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Blood for sale case study

Blood for sale: India’s illegal ‘red market’

One of the hospital’s security guards has instructed us to look for a man with one leg.

We find the tout, Rajesh, sitting on a tattered blanket next to a tea stall drinking milky tea from a flimsy plastic cup as monkeys traverse electrical lines overhead.

Posing as the relatives of an accident victim, we tell him we need three units of blood.

“Three thousand rupees ($48; £30) per donor,” Rajesh says. “I’ll arrange everything.”

Selling blood and paying donors in India is illegal, but across the country, a vast “red market” proliferates.


Blood is in chronic short supply in India, according to the World Health Organization (WHO), which stipulates that every country needs at least a 1% reserve.

India, with its population of 1.2 billion people, needs 12 million units of blood annually but collects only 9 million – a 25% deficit.

In summer, the shortfall often hits 50%, leading to a spurt in professional donors cashing in on the needs of desperate patients.

Rajesh used to be a housepainter, but after losing his leg in an accident and spending months recovering at this hospital, he realised he could earn commissions by supplying donors to those in need of blood transfusions in exchange for cash.

Rotary Blood Bank is India’s largest blood bank but the country does not have a central blood collection agency

India’s lack of a central blood collection agency, along with taboos against exchanging blood with people of different castes, largely accounts for the shortage, experts say.

It fuels a vast illegal market, despite a 1996 Supreme Court ruling that banned paid donors and unlicensed blood banks.

Little has changed since then. Demand still outstrips supply. Private blood banks are legal as long as they obtain a government licence for $120 (£80).

The illicit market in blood has simply moved underground, or in some cases, into the realms of the macabre.

Caged for their blood

In 2008, Hari Kamat, an impoverished artisan from the state of Bihar, was rescued along with 16 other people from a “blood farm” in the town of Gorakhpur, close to India’s border with Nepal.

The victims, all poor migrants, were lured to a house on the pretext of being given jobs and were then convinced to sell their blood for the princely sum of $7 per unit.

“Initially, they did it willingly,” says Neha Dixit, who covered the story for Tehelka magazine.

“But when I met Hari Kamat in the hospital recuperating, he said that after a while, they became too weak to resist and when they had the energy to try and escape, they were beaten and locked up.”

Hari and the others were forced to give blood three times per week for a period of two and a half years. The Red Cross says donors should give blood only once every eight to 12 weeks.

They were never paid the amount they were promised, and received only a token sum.

“It was actually like a dairy,” says Ms Dixit. “These people were caged, not given enough food and their blood was extracted 16 times a month.”

Ms Dixit says the blood was then sold to local hospitals and blood banks for $18 a unit – 15 times the government rate. Some private blood banks were accused of being complicit, putting official stamps and barcodes on these bags of blood.

Professional donors

There are no official statistics on how large India’s illegal blood market is or how many such farms have been uncovered.

But if we were to take as a rough calculation the three million units needed in India, multiplied by its street value of $15, that suggests that it could be worth as much as $45m (£30m).

Experts say that even many legal, licensed blood banks, who don’t necessarily pay for blood themselves, still tolerate professional donors.

“You can see by the number of pricks on the arm that they’re a professional donor, but the blood banks don’t bother, they look the other way,” says Sudarshan Agarwal, president of the non-profit Rotary Blood Bank in New Delhi.

The 1996 judgement led India to implement a system of “replacement donors”. Patients needing blood from a hospital would first have to provide donors from amongst family or friends – a separate donor for each unit of blood required.

The idea was to promote altruistic donation. But patients continue to turn to touts, especially if they need multiple units of blood and cannot arrange multiple donors.

“Some patients travel from faraway places. They have no family or friends nearby,” says Asha Bazaz, chief technical officer for the Rotary Blood Bank.

“Even if you live here, you have to take time off work, travel across town and the experience in many blood banks is not good.”

Health risks

In rural areas, the situation is far more grim.

“I’ve seen patients being transfused directly from a donor, without any testing of their blood,” says Dr JS Arora, general secretary of the National Thalassemia Welfare Society.

In these areas, unregulated blood banks flourish or patients buy packs of blood directly from touts operating near hospitals. Rarer blood types fetch higher prices.

The resulting situation is life-threatening for millions of people.

Eight-year-old Alok Kumar wolfs down potato curry in the waiting room of a charity clinic early one Sunday morning.

He suffers from thalassemia, a genetic blood disorder so serious it requires monthly transfusions for life.

This summer, Alok contracted Hepatitis C from a poorly screened transfusion in a government hospital where he qualifies for free care. Hepatitis C, if not properly treated, can lead to cirrhosis of the liver or cancer.

“Already, we are struggling to cope,” says his father Kishore Kumar, who earns $120 per month. “I’m so angry – how could they make my child sicker?”

Widespread problem

The National Thalassemia Welfare Society estimates that 6-8% of its own patients contract diseases, including HIV, through transfusions. Professional donors are usually drawn from India’s impoverished population and are at higher risk of HIV, hepatitis and other diseases.

In 2013, two thalassemic children died and 21 others were diagnosed with HIV after a single, unlicensed blood bank was found to be transfusing patients without testing in Junagadh, Gujarat, reported the Indian Journal of Medical Ethics.

Even legal blood banks contribute to the overall problem.

State-of-the-art private hospitals charge up to $65 per unit, not for the blood itself, which is illegal, but for processing and testing. They also require replacement donors.

In March 2014, public interest litigation filed in Ahmedabad, Gujarat, where voluntary blood donation levels are high, revealed that local blood banks had earned up to $1.9m by selling on blood components.

They had collected blood for free from voluntary donors, but rather than sharing stocks with poorer hospitals, they had profited handsomely.

Non-profit blood banks, like those run by the Lion’s Club or Rotary, charge between $38 and $45 per unit of blood, enough to cover the costs of running voluntary donor camps and offering high-end disease screening. But their services are concentrated in big towns and cities.

For hundreds of millions of impoverished Indians, paying for blood, particularly safe blood, is simply unaffordable. With supplies still woefully low, the system of touts is unlikely to disappear soon.

Until the government establishes a nationwide system of donor-friendly camps, where volunteers can give blood safely and comfortably, combined with uniform and rigorous testing facilities, it’s unlikely India’s blood market will disappear.

“There is this attitude now that you can pay money and get whatever you want,” says Neha Dixit of Tehelka.

“If you’re part of the urban, middle-class elite, you know you can afford it. The rest of India is not so lucky.”

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Blood safety and availability

Blood transfusion saves lives and improves health, but many patients requiring transfusion do not have timely access to safe blood. Providing safe and adequate blood should be an integral part of every country’s national health care policy and infrastructure.

WHO recommends that all activities related to blood collection, testing, processing, storage and distribution be coordinated at the national level through effective organization and integrated blood supply networks. The national blood system should be governed by national blood policy and legislative framework to promote uniform implementation of standards and consistency in the quality and safety of blood and blood products.

In 2018,72 % of reporting countries, or 123 out of 171, had a national blood policy. Overall, 64% of reporting countries, or 110 out of 171, have specific legislation covering the safety and quality of blood transfusion, including:

  • 79% of high-income countries
  • 63% of middle-income countries
  • 39% of low-income countries.

Blood supply

About 118.4 million blood donations are collected worldwide. 40% of these are collected in high-income countries, home to 16 % of the world’s population.

About 13 300 blood centres in 169 countries report collecting a total of 106 million donations. Collections at blood centres vary according to income group. The median annual donations per blood centre is 1 300 in the low-income countries, 4 400 in lower-middle-income countries and 9 300 in upper-middle-income countries, as compared to 25 700 in high-income countries.

There is a marked difference in the level of access to blood between low- and high-income countries. The whole blood donation rate is an indicator for the general availability of blood in a country. The median blood donation rate in high-income countries is 31.5 donations per 1000 people. This compares with 15.9 donations per 1000 people in upper-middle-income countries, 6.8 donations per 1000 people in lower-middle-income countries, and five donations per 1000 people in low-income countries.

62 countries report collecting fewer than 10 donations per 1000 people. Of these, 34 countries are in the WHO African Region, four in the WHO Region of the Americas, six in the WHO Eastern Mediterranean region, three in the WHO European Region, six in the WHO South-Eastern Asia Region, and nine in the WHO Western Pacific Region. All are low- or middle-income countries.

Blood donors

Age and gender of blood donors

Data about the gender profile of blood donors show that globally 33% of blood donations are given by women, although this ranges widely. In 14 of the 111 reporting countries, less than 10% of donations are given by female donors.

The age profile of blood donors shows that, proportionally, more young people donate blood in low- and middle-income countries than in high-income countries. Demographic information of blood donors is important for formulating and monitoring recruitment strategies.

Types of blood donors

There are 3 types of blood donors:

  • voluntary unpaid
  • family/replacement
  • paid.

An adequate and reliable supply of safe blood can be assured by a stable base of regular, voluntary, unpaid blood donors. These donors are also the safest group of donors as the prevalence of bloodborne infections is lowest among this group. World Health Assembly resolution WHA63.12 urges all Member States to develop national blood systems based on voluntary unpaid donations and to work towards the goal of self-sufficiency.

Data reported to WHO shows significant increases of voluntary unpaid blood donations in low- and middle-income countries:

  • An increase of 7.8 million blood donations from voluntary unpaid donors from 2013 to 2018 has been reported by 156 countries. The highest increase of voluntary unpaid blood donations is in the Region of the Americas (25%) and Africa (23% ). The maximum increase in absolute numbers was reported in the Western Pacific Region (2.67 million donations), followed by the Americas (2.66 million donations) and South-East Asia (2.37 million).
  • 79 countries collect more than 90% of their blood supply from voluntary unpaid blood donations (38 high-income countries, 33 middle-income countries and eight low-income countries). This includes 62 countries with 100% (or more than 99%) of their blood supply from voluntary unpaid blood donors.
  • In 56 countries, more than 50% of the blood supply is still dependent on family/replacement and paid blood donors (nine high-income countries, 37 middle-income countries and 10 low-income countries).
  • 16 countries report collecting paid donations in 2018, around 276 000 donations in total.

Blood screening

WHO recommends that all blood donations should be screened for infections prior to use. Screening for HIV, hepatitis B, hepatitis C, and syphilis should be mandatory. Blood screening should be performed according to quality system requirements. Of reporting countries, 12 are not able to screen all donated blood for one or more of the above infections.

99.8% of the donations in high-income countries and 99.9% in upper-middle-income countries are screened following basic quality procedures, as compared to 82% in lower-middle-income countries and 80.3 % in low-income countries. The prevalence of transfusion-transmissible infections in blood donations in high-income countries is considerably lower than in low- and middle-income countries (Table 1).

Table 1. Prevalence of transfusion-transmissible infections in blood donations (Median, Interquartile range (IQR)), by income groups

HIV HBV HCV Syphilis
High-income countries 0.001% 0.01% 0.06% 0.01%
(0% – 0.01%) (0.003% – 0.13%) (0.002% – 0.05%) (0.002% –0.11%)
Upper middle-income countries 0.10% 0.29% 0.18% 0.34%
(0.03% – 0.23%) (0.15% – 0.62%) (0.06% – 0.35%) (0.11% –1.08%)
Lower middle-income countries 0.19% 1.96% 0.38% 0.69%
(0.03% – 0.77%) (0.76% – 5.54%) (0.03% –0.80%) (0.16% – 1.25%)
Low-income countries 0.70% 2.81% 1.00% 0.92%
(0.33% – 1.66%) (2.00% – 4.50%) (0.50% – 2.23%) (0.60% – 1.81%)

These differences reflect the variation in prevalence among population who are eligible to donate blood, the type of donors (such as voluntary unpaid blood donors from lower risk populations) and the effectiveness of the system of educating and selecting donors.

Blood processing

Blood collected in an anticoagulant can be stored and transfused to a patient in an unmodified state. This is known as ‘whole blood’ transfusion. However, blood can be used more effectively if it is processed into components, such as red cell concentrates, platelet concentrates, plasma and cryoprecipitate. In this way, it can meet the needs of more than one patient.

The capacity to provide patients with the different blood components they require is still limited in low-income countries: 37% of the blood collected in low-income countries is separated into components, 69% in lower-middle-income countries, 95% in upper-middle-income countries, and 97% in high-income countries.

Supply of plasma-derived medicinal products (PDMP)

World Health Assembly resolution WHA63.12 urges Member States to establish, implement and support nationally coordinated, efficiently managed and sustainable blood and plasma programmes, according to the availability of resources, with the aim of achieving self-sufficiency. It is the responsibility of individual governments to ensure sufficient and equitable supply of plasma-derived medicinal products, namely immunoglobulins and coagulation factors, which are needed to prevent and treat a variety of serious conditions that occur worldwide.

Only 55 of 171 reporting countries produce plasma-derived medicinal products (PDMP) through the fractionation of plasma collected in the reporting country. A total of 90 countries reported that all PDMP are imported, 16 countries reported that no PDMP were used during the reporting period, and 10 countries did not respond to the question.

Around 25.6 million litres of plasma from 39 reporting countries was fractionated for the production of PDMP during the year. This includes around 47% of plasma recovered from the whole blood donations.

Clinical use of blood

Unnecessary transfusions and unsafe transfusion practices expose patients to the risk of serious adverse transfusion reactions and transfusion-transmissible infections. Unnecessary transfusions also reduce the availability of blood products for patients who are in need.

WHO recommends the development of systems, such as hospital transfusion committees and haemovigilance, to monitor and improve the safety of transfusion processes. In this regard:

  • 128 countries have national guidelines on the appropriate clinical use of blood: 32 countries in the African region (74% of reporting countries in the region), 22 in the Americas (67 %), 13 in the Eastern Mediterranean (68 %), 33 in Europe (80%), nine in the South East Asia (90 %), and 19 in the Western Pacific (76%).
  • Transfusion committees are present in 50 % of the hospitals performing transfusions: 65% in hospitals in high-income countries, 35% in upper-middle-income countries, 31 in lower-middle-income countries and 25% in low-income countries.
  • Systems for reporting adverse transfusion events are present in 57% of the hospitals performing transfusions: 76% in hospitals in high-income countries, 35% in upper-middle-income countries, 22% in lower-middle-income countries and 18% in low-income countries,
  • 49% of reporting countries have a haemovigilance system. The European region has the highest percentage of countries with haemovigilance systems (83%), followed by the Western Pacific (48%), the Eastern Mediterranean (47%), Africa (40%), South-East Asia (40%), and the Americas (21%).

Blood transfusions

There are great variations between countries in terms of age distribution of transfused patients. For example, in high-income countries, the most frequently transfused patient group is over 60 years of age, which accounts for up to 75% of all transfusions. In low-income countries, up to 54% of transfusions are for children under the age of 5 years.

In high-income countries, transfusion is most commonly used for supportive care in cardiovascular surgery, transplant surgery, massive trauma, and therapy for solid and haematological malignancies. In low- and middle-income countries it is used more often to manage pregnancy-related complications and severe childhood anaemia.

WHO response

The risk of transmission of serious infections, including HIV and hepatitis, through unsafe blood and chronic blood shortages brought global attention to the importance of blood safety and availability. With the goal of ensuring universal access to safe blood and blood products, WHO has been at the forefront to improve blood safety and availability, and recommends the following integrated strategy for blood safety and availability:

  • Establishment of a national blood system with well-organized and coordinated blood transfusion services, effective evidence-based and ethical national blood policies, and legislation and regulation, that can provide sufficient and timely supplies of safe blood and blood products to meet the transfusion needs of all patients.
  • Collection of blood, plasma and other blood components from low-risk, regular, voluntary unpaid donors through the strengthening of donation systems, and effective donor management, including care and counselling.
  • Quality-assured screening of all donated blood for transfusion-transmissible infections, including HIV, hepatitis B, hepatitis C and syphilis, confirmatory testing of the results of all donors screen-reactive for infection markers, blood grouping and compatibility testing, and systems for processing blood into blood products (blood components for transfusion and plasma derived-medicinal products), as appropriate, to meet health care needs.
  • Rational use of blood and blood products to reduce unnecessary transfusions and minimize the risks associated with transfusion, the use of alternatives to transfusion where possible, and safe and good clinical transfusion practices, including patient blood management.
  • Step-wise implementation of effective quality systems, including quality management, standards, good manufacturing practices, documentation, training of all staff, and quality assessment.

WHO supports countries in developing national blood systems to ensure timely access to safe and sufficient supplies of blood and blood products and good transfusion practices to meet patient needs. WHO provides policy guidance and technical assistance to countries for ensuring universal access to safe blood and blood products and work towards self-sufficiency in safe blood and blood products based on voluntary unpaid blood donation to achieve universal health coverage.

*Data source: This fact sheet is based on data obtained through the WHO Global Database on Blood Safety from 108 countries for the year 2018. To give a more complete overview of the global situation, data for the year 2017 have been used for 40 countries and data for the year 2015 have been used for 23 countries, where current data are not available. Overall, responses received from 171 countries cover 97.5 % of the world’s population.