Blood Feud
Are non-commercial blood collectors and commercial plasma collectors competitive rivals? In this Quarterly, we explore whether this is more myth than reality
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What is the economic relationship between the noncommercial blood and the commercial plasma sectors?
One view, popular among those who work in blood collection, is that they are rivals. They are competing over the same, limited pool of donors.
They think that they are like Blockbuster video when Netflix showed up.
Blockbuster was a very popular movie rental store. It was worth billions, had millions of customers, and thousands of locations when Netflix arrived in 1997. But you had to drive to the store to rent the movies and return them three days later or else pay late fees.
Netflix was more convenient. You selected the movies you wanted and got them in the mail. It was cheaper. And there were no late fees.
The result was predictable. Give the average person an option to choose between convenient and cheap Netflix or inconvenient Blockbuster with its late fees, and the average person will pick Netflix.
That’s what happened.
Blockbuster went bankrupt quickly thereafter:
Many worry that this is the right analogy for blood and plasma collectors.
Blood organizations seem to think that if you give the average person a choice between donating blood for milk and cookies or donating plasma and getting 20 Euro or U.S.$50 in return, the average person will donate plasma.
Many influential organizations have said the same.
For example, the World Health Organization, The European Blood Alliance, and the American Red Cross, have all said this.
World Health Organisation1, the European Blood Alliance2, and the American Red Cross3 have all said this.
They use strong language. They say plasma collection will “compromise,” “erode,” even “cannibalize” blood collection.
That’s what my students think too when I ask them. They say most people will follow the money, that it’s simple economics.
But is it true?
My first clue came from a follow-up question I’d ask my students. I ask those that have donated blood if they would switch to plasma. Some say they would.
But the vast majority say they wouldn’t.
It takes too long, they say. The commitment is too much. They like donating blood two or three times a year and no more.
Meanwhile, when I ask the students who had never donated blood or plasma why they hadn’t, some say they’re scared of needles, but most say they didn’t know it was important or needed. That no one asked them to.
They weren’t unwilling, they were just unaware.
These responses give us an alternative possible view to the dominant one:
Instead of plasma centers competing with blood centers, could they help improve awareness and make donating a substance of human origin more ordinary and normal?
To illustrate, let’s consider Farragut Square in Washington DC.
It was surrounded by restaurants when food trucks started to show up in 2014. It was a few at first, but then it was more than 20!
What do you think happened to the restaurants?
Most predicted doom. Food trucks were more convenient, had more variety, and were cheaper. How can restaurants compete?
That’s what the restaurants thought. And so they fought hard to try to pass laws to make it illegal for food trucks to park in the Square, and lobbied for different rules and regulations.
But their lobbying failed, and the trucks kept coming.
Did the food trucks compromise, erode, or cannibalize the restaurants?
No. The restaurants did just fine, thank you very much. Not one restaurant had to close. In fact, four new restaurants opened in Farragut Square thanks to the food trucks.
How?
The food trucks increased the foot traffic of hungry customers in Farragut Square, and food trucks appealed to different people than the restaurants did.
Instead of rivals, they turned out to be complements!4
So which analogy better fits blood and plasma donation? Is it like Blockbuster and Netflix, or is it more like Farragut Square?
What does the actual evidence say?
So far, in every country for which we have good data, the situation looks a little more like Farragut Square than it does Blockbuster Video.
Let me give you some examples.
The Bayerische Red Cross from Germany presented data at the International Plasma Fractionation Association Conference in 2019. They showed data from the INGOLSTADT area, from Wurzburg, and, as you can see in the image, from Bayreuth as well.5
The plasma centers did not negatively impact blood donations. Not anywhere.
They concluded that there was no “crowding out” in Germany
Dr. Franz Weinauer, the former medical director of the Bavarian Red Cross said the same thing.
He told The Source magazine that "Blood and plasma donors are not part of the same donor population." Plasma donors were younger, while blood donors were older.6
The most recent data we have from the Paul Ehrlich Institute shows that plasma donations increased by 12.7% from 2022 to 2023. Did this hurt non-compensated blood donation?
No. Blood donations also increased by 2.6%.7
The Czech Republic tells a similar story. When commercial plasma collectors arrived in late 2006, the public blood and plasma collector was worried.
But they didn’t need to worry.
Between 2007 and 2010, plasma donations increased more than sevenfold:
Whole blood donations, the red line in the graph, remained stable throughout.
More remarkably, non-compensated plasma donations, the yellow line, increased alongside commercial plasma donations!
Milan Maly drew my attention to a 2019 Czech study that tracked individual donors in the city of Brno which had one public blood collector and one private plasma collector.
Early on, more people switched from the public to the private collector, but that trend reversed by 2012. Today, overall more people switch from donating plasma at the commercial center to donating blood at the public center in Brno:
Before Canadian Blood Services partnered with Grifols for plasma collection in Canada, they asked blood collectors in Germany, Austria, Hungary, and Czechia if blood donations decreased because of commercial plasma collections.
The "Bottom line" answer was “no”:8
The story is much the same in Canada and the United States.
My colleague and I investigated the situation in Canada. We found no negative effect in the three cities that saw the introduction of commercial plasma centers in 2016 and 2017. Instead, there was a small, but statistically significant, positive effect.
For every 1,000 plasma donations, there were an extra 80-100 blood donations.9
If there’s going to be a negative effect anywhere, it will be in the United States. Just look at the growth of commercial plasma centers!:
There are 1,255 centers in the U.S., or a center for every 271,000 Americans! That’s more than anywhere else in the world. (See America’s plasma contribution to the world).
Canadian Blood Services asked managers of 17 blood centers in the U.S. if the commercial sector was impacting their blood collection activities.
Most said that it “makes sense” to think that plasma would negatively impact blood donations, but they had no analysis. Two thought it “seems to exist,” but they had no evidence.
They thought it was Blockbuster and Netflix.
My colleague and I followed our analysis of Canada by looking at a much larger data set of 39 cities in the U.S.
What did we find? The cities with plasma collection collected no less blood than cities without plasma collection, and the cities that saw plasma enter did no worse either.
Again, there was no negative impact on blood donations.
Instead, there was a very small, but statistically significant, positive effect — an extra 8-16 blood donations for every 1,000 plasma donations.
Evidence from the countries that allow the commercial sector to operate consistently points towards plasma collection growing the donor pie, not taking slices from the blood sector.
So then why?
Why does evidence suggest blood and plasma are more like the complements dynamic of Farragut Square than the rivalry dynamic of Blockbuster and Netflix?
And why does almost everyone wrongly assume that they are rivals?
Let me close with two preliminary answers.
Why might they be complements?
I suspect the commercial plasma sector increases awareness and helps normalize donating substances of human origin.
My marketing colleagues call this the Advertising Spillover Effect. Nike ads boost Reebok sales because it reminds someone they need new running shoes, not just Nike shoes.
But why does it “make sense” to think commercial plasma centers will take whole blood donors?
Again, maybe my students can give us a clue to the answer.
Each year, I ask my students to fill out a motivation survey. The survey asks them two questions. The first asks them to rank order from a list of 8 options what motivates them from most to least. Four of the options are intrinsic motivators, while the other four are extrinsic.
Here is an example of how my students answered this recently:
My students tell me that what motivates them the most is “Accomplishing something worthwhile,” and “Doing something that makes you feel good about yourself.”
The survey then asks each student to rank order the motivators from the same list but for the other students in the class.
Here are those answers:
The results are dramatically different.
What motivates me? Doing something worthwhile. What motivates you? Money.
This is a well-documented psychological bias: We project an overly simplified, money-driven motivation onto others.
Donating blood and donating plasma are profoundly meaningful. It saves lives.
Commercial plasma centers appear to increase the total number of people who become willing and able to donate.
Noncommercial blood centers appear to sometimes benefit from the larger donor pool, and nowhere have they been compromised, eroded, or cannibalized.
Where does this leave us?
The pandemic was the first big shock around the world, including in Europe. The recent policy shifts in the United States threaten to be yet another shock for Europe.
To deal with these shocks, we need to move beyond the rivalry assumption, and refocus on the shared mission.
The mission of collecting blood and plasma isn't to promote altruism, community solidarity, jobs or profits. These might be nice bonuses, but the primary point is to meet the critical needs of patients.
Continuing a feud based on a likely flawed assumption isn’t helping patients.
What we need is to explore ways to coexist, maybe cooperate, and to acknowledge that we need both sectors.
Note: I presented a longer version of the above on May 14 for UNITAR (my presentation begins around the 1:11:40 mark of the video), as well as at the European PPTA meeting in Warsaw on May 19.
THE BIG THREE
(I’ll post Octapharma and Kedrion results when they issue their annual reports, so it’s just the “Big Three” this time)
Ig revenue is up by double-digits for Takeda, Grifols, and CSL.
Takeda released their FY2024 Q4 results on May 8, showing Ig revenues up 11.5%. Grifols issued their FY2025 Q1 results on May 12, reporting a 13.2% rise in Ig revenues. (Biotest, now part of Grifols, also released results on May 12 showing a 10.2% rise in revenues for their new Ig product, Yimmugo). As mentioned in the last Quarterly, CSL’s FY2025 1H results showed a 15% increase in Ig revenue.
Takeda is rolling out their Fresenius Kabi Adaptive Nomogram in U.S. centers which is showing a ~11.9% increase in per donor plasma collection. CSL Plasma, which uses the RIKA plasma donation system, rolled out that system’s iNomi nomogram to 220 centers. They report it is increasing plasma volume by an average of 10%.
OTHERS
April 28: ADMA received FDA approval for their yield improvement technology which is increasing Ig yields (how much immunoglobulin they can fractionate from a liter of plasma) by around 20%.
PRESENTATIONS
Matthew Hotchko presented at the EDQM Plasma Supply Continuity Conference on March 26, and 27. He reported that plasma collections have rebounded and have reached new records in 2023 and 2024. Global collections are now in excess of 90 million liters. Here is one of his slides:
May 14: UNITAR hosted an event entitled “Donor health in focus: Advancing safety and sustainability in plasma donations” (sponsored by Takeda). My talk (“Ending the Blood Feud: Rivals or Complements?”), the text of which opened this Quarterly, begins at 1:11:40 in this video (YouTube)
NEWS
The most anticipated news this past quarter was a documentary podcast by BBC World hosted by journalist Kathleen McLaughlin. The documentary was released on May 25 and is provocatively titled “America: The Human Plasma Factory.” Despite the provocative title, the documentary is balanced, and makes for a good introduction to the world of plasma for people who don’t know about it. This is in contrast to McLaughlin’s book Blood Money, which was much less balanced.
March 10: UK patients are finally receiving some therapies made from UK plasma. Since 2021, when the ban was lifted, 250,000 liters have been collected in England. The NHS hopes to reach 25% self-sufficiency in Ig this year and 80% in albumin next year.
Apr 22: The Paul Ehrlich Institute reported increases in blood and plasma donations in Germany in 2023. As mentioned above, whole blood donations are up 2.6%, while plasma for fractionation donations rose 12.7%.
Apr 23: Ukraine's Biopharma Plasma announced plans for a (€37 million) fractionation facility in Romania focused on immunoglobulin (1.2 million liters)
May, 2025: Spanish Immunologists released a Position Paper on plasma collection in Spain. The Paper urges Spain to be more serious about plasma collection, including by looking at introducing fixed-rate compensation as practiced in Germany and Austria, and as is permitted under the new SoHO regulations. The Paper was covered by La Vanguardia on May 6. Titled, “Immunologists warn about Spain’s external dependence on blood products, drugs from human plasma,” the article reads:
A group of experts presented this Tuesday the report 'Necessary measures in the face of an unsustainable situation', a document in which they ask to guarantee the production and access to blood products, while warning about the external dependence that Spain has on this type of drug. (Translated by Google Translate)
May 13: The European Blood Alliance released a position paper of their own entitled “Blood is a Gift.”
The European Blood Alliance has updated its position on Voluntary Unpaid Donation (VUD), highlighting its profound importance to the quality and safety of blood, the safety and well-being of donors and patients, and the sustainability of the collection and supply system for all blood components.
The paper has a paragraph on “crowding out” that reads (page 8):
“There are concerns around the ‘crowding out’ hypothesis, where the introduction of payments for plasma donations may negatively impact donations from internally motivated donors remain. Of note, Canada, when introducing a paid plasma donation system alongside an unpaid blood and plasma collection system in 2023, included contractual controls to mitigate Canadian Blood Services’ ‘encroachment concerns’ while Hungary introduced legislation imposing mandatory blood donations for paid-plasma donors.”
Yes, there are such concerns, though I tried to explain why these concerns are unfounded in my opening.
May 26: (EU Observer) “Pay in Blood: The worrying EU dependency on U.S. plasma”
June 11: (CNS) Italy discussed their plasma collections in 2024. They are up over 906,938 liters, representing an increase of 3% in plasma collections from 2023. However, demand for Ig rose by 3.6% in 2023, and it’s likely that demand will again increase by more than 3%. If so, then Italy’s self-reliance will fall further behind (it stood at 64% in 2022, 62% in 2023, but 56% in 2020).
June 15: (Sunday Star-Times) In “Why plasma donors are real life-savers,” the New Zealand Blood Service requests 4,000 new plasma donors over the next 12 months in order to avoid further behind in plasma collection. In 2024, New Zealand was 81% self-reliant, down from 82% in 2023, and 89% in 2020.
OTHER NEWS
Uzbekistan joins the growing list of countries that are adopting a compensated plasma collection system with one company, Haematech, already operating centers there. Since 2020, Ukraine, parts of Canada, and Egypt have all shifted to compensated plasma collection with other countries actively considering doing the same (I discussed some of this in the last Quarterly).
Thank you for reading!
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“Payment for the donation of blood (including donations of plasma and cellular components) not only threatens blood safety, it also erodes community solidarity and social cohesion that, on the contrary, can be enhanced by the act of voluntary non-remunerated donation. By placing an onus on under-privileged populations in need of money, it also compromises the development of a voluntary, non-remunerated blood donor programme. There are concerns that sufficient safe donations and sustainable supply, availability and access to blood and blood products based on VNRBD may be compromised through the presence of parallel systems of paid donation.” WHO Expert Group, “Expert Consensus Statement on achieving self-sufficiency in safe blood and blood products, based on voluntary non-remunerated blood donation (VNRBD),” 2012.
“Payments to blood and plasma donors by commercial suppliers erode the current community-based, non-remunerated, donor population, which is the key element to secure a sustainable blood supply. In countries with dual systems (where unpaid and paid collection coexist), blood establishments who collect components for transfusion encounter increasing difficulties in recruiting and retaining unpaid donors.” European Blood Alliance, Fact sheet, “European self-sufficiency for blood components and plasma for fractionation,” Oct., 2016.
“Intensifying the risk of too few eligible donors is the rapid proliferation of paid plasma collections and the potential cannibalization of volunteer blood donations. Plasma collections in the U.S. have nearly quadrupled since 2005. Both volunteer and paid plasma collections are important contributors to healthcare, however, U.S. paid plasma collections far exceed the U.S. demand for the resulting therapies.” Chris Hrouda, President, Biomedical Services, American Red Cross, “Open letter to the health care community,” Oct. 19, 2019.
There’s evidence to suggest that in general food trucks help, not hurt, restaurants. See Food Truck Truth study, Institute for Justice, 2022
IPFA presentation, “Plasma Collection Facilities and Logistics — international experiences, Germany,” 2019.
Paul-Ehrlich Institut publishes report on Notifications in accordance with Section 21 of the Transfusion Act for 2023, Paul Ehrlich Institut, March 7, 2025.
“Navigating complexity: Ensuring security of supply of PDMPs in the Canadian context,” Jean-Paul Bédard, Vice-President, Plasma Operations Canadian Blood Services, IPFA presentation, January, 2020.
“The Introduction of paid plasma in Canada and the U.S. has not decreased unpaid blood donations,” Jaworski, English, 2020