidential Develop a system to maintain confidentiality of donor information, including the identification of blood units by unique donation numbers or codes, not by the name of the donor.
Introduce a system for confidential unit exclusion, such as a form or a confidential telephone call-back system, to enable donors who may be under pressure to donate to request that their blood should not be used for transfusion.
Provide donors with contact details so they can report if they develop any significant infection or illness in the weeks after they donate.

# Strategy 19

# Provide blood donor counselling
The service has a duty of care to deferred donors by informing them of the reason for their deferral and referring them for further investigation, treatment and support, if required. Identifying and counselling donors who might benefit from available medical interventions is the responsibility of all donor selection and care staff. It is unethical to let a deferred blood donor who has been found to have morbidly high blood pressure or severe anaemia during the pre-donation medical check-up walk out of the blood centre without advice on what to do or where to go to get help. Similarly, donors whose responses to the pre-donation check suggest they may be at risk of having or acquiring transfusion-transmissible infections should be given information about infections, how they are transmitted, the implications for their health and opportunities for treatment, if needed. They should also be counselled on how to maintain a healthy lifestyle and avoid future risk behaviour. Donors who have suffered reactions to donation should be counselled on the reasons for the reaction, advised on whether they should seek further medical treatment and followed-up to check that they have recovered from the incident.
Post-donation counselling and referral services should also be provided for individuals whose donations test positive for transfusion-transmissible infections in order to confirm their test results and establish their true infectious status. The blood transfusion service's policy on the management of individuals identified as seropositive for transfusion-transmissible infections should be consistent with the national policy on notification and referral. Donors may be notified either verbally or in writing about their test results. Blood transfusion services may choose to notify all donors regardless of the test results or only those donors with reactive/ positive test results. Post-donation counselling for a transfusion-transmissible infection should be conducted as soon as the results are available.
All deferred donors should be counselled and treated with sensitivity, care and understanding and donor confidentiality should be maintained. Counselling should be provided at a reasonable and understandable pace in a language with which the donor is familiar and in a culturally sensitive manner. It should take place in a private location to ensure that donor information is kept confidential.
The quality of care and counselling provided to deferred donors will directly influence their attitudes towards blood donation in the future. Donors who are deferred often experience fear about their health or a sense of rejection, frustration and disappointment. Temporarily deferred donors are less likely to return to donate after the period of deferral than donors who are not deferred, often because of fear of being rejected again or unfavourable opinions about the blood transfusion service.  Negative feelings associated with temporary deferral can sometimes be reduced by explaining the reasons for deferral, informing donors when they may be eligible to donate blood again and encouraging them to do so. Fixing an appointment for them to donate after a suitable period of time may help to motivate them to return. Regular donors who value their identity as blood donors are more likely to return after temporary deferral than new donors and those who have donated only once or twice. 59 Donors who have been permanently deferred may welcome a different role as advocates for voluntary blood donation, even though they are unable to donate themselves, or involvement in other health promotion activities.

# Action points
Develop protocols for the management and counselling of donors who are temporarily or permanently deferred.
Train all staff involved in donor counselling in implementing standardized procedures based on these protocols.
Provide specialist training for staff who are responsible for the post-donation counselling of donors who are seropositive for a transfusion-transmissible infection.
Develop information materials for deferred donors on medical conditions that require deferral, how to maintain healthy lifestyles and sources of further information, support and care.
Establish a system for:
Referral of deferred donors to their doctors or appropriate medical services for follow-up, investigations and treatment, when necessary Post-donation notification, counselling and referral of seropositive donors and linkages with specialist clinical services.
Engage deferred donors in continuing to support the blood transfusion service by encouraging other people to donate blood.

# Strategy 20
Make blood donation a safe and pleasant experience Donating blood should be a positive experience. Donors' assessments of the quality of the overall donation experience play a crucial role in their decisions on whether to return for future donations. Maintaining a pool of satisfied donors who return regularly requires a donorfocused culture in the environment, the blood donation process and the service provided. Unprofessional, unfriendly or unsafe donor service and care are obvious deterrents, particularly for first-time and relatively inexperienced donors. Staff and volunteers should always be welcoming and friendly, with a positive attitude and ability to interact effectively with donors.
A smart, clean appearance and high standard of personal hygiene are essential.
Donors may be apprehensive about the procedures that will be involved, particularly what may appear to be intrusive questioning about very personal matters during donor selection. For many people, especially first-time donors, the venepuncture is a source of uneasiness or fear. All staff involved in the blood donation process should be trained to anticipate and respond to the concerns and anxieties of donors.
Volunteers, particularly if they are blood donors themselves, can play an important role in welcoming new and apprehensive donors, guiding them through the donation experience and providing information and reassurance. They can also assist in non-technical areas such as providing refreshments and making appointments for donors to return for their next donation. All volunteers should receive training in the functions they perform.
The collection of blood must always be performed in a controlled way using sterile, disposable lancets, blood collection bags and needles. Venepuncture should be performed only by staff who have been trained in the procedure. They should take all possible precautions and follow standardized procedures to maintain hygiene and prevent bruising, haematoma and other avoidable reactions while collecting blood as these are potential deterrents to the return of donors. Staff should be trained to maintain needle safety and reassure donors that the blood collection procedure is safe and there is no risk of contracting an infection.
Simple measures can be introduced to minimize donor reactions, such as providing donors, with fluids to drink immediately before donation 60 and drawing attention away from the blood collection procedure by engaging them in conversation. Young donors in particular, benefit from fluid intake before donation. There is some evidence to suggest that, in addition to the obvious importance of technical skills, the interpersonal skills of the phlebotomist may directly influence the rate of donor reactions. 61 Even when the good quality care is provided, some donors may experience discomfort or reactions such as dizziness, sudden weakness or fainting during or immediately after donation. Donor reactions have a significant detrimental effect on the likelihood of subsequent donations. 62 The way in which they are managed may determine whether donors remain motivated to donate blood in the future or leave with a negative attitude and loss of trust in the blood transfusion service. All staff and volunteers working in the blood donation area should not only be well-trained but also retrained at regular intervals in preventing, recognizing, managing and recording all adverse donor events and reactions.

# Action points
Create a pleasant, comfortable and donor-friendly atmosphere in all facilities used for blood donation and ensure that they are safe, clean, hygienic and tidy.
Ensure that staff who perform venepuncture are qualified to perform the procedure and are trained to follow standardized procedures.
Train all staff in interpersonal communication and donor care skills to provide reassurance to donors that donor health and safety are paramount.
Train staff to follow universal safety precautions throughout blood collection, including using a standardized aseptic technique, maintaining hand hygiene and disposing of waste safely.
Provide donors with fluids before donation to reduce the risk of vasovagal reactions.
Provide comfortable donor beds or couches.
Provide post-donation refreshments in an area in which donors can be observed for any postdonation reactions.
Train all staff and volunteers to follow standard operating procedures for monitoring donors during and after donation.
Provide regular training for staff and volunteers in preventing, recognizing, managing and reporting donor reactions, including first aid and cardiopulmonary resuscitation.
Establish a system to record, investigate and take corrective and preventive action for all adverse donor events, including errors, accidents and donor reactions.
Follow up all donors who have experienced an adverse event to check whether they require further advice, support or care.
Train staff to thank every donor when they have completed their donation and encourage donors to make an appointment for their next donation.
Conduct regular donor satisfaction surveys and seek feedback and suggestions for improvement: for example, through a feedback form or suggestions box.
Investigate and respond to all donor complaints promptly and take action to prevent their recurrence.
Monitor blood donor sessions systematically to identify ways of improving the service provided to donors.

# Global calls for action on voluntary non-remunerated blood donation World Health Assembly Resolutions
The importance of voluntary blood donation has long been recognized on the global health agenda at the highest political level. As long ago as 1975, in resolution WHA28.72 (),the World Health Assembly urged its Member States to promote the development of national blood services based on the voluntary non-remunerated donation of blood. It also called on them to enact effective legislation governing the operation of blood services and to take other actions necessary to promote and protect the health of blood donors and the recipients of blood and blood products. The resolution requested the World Health Organization to increase assistance to Member States in the development of national blood services based on voluntary donations, when appropriate in collaboration with the League of Red Cross Societies, the forerunner of the International Federation of Red Cross and Red Crescent Societies.
Subsequent World Health Assembly resolutions have also addressed the issues of blood safety and availability. In 2000 and 2003, the safety of national blood supplies was recognized as a key element of HIV/AIDS prevention and, in 2002, in ensuring the quality of care and patient safety. In 2005, in resolution WHA58.13, WHO Member States endorsed the establishment of World Blood Donor Day as an annual event to be held on 14 June to recognize the important role that voluntary blood donors play in the health sector and the wider community. The wideranging resolution specifically identified voluntary, non-remunerated blood donation as the cornerstone of a safe and adequate national blood supply and called on all Member States to establish or strengthen systems for the recruitment and retention of voluntary, blood donors and the implementation of stringent criteria for donor selection. In 2007, resolution WHA60.18 recognized the need to support and foster the active engagement of communities, civil society and the public in health promotion -a role that is epitomized by voluntary blood donors who lead healthy lifestyles and promote them to others.
Resolutions on blood safety and availability have also been adopted by the governing bodies of the WHO regional offices for the Americas in 1999 and for Africa in 2001.
To support the implementation of this strategy, the WHO Blood Transfusion Safety programme provides Member States with policy guidance through norms, standards, guidelines and recommendations on all aspects of national blood programme development. It also fosters collaboration and partnerships at global, regional and national levels and capacity building through technical support, training and materials. It is assisted by the WHO Expert Advisory Panel on Blood Transfusion and a network of WHO Collaborating Centres, blood transfusion services, collaborating organizations and individual experts from all regions.
WHO supports countries in creating an enabling environment for 100% voluntary blood donation through advocacy and guidance on the development of national blood policies and ethical and legal frameworks and the development of training and learning materials on blood donor recruitment and donor care.
The WHO Global Database on Blood Safety (GDBS) was established to monitor trends and progress in global blood safety and availability, including voluntary blood donation. The data reported by countries provide the best available information on blood transfusion services in Member States and enable countries to monitor their own progress in relation to regional and global trends. Data have been collected and analysed for the periods 1998-1999, 2001-2002-2005, the annual collection of blood safety indicators was initiated. Regional data are also reported by the WHO Regional Office for Africa and the WHO Regional Office for the Americas/Pan American Health Organization. These data provide an important mechanism for monitoring the effectiveness of strategies to achieve 100% voluntary blood donation and their impact on the sufficiency and safety of national blood supplies. Unless otherwise indicated, the WHO Global Database on Blood Safety and Blood Safety Indicators are the source of all data cited in this document.