The objective of PEPFAR's support to the Malawi Blood Transfusion service (MBTS) is to reduce the incidence of HIV and other diseases transmissible by blood transfusion in the Malawi population. The MBTS will use year one funds to consolidate prior PEPFAR investments in the blood transfusion services of Malawi. We will use FY-10 funds to expand services that assure national coverage of safe blood interventions in the country.

MBTS is a nationally coordinated blood service and was established in 2004 with initial funding from the European Union. Currently, MBTS is funded by the Malawi Government and the Global Fund for AIDS Tuberculosis and Malaria (GFATM) through National AIDS Commission to collect, test, process, and store and distribute blood and blood products to hospitals in Malawi. However, the current funding level does not allow MBTS to fully meet the country need for blood and blood transfusion services.

MBTS accepts blood donations only from voluntary non-remunerated blood donors from low risk population groups. Donated blood is tested by using highly sensitive and specific reagents and techniques in a quality assured manner for: HIV, Hepatitis B and C, syphilis and malaria. MBTS prepares five blood products: whole blood, adult and pediatric red cell suspensions, platelet concentrates, fresh frozen plasma and cryoprecipitate.

Most hospital blood banks (HBBs) do not have the capacity and the infrastructure to order, store, cross match and issue safe blood to individual patients. Modern transfusion medicine was not adequately covered during the undergraduate training of practicing medical doctors, laboratory technicians, nurses and clinical officers, before the establishment of MBTS. There was no provision for the training of the Health care Workers and for advocacy on appropriate clinical use of blood. The blood supply is also characterized by blood shortages during school holidays as 80% of blood donors are the youth in schools and colleges. There are no guidelines on the appropriate clinical use of blood and blood products among other challenges.

PEPFAR's funding seeks to improve the infrastructure and capacity of Central and District-Level Hospital Blood Banks and promote the appropriate Clinical Use of Blood and Blood Products to prevent the transmission of HIV and other infectious agents through blood transfusion. With increased PEPFAR funding in FY2010, MBTS will scale-up its activities. In addition, MBTS will coordinate the development of blood safety policies and procedures and national guidelines for appropriate clinical use of blood and blood products as well as the expansion of blood collection through promotion of increased donor pools of voluntary, non-remunerated, low-risk blood donors.

The specific objectives of PEPFAR'S funding are: • Improve the infrastructure of Central and District-Level Hospital Blood Banks through rehabilitation of hospital blood banks and provision of basic blood bank equipment; • Strengthen the national capacity in blood safety through in-service and pre-service training of Health Care Workers (Laboratory technicians, nursing and clinical staff) already enrolled in colleges and those working in Central and District-Level Hospitals; • Promote quality assurance system through establishment and implementation of a National Quality Assessment Scheme (NQAS), development of Standard Operating Procedures (SOPs) and monitoring and evaluation of performance. • Support the expansion of blood collection through promotion of increased donor pools of voluntary, non- remunerated, low-risk blood donors. • Support the development of blood safety policies and procedures and national guidelines for appropriate clinical use of blood and blood products.

The program contributes to HIV prevention which is the priority area of the National Action Framework and the Malawi Growth and Development Strategy (MGDS). The strategy of the program improves the quality and access to services supported by the GFATM and Malawi Government and supports the PF goals of reducing new HIV infections and health system strengthening through support in laboratory services and training of human resources for health. The availability, appropriate use and adequate safe blood supplies also supports Millennium Development Goal (MDG) number 4 and 5, "Reducing Child mortality and improve maternal health respectively". Currently, over 67% of transfusions are carried out in children and mothers who are the most vulnerable and in need for HIV/AIDS prevention, treatment, and care services.

The program is contributing in building a sustainable, safe and adequate blood supply system for the country through improvement of the functionality of HBBs and training health care workers. The improved infrastructure, human capacity and the NQAS will support blood safety activities in the future with minimal maintenance. The trained undergraduate biomedical students will need minimal follow up after graduation. PEPFAR's support for expanded donor pool of voluntary, non-remunerated, low-risk blood donors will ensure continuity of supply of adequate and safe blood.

Budget Summary PFIP Year 1 Funding - $250,000 PFIP Year 2 Funding - $1,140,000

Budget Code: HMBL $250,000 - Year 1 $1,140,000 - Year 2

With PFIP year 1 funds we expect to implement the following activities:

• Rehabilitate 10 hospital blood banks and provide them with basic but critical blood bank equipment • Train 140 Health Care Workers (30 laboratory technicians, 50 nurses, and 20 clinicians from the District-Level Hospitals whose blood banks will be rehabilitated and 40 undergraduate students of biomedical sciences) and tutors from training colleges in appropriate use of blood and modern blood transfusion medicine. • Establish quality assurance systems in 10 hospitals whose blood banks will be rehabilitated and enroll them into the National Quality Assurance Program.

These activities will be continued in PFIP year 2. The National Quality Assessment Program (NQAP) is a program established using PEPFAR funds in 2006. It is a program through which MBTS assesses the competence of hospital blood banks in carrying out immuno-hematological testing. Currently 29 out of 54 hospitals are participating in the program. With the additional funds the program will be extended to all 54 hospitals in the next two years (10 in year 1 and 15 in year 2).

Activity 1: Rehabilitate 10 hospital blood banks and provide them with basic but critical blood bank equipment

With funding from GFATM through NAC and Malawi Government, the MBTS, collects blood, tests for transfusion-transmissible infections, prepares blood and blood products, stores and distributes or supplies blood and blood products to all hospitals in Malawi that include Central and major district and mission hospitals (district-level hospitals) in accordance with WHO standards. However, the quality and safety of processes for storage, cross-matching, issuing and clinical use does not meet the required standards in most of the hospitals that have not yet been reached by this program. Currently, only 29 out of 54 hospitals have functional HBB as a result of this program. There is need to improve the infrastructure and quality systems in the other hospitals. With FY-10 funds from PEPFAR the MBTS will rehabilitate 10 hospital blood banks and provide them with basic blood bank equipment. Specific targets are government and Christian Health Association of Malawi (CHAM) or mission hospitals that serve the poor, rural and vulnerable populations including women and children who are the population groups receiving over two thirds of all transfusions in the country. The program will be extended to other hospitals in subsequent years.

Activity 2: Train tutors from training colleges and 100 Health Care Workers (30 laboratory technicians, 50 nurses, and 20 clinicians) from the District-Level Hospitals whose blood banks will be rehabilitated in appropriate use of blood and modern blood transfusion medicine

It is essential to equip the staff with the appropriate knowledge and skills in blood safety and modern transfusion medicine. In-service training for 30 laboratory technicians, 50 nurses, 20 clinical officers, medical doctors and tutors from training colleges will continue. These will essentially come from the 10 hospitals whose blood banks will be rehabilitated and a few others from the facilities that were rehabilitated in previous years. Training of 40 undergraduate students of biomedical sciences will continue as well. These students will come from training colleges in the country and those attached to the hospitals referred to in the above activities.

Activity 3: Establish quality assurance systems in 10 hospitals whose blood banks will be rehabilitated and enroll them into the National Quality Assurance Program -

Since the establishment of in the National Quality Assessment Program (NQAP) in 2006 with funding from PEPFAR, 29 hospitals whose blood banks were rehabilitated participate in the program. Through this program, MBTS assesses the competence of hospital blood banks in carrying out immuno- hematological testing. MBTS will establish the quality assurance systems in the 10 hospitals whose blood banks will be rehabilitated and enroll them in the NQAP. MBTS will also continue to monitor and provide support to the current 29 hospitals already enrolled in the NQAP in their quality assurance activities.

$1,140,000 - Year 2

MBTS will continue implementing year 1 activities. Increased funding in PFIP year 2 will enable MBTS to scale-up the activities. In addition, MBTS will support the expansion of blood collection through promotion of increased donor pools of voluntary, non-remunerated, low-risk blood donors and to support the development of blood safety policies and procedures and national guidelines for appropriate clinical use of blood and blood products.

Activity 1: Rehabilitate 15 additional hospital blood banks and provide them with basic but critical blood bank equipment

MBTS will scale up rehabilitation to cover the remaining 15 hospitals blood banks in order to reach all 54 hospitals that transfuse blood in the country.

Activity 2: • Train 165 Health Care Workers (20 laboratory technicians, 75 nurses, and 30 clinicians from the District-Level Hospitals whose blood banks will be rehabilitated and 40 undergraduate students of biomedical sciences) and tutors from training colleges in appropriate use of blood and modern blood transfusion medicine

In-service training for laboratory technicians, nurses, clinical officers and medical doctors from the 15 hospitals whose blood banks will be rehabilitated including tutors from training colleges will continue. Another cohort of 40 undergraduate students of biomedical sciences will be trained.

Activity 3: Establish quality assurance systems in 15 hospitals whose blood banks will be rehabilitated and enroll them into the National Quality Assurance Program

15 additional hospitals will participate in the National Quality Assessment Program bringing the total to 54 hospitals (100%).

Activity 4: Support the expansion of blood collection through promotion of increased donor pools of voluntary, non-remunerated, low-risk blood donors

The increased resources in FY2010 will allow MBTS to strengthen its blood donor associations, mainly the Blood Donor Association of Malawi (BDAM) and its youth wing, The Malawi Club 25, to recruit and retain more adult blood donors nationally and to retain more young blood donors particularly those out of school. The target is to recruit 50 new adult blood donors around each of the 41 district hospitals. This is important in addressing the blood scarcity that occurs during school holidays. 6,500 out of school youths will be retained in the 3 cities of Blantyre, Lilongwe and Mzuzu. Preliminary data suggests that 60% of the Malawi blood supply is voluntary and non-remunerated. With FY2010 funds, the percentage will increase to 70 as Malawi progresses to meet the WHO target of 80% voluntary and non remunerated blood by 2012. It is expected that Malawi will have established its baseline blood supply by the end of 2009 calendar year.

Activity 5: Support the development of blood safety policies and procedures and national guidelines for appropriate clinical use of blood and blood products

Hospital transfusion committees will be strengthened nationally starting with all central hospitals. Through these committees national guidelines on the appropriate clinical use of blood and blood products will be finalized and published. PEPFAR funds will be used to print and distribute copies of the guidelines to all institutions and officials involved in the blood transfusion services.

The establishment of transfusion committees will sustain the administration of transfusion services in hospitals beyond the funding period. The guidelines will be used for many years with revisions that may not be costly. MBTS will monitor the number of new adult blood donors recruited; the number of out of school youths retained, the number of blood units collected during school holidays and publication of guidelines on the clinical use of blood and blood products to determine the achievement of the activities

number 4 and 5.