Cambodia Blood Safety Project Represents Collaborative Model for Successful Implementation of Health System Strengthening Efforts
A blood safety project in Cambodia has emerged as an effective model for coordinated international co-operation in development that has delivered strong results in capacity building, critical infrastructure and equipment, and human resources, with the direct results being improved blood safety across this Southeast Asian nation of nearly 16 million people.
Launched in 2013 with support from the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) and the U.S. Centers for Disease Control and Prevention (CDC), the project is managed by the American International Health Alliance (AIHA) and implemented by the Australian Red Cross and Blood Service, which had been working with the Cambodian Blood Service since 2011.
The project management model aligns the funding and development priorities of the Government of Cambodia, PEPFAR, and CDC with those of the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund); the World Health Organization (WHO); and the U.S. Pacific Command (US-PACOM). AIHA and the Australian Red Cross Blood Service worked not only to deliver the core activities of the Cambodian Blood Safety Project, but also to promote coordination among all stakeholders to help achieve the common goal of safe and sufficient blood for all patients in Cambodia.
Over the course of the project, key achievements include new clinical guidelines for blood use, revised donor selection guidelines, new donor counselling guidelines, and improved testing algorithms — all supported through a comprehensive training program comprised of more than 35 education and training sessions. Additionally, the Australian Red Cross Blood Service trained more than 500 staff, implemented 40 standard operating procedures (SOPs), and worked in consultation with local partners to ensure these documents were developed in accordance with Good Manufacturing Practice (GMP) and were essential in supporting the longer term goal of accreditation for the Cambodian blood service. Where possible, train the trainer sessions were included as part of the training to assure sustainability and the transfer of knowledge and skills to new staff over time.
“To see the changes within the laboratory and represented in the monitoring data is brilliant, especially when you know what it means for the patient at the other end. Minimising the spread of infection through blood transfusion is so important because treatment, even when it is available, is so difficult to get, so preventing transmission in the first instance will make such a significant difference to the recipient’s quality of life,” says Ms. Linda Nicolo, Australian Red Cross Blood Service Humanitarian Project Scientist.
“Cambodian Blood Service staff want to do things better and are only limited by their resources, training, and funding,” Ms. Nicolo explains. “To be able to bridge that gap for them, to guide them and present them with qualified methods to improve the availability, quality, and safety of blood is an extraordinary chance for their doctors to be able to treat their patients reliably and effectively using these products. It’s all about quality of life and patient treatment — that’s our mission!”
Echoing her colleague’s enthusiasm, Dr. Sally Thomas, Australian Red Cross Blood Service Director for International Services, acknowledges the significance of this achievement: “The success of the program reflects the amazing support and commitment of all the technical assistance partners, as well as the Cambodian Ministry of Health and Cambodian blood service, who have worked together with incredible dedication and enthusiasm to make a real difference.”
The results speak for themselves. In 2016, more than 65,000 units of blood were collected nationally, a 36 percent increase (17,000 units) from 2012 when the project started. In 2012, 8 percent of donated blood tested positive for a transfusion transmissible infection (TTI) such as HIV, HBV, HVC, or syphilis; in 2016 the TTI rate had decreased to 5.6 percent. Cambodian hospitals were also primarily only transfusing whole blood with limited availability of specific components for directed therapy. In 2016, more than 70 percent of the blood supplied by the National Blood Centre in Phnom Penh was components, contributing to better therapeutic outcomes after transfusion.
In 2014, a shift in PEPFAR priorities to focus on assisting blood services to achieve accreditation and implement blood bank information management systems meant that project support for clinical blood use and voluntary non-renumerated blood donation (VNRBD) ceased. However, the partnership approach to blood safety in Cambodia has meant that other partners, including US-PACOM, Global Fund, and WHO have been able to provide support in these areas.
US-PACOM support to the Cambodian Blood Service has been fundamental in assisting them to meet crucial in improving the standards and capacity of facilities in the country’s blood system. In collaboration with the U.S. Army Corps of Engineers (USACE), US-PACOM provided financial support for the oversight and construction of three new state-of-the-art blood banks in Phnom Penh, Siem Reap, and Kampong Cham. Two more facilities will be constructed in Takeo and Battambang provinces in 2017-2018. New facilities in these key provinces will assist to increase the quality and accessibility of blood in remote areas of the country.
US-PACOM also provided critical equipment for the blood service and continues to be a key contributor to ongoing professional education and development for transfusion staff, providing one blood-related workshop per year covering an identified topic of interest or priority.
“The [construction] has been very successful due in large part to US-PACOM’s commitment to a multi-year effort to build out the needed infrastructure to properly house the blood banks,” says Mr. Scott Olson of the U.S. Army Corps of Engineers (USACE). Mr. Olson has been overseeing construction of schools, health posts, referral hospitals, and the blood banks through USACE’s humanitarian assistance program since 2012.
US-PACOM support has continued to provide seamless delivery of project activities in Cambodia with strong integration with the Cambodian government, the National Blood Service, and technical assistance partners. As a result, the new buildings comply with GMP standards and are culturally fit for purpose. “Hand in hand with that is USACE’s ability to work with subject matter experts like the Blood Service to develop standard designs and ensure proper building materials were used, such as homogenous vinyl flooring and anti-microbial paint ,” Mr. Olson explains, noting that this also assured the sites were set up to facilitate proper operations and work flow, from greeting potential donors, to interviewing them, to blood collection, and last, but certainly not least, laying out the laboratories to ensure blood product fidelity.
Mr. Olson says the accomplishments of the project are closely linked to the open collaboration and sharing of information among partners, the National Blood Service, and the Cambodian Government. “From our perspective, the projects would not have been nearly as successful without all the various partnerships, such as US-PACOM’s commitment to the buildings, the staff training, and supplying many of the consumables necessary for a blood bank to operate properly,” he says, stressing the important role CDC, the Australian Red Cross Blood Service, and the Cambodian Blood Service also played in helping to develop the most functional buildings possible.
Recognizing that the provision of the latest technology blood analysers and other equipment is critical for assuring quality within the blood service, the Australian Red Cross Blood Service technical experts advised the Cambodian Blood Service on its site-level equipment requirements and specifications. They also helped manage inputs from US-PACOM and the Global Fund to ensure procurement of fit-for-purpose equipment and avoid duplication of effort, and maintained a dialogue with government authorities who oversee the provision of reagents and testing kits.
This highly successful collaboration among multiple and diverse partners can be largely attributed to open communication, the sharing of a common goal and strategic directive to identify where each could “fill the gaps,” and a willingness to provide the missing pieces for ongoing improvement.
“One example of this is in blood service accreditation, which ensures safe and quality blood products can be provided to Cambodian people,” says the Australian Red Cross Blood Service Program Manager for International Humanitarian Blood Projects Ms. Emily Tonks. “US-PACOM is building state-of-art blood bank facilities that meet building requirements for accreditation, PEPFAR has been funding activities to support the Cambodian blood service in reaching minimum level accreditation standards, and the Global Fund has provided funding to assist with the hospital and VNRBD aspects of accreditation,” she explains.
“All relevant partners openly share, actively communicate, and collectively drive toward a common goal per the National Blood Transfusion Services Strategic Plan 2013-2017,” says Dr. Ly Vanthy, Deputy Director for CDC/Cambodia based in Phnom Penh. “The project has been successful through the implementation of international standard blood bank facilities equipped with the latest technology analysers and equipment to provide high quality of blood services in Cambodia. All are recognized by [the Royal Government of Cambodia], the Ministry of Health, and health partners.”
With myriad diverse actors, including local governments, international and civil society organizations, foundations, the private sector, and bilateral and multilateral funding agencies all working in the international health systems strengthening arena, it’s not uncommon to have multiple projects duplicating efforts or even working at cross-purposes.
The CDC-supported blood safety project in Cambodia represents an effective and collaborative model for uniting multiple actors to achieve a common objective — ensuring a safe and sufficient blood supply for all patients in the country in 2017 and well into the future.
The activities described in this article are supported by the US Centers for Disease Control and Prevention (CDC) under Cooperative Agreement Number 1U2GGH000861. The contents of this document are solely the responsibility of the authors and do not necessarily represent the official views of the CDC, the US President’s Emergency Plan for AIDS Relief, or the US Government.