South African Blood Service briefing on services they provide, their challenges & achievements

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Health

13 October 2009
Chairperson: Mr B Goqwana (ANC)
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Meeting Summary

The South African National Blood Service (SANBS) met with the Portfolio Committee on Health to inform them about the services they provided, the challenges they faced and their achievements in order to garner the Committee's support. This was a first meeting between both parties and the Committee appreciated the information shared by SANBS.
The SANBS reported that it was the most prominent blood services organisation in the country, servicing 90% of the population in South Africa in 8 out of 9 provinces. SANBS is an association of voluntary blood donors that provided all patients with sufficient, safe, quality blood products and medical services related to blood transfusions, in an equitable and cost effective manner. SANBS was also accredited with the South African National Accreditation System (SANAS) to enable then to fulfill their vision of being nationally and internationally acknowledged as a centre of excellence in the discipline of blood transfusion.

SANBS' financial concerns were their highest priority and they reported that this could have a severe impact on sustainability and cash flow.  The financial concerns were mainly due to late and non-payments for services, higher private sector prices (sometimes more than 20% higher than public sector prices), medical aids reluctance to pay for some services and  increasing bad debt among non-medical aid patients going to private hospitals. These were just some of the contributors to the significant increase in bad debt.
Other challenges were HIV prevalence among donors, increasing the black donor base, and the collection of group O type blood.

Meeting report

Briefing by the South African National Blood Services
Ms Loyiso Mpuntsha, Chief Executive Officer: SANBS, gave a detailed presentation on the work done by SANBS (see attachment). The presentation looked at the products and services offered, population served, operational costs, supply chain logistics, current and future challenges, business model, strategic plans, research activities, service delivery, business partner and social responsibility, including the solutions they intended implementing to solve problems.

The SANBS was established as a Section 21 Company (not for gain) and they operated on a fee-for-service basis. The SANBS was structured in line with the National Health Act and the key strategies of the Departments of Health, designed to provide equitable service at regional levels that included urban, semi- urban and rural models to distribute blood. The services were delivered upfront and billing was done later with no payment guarantee required up front. Private patients comprised 41% of total patients and their fees included a premium of 20%. Medical aids were reluctant to pay for some services and private hospitals played no part in the invoicing and collection of private patients’ debt for blood transfusion, this lead to late payments and unrecoverable debts .The public sector comprised 59% of the total patients. Provinces and hospitals did not have adequate budget capacity to meet blood services invoicing. The historical model of using services fees and the state budget to meet blood services expenditure was no longer appropriate. The debt cost amounted to R60 million annually.  This would have a major impact on essential service delivery and SANBS' financial sustainability in the near future.
This raised a concern among members.

Mr M Waters (DA) asked about the outstanding balance owed to SANBS by each province and the private sector. 

Mr R Reddy, Chief Operational Officer: SANBS gave a detailed presentation dealing with cost breakdown and indicating how the R60 million debt figure was reached. (see attachment)

Mr M Hoosen (ID) suggested that the SANBS should change their strategy to being that of services offered upon payment instead of services first followed by payment.

This was noted favourably by the SANBS and would be embraced as part of the solutions for the problem. However, emergencies would not be affected. Blood supply in emergencies would continue so that patients’ health was not compromised

Ms Mpuntsha continued with the presentation.

The SANBS provided vein-to-vein blood transfusion and had two testing centres in Johannesburg and Durban, & blood processing centres.  Issuing of blood was via 79 SANBS blood banks using over 400 emergency blood fridges, serving 1000 hospitals and clinics. Blood was processed into components in 7 laboratories using state of the art testing on every donation.  A total of 780 000 units of blood was needed annually and SANBS had 380 000 blood donors which was supplied to 285 000 patients.  High prevalence of HIV continued to present a challenge in collecting low risk blood especially among the 20 to 39 year olds.  12 -14% of blood was discarded due to operating in environments with high HIV and Hepatitis-B Virus prevalence and cases where blood expired.

All collection, processing, storage and testing costs for these almost 100 000 units of blood had to be recovered for the service to be sustainable. There was therefore a need to put more focus on schools in increasing donor numbers among 16 to 19 year olds. A total of 17.5% of the overall blood supply was collected from this age group collected. There were, however, problems with stocks during school holidays, especially in provinces like Kwazulu-Natal, which collected a large proportion from this age group.

Ms T Kenye (ANC) inquired about the HIV window period for blood donors and how infections were detected during that phase.

Mr S Gulube, Medical Director: SANBS, responded said that 3000 units of blood were tested after being donated. Serology tests for HIV, HCV and HBV as well as RNA tests were all conducted to ensure the safety of the blood. This method has proved successful since 2005 wherein vein-to-vein transfusions were performed with no report of AIDS transmission. Other methods such as screening tests using detailed questionnaires were employed as well.

Ms P Tshwete (ANC) asked about SANBS human capital, the number of staff they employed, whether it was enough and how their service coped with the workload.

Ms Mpuntsha answered that SANBS employed 2200 staff and these nurses are provided with training, transformation and skills development using courses accredited through the Health Professions Council being supported by the Health and Welfare Sectoral and Education Training Authority (HWSETA). Other resources included building capacity through management programmes, training of technologists, registered nurses using learnerships to become phlebotomists. A total of 303 registered nurses were employed and this only made up 15% of the numbers, phlebotomists made up 6%, whilst medical doctors accounted for only 1%. The general staff totalled a high of 39% with 816 personnel and the next highest percentage was technologists at 610, accounting for 28% of staff.

Mr Reddy informed members that during March 2008, SANBS experienced a scarcity of registered nurses and as a result undertook to offer training to interested students residing in Johannesburg, Pretoria and Durban. 50 matriculants (with mathematics and science subjects) were taken in and offered classroom training with courses accredited through the Health Professions Council.  These were thereafter employable at the SANBS for a compulsory period of two years. They were also employable in pathology laboratories, hospitals and clinics.

Ms Tshwete asked about the location of the emergency blood fridges, their location and number. 

Mr Reddy responded that SANBS used 89 clinics in 8 provinces and 60 – 70 mobile clinics that operated weekdays from 8am to 6pm. He clarified that 72 hospitals owned fridges and a Memorandum of Understanding was signed with the hospitals concerning this. New fridges were needed to replace the old fridges and this would be completed by March 2010, as SANBS installed 15 fridges per month.
Increasing demand for group O blood in 2009 amounted to 55% of all supplies with approximately 17% for rural areas and emergency use.  Large differences in population prevalence and usage led to many challenges. Group O prevalence amongst whites was 47%, 45% in Blacks and 38% in Asians. A return rate of less than 2 donations per annum was not sustainable hence Kwazulu-Natal with its large Indian donor base, needed to import group O blood from other provinces to meet their demand. The SANBS needed at least 5 – 7 days of group O stock to ensure adequate distribution and stock on blood bank shelves.

Ms A Luthuli (ANC) wanted to know about the low black donor base and its causes, what measures were taken in dealing with the matter and about the challenges in donor retention.

Ms Mpuntsha responded that cultural myths like potency are some of the contributing factors to this problem. The other issue was that of lack of trust by black people due to previous policy and information on how black blood was thrown away after being donated. The SANBS was faced with the challenges of building up that trust, to increase black donor base. Although the number of black donors had steadily increased over the past few years the contribution of donations was not increasing proportionately. In 2005 blood collections from new black donors totalled 11.75%, in 2006 15.58%, in 2007 23.97% and in 2008 rose to 31.79%. SANBS was still had not managed to increase the return rate favourably among black donors. The low retention and repeat rate of donors was a challenge whilst the background issue  of HIV prevalence was being constantly monitored.

Ms M Dube (ANC) posed a question on the compensation for blood donors. She asked if donors were informed of the result of blood tests.

Ms Mpuntsha said that the World Health Organisation (WHO) was against compensation for blood donations but that discounts and cancellation of debts might be offered to donors depending on the situation.

Mr Gulube added that the results for the infected blood were given to the donors by means of calling the donors back to the testing station where they are referred to the doctor for further information. Donors whose status changed were also called in for more questions. Other donor related services included HIV prevention through education at schools, churches and work places in addition to a healthy lifestyle promotion. 

Ms Dube wondered about the issue of imported packaging, specifically whether the same products were not available locally.

Mr S Coffey, Chief Financial Officer: SANBS, replied that there are no local companies that manufactured the kind of packaging they used for their products and that if there local companies who manufactured comparable products, the quality standard and safety was inferior.

Dr S Pillay (ANC) did not understand why patients were billed for blood transfusions if the blood was donated freely.

Ms Mpuntsha clarified that the charges are not for the blood itself but for the processing of it, which included the components added to blood to prepare it and make it safe for transfusion.

Ms Kenye expressed concern about the Western Cape's independence in the blood transfusion department. Ms Mpuntsha had informed her, that in 2000 the Ministry of Health signed an amalgamation which it later withdrew due to unhappiness. The Department   of Health moved to re-look at this situation in past meetings held with SANBS but implementation was still pending.

Ms Kenye pointed to the fact that there were three footprints for Eastern Cape compared to just 1 in the Northern Cape. She wanted to know whether these were determined according to population density.

Mr Reddy said that the footprints were used mainly for the collection of blood and focussed on Upington, Kimberly and Springbok in the Northern Cape. He emphasised that these areas did have blood banks and that large hospitals would have more emergency blood fridges accessible, 24 hours a day. Medical personnel also needed to be educated on how to use blood appropriately so as to minimise wastage, to conserve blood and reduce costs. Hospital Transfusion Committees were formed at major hospitals to promote regular meetings wherein blood related issues were to be discussed and also the giving of reports to hospitals detailing blood usage per ward. The pilot study in Johannesburg and roll out was in progress to other areas.

Research activities are to monitor long term effects of blood transfusion, contribute to the knowledge of science, improve donor selection and retention strategy, reduce donor deferrals, and to improve the understanding of the pathogenesis of Hepatitis B amongst other things.

He added that procurement excellence was achieved in 2009 with an average of 5 days stock for most of this period - hence the SANBS had met targets for the first time in past few years. Zones worked well in managing collection of blood 7 days a week. And SANBS collected 97.8% of O group blood for the months of April to August 2009 and 100.3% for all blood group targets.

Ms Kenye asked about the cold chain maintenance and what precautionary measures were to be taken and when it was appropriate to use cold blood versus warming it.

Mr Gulube pointed that only when blood is being used rapidly should it be warmed; otherwise it is safe to use cold when used slowly.

The Chairperson stated that all unanswered questions should be responded to in writing.

The meeting was adjourned.

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