Republic of the Philippines

REGIONAL OFFICE III

DEPARTMENT OF HEALTH
City of San Fernando, Pampanga
www.ro3.doh.gov.ph

October 26, 2016

Regional Memorandum Circular

No. 2016-011

TO: Lead Blood Service Facilities, Hospital and Non-Hospital Based Blood Service
Facilities, Local Blood Councils, Hospital Blood Transfusion Committee,
Provincial/City/Municipal Health Officers and Barangay Health Stations,
Provincial/City/Municipal Blood Program Coordinators and other concerned

SUBJECT: Regional Blood Services Network (RBSN) Guidelines

I. RATIONALE

Pursuant to Administrative Order No. 2005-0002 dated January 10, 2005 re: Rules and
Regulations for the Establishment of the Philippine National Blood Services Amending
Pertinent Provisions of Administrative Order No. 9 s, 1995 (Rules and Regulations
Implementing R. A. 7719, otherwise known as the Blood Service Act of 1994). Blood
Service Network shall be established to provide for the blood needs of specific geographic
areas in the Philippines through efficient distribution of voluntarily donated blood and
ensuring its availability to all patients, maximizing utilization of available blood and
avoiding its wastages.

All licensed blood service facilities within their catchment areas , government and private
hospital and non- hospital based health facilities performing transfusion, the National
Reference Laboratory, Local Government Units and the community-based volunteer blood
donors shall endeavour to address blood adequacy and safety while maintaining quality care
for both volunteer blood donors and recipients by organizing into Blood Service Networks
each designed to adopt to the unique situation of their localities but nevertheless adhering to
the standards that have been set.

To strengthen the blood services network among different blood service facilities the
National Voluntary Blood Services Program (NVBSP) issued Department Circular No. 2012-
0359, designating Dr. Paulino J. Garcia Memorial Research and Medical Center, Jose B.
Lingad Memorial Regional Hospital and Bulacan Provincial Blood Center as the lead blood
service facilities in Region 3, identifying their roles and responsibilities herein as well as the
shared responsibilities of other blood service facilities in the collection, testing and
processing of blood in their defined service areas. Despite this strategy, maintenance of a
systematically coordinated blood service network remained a great challenge, as our
indicators and analysis of data from monitoring still demand for a more systematic network
on ensuring safe, available and accessible blood supply. Also, there is a need to designate
James L. Gordon Memorial Hospital as one of the lead blood service facilities to augment in
the collection, testing and processing of blood in strategic service areas.

For these reasons, the Department of Health-Regional Office 3 Regional Voluntary Blood
Services Program (DOH-RO 3 RVBSP) aims to establish Regional Blood Service Network
Guidelines to support implementation of Department Circular 2010-0013 (Operational
Guidelines for Blood Service Network in Support to the Implementation of the National
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 Republic of the Philippines

REGIONAL OFFICE III

DEPARTMENT OF HEALTH
City of San Fernando, Pampanga
www.ro3.doh.gov.ph

Blood Services Program for Blood Safety and Adequacy, Quality Care and Patient
Safety) to significantly improve delivery of blood services in Central Luzon and thereby
contribute to the attainment of Sustainable Development Goal (SDG) No. 3: Ensure healthy
lives and promote well-being for all at all ages, maternal mortality reduction and control
spread of HIV/AIDS, among others.

This Regional Administrative Order is in support of the “Revised Implementing Rules and
Regulations of the National Blood Services Act of 1994 (RA 7719 whereby one of its
provisions is the promotion and encouragement of voluntary blood donation by the citizenry
to bring about the supply of safe blood under the National Voluntary Blood Services
Program. It also supports its provision of mobilizing all sectors to participate in the
mechanisms of voluntary and non-profit collection of blood highlighting the critical role of
community involvement to become the main source of low-risk regular volunteer blood
donors.

II. REFERENCES

1. AO 2005-0002 (Rules and Regulations for the Establishment of the Philippine

National Blood Services Amending Pertinent Provisions of AO No. 9 s1995
2. Administrative Order No. 2008-0008 and AO 2008-0008-A (Rules and
Regulations Governing the Regulation of Blood Service Facilities)
3. Administrative Order 2010-0001 (Policies and Guidelines for the Philippine
National Blood Services and the Blood Services Network (BSN)
4. AO 2010-0002 (Guidelines on Establishing a Local Blood Council)
5. Department Circular 2010-0013 (Operational Guidelines for Blood Services
Network in Support to the Implementation of the National Voluntary Blood
Services program for Blood Safety, Quality Care and Patient Safety
6. Department Circular No. 2012-0198 (Guidelines for Referring of Blood Units for
Confirmatory Tests to National Voluntary Blood Services Program-National
Reference Laboratory at Research Institute for Tropical Medicine)
7. Department Circular No. 2013-0132 (National Council for Blood Services –
Technical Committee Recommendations, Strategies, Methodologies and
Algorithms for Testing Blood Units for Transfusion Transmissible Infection)
8. AO 2015-0045 (New Maximum allowable Service Fees for Whole Blood and
Blood Components in Blood Service Facilities
9. Department Circular No. 2012-0359 (Designation of Lead Blood Service
Facilities)

III. OBJECTIVES

General Objective:
To provide guidelines that will govern the operation of the Blood Service Network in
Central Luzon.

Specific Objectives:
To set the guidelines that will:

1. Establish an equitable scheme of distribution and collection of blood;

2. Establish an efficient referral system among Blood Service Facilities (BSFs) in the
Regional Blood Service Network (RBSN);
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REGIONAL OFFICE III

DEPARTMENT OF HEALTH
City of San Fernando, Pampanga
www.ro3.doh.gov.ph

3. Clearly define the roles and functions of different blood service facilities, LGUs and
other members of the community in the RBSN;
4. Guide Blood Service Facilities on the recommended and standard procedures of
testing of donated blood;
5. Establish scheme for data reporting and collection, as well as information sharing
among Blood Service Facilities;
6. Strengthen the implementation of the New Maximum Allowable Service Fees for
whole blood, blood components in Blood Service Facilities;
7. To advocate the conduct of regular community-based Mobile Blood Donations
(MBD) for blood safety, adequacy and efficiency among Blood Service Facilities;
8. Ensure financial sustainability through cost sharing with LGUs (budget
appropriation), cost recovery and grants;
9. Encourage formation of Local Blood Councils (LBC) at all levels (Regional,
Provincial, City/Municipal and Barangay);
10. Ensure an adequate supply of safe blood through voluntary blood donation.

IV. DEFINITION OF TERMS

A. APHERESIS – blood collection procedure in which whole blood is removed, a

selected component separated and the remainder returned to the blood donor.

B. Basic Emergency Obstetric and Newborn Care Facilities (BEmONC)- Are

capable of performing 6 signal obstetric functions which include:
1. Parenteral administration of Oxytocin in the third stage of labor;
2. Parenteral administration of loading dose of anti-convulsants;
3. Parenteral administration of initial dose of antibiotics;
4. Performance of assisted deliveries;
5. Removal of retained products of conception; and
6. Manual removal of retained placenta
BEmONC facilities are also capable of providing neonatal emergency interventions
which include at the minimum:
1. Newborn Resuscitation;
2. Treatment of Neonatal Sepsis/ Infection; and
3. Oxygen Support
It shall also be capable of providing blood transfusion services on top of its standard
functions.

C. BLOOD CENTER (BC) – a non-hospital based blood service facility, licensed by

the DOH -HFSRB, whose main function is to process blood units into blood
components and testing of these units for the five (5) infectious disease markers. It
advocates and promotes voluntary blood donation and healthy lifestyle. It recruits and
cares for voluntary blood donors, collects blood from qualified voluntary blood
donors and conducts health education and counselling. It stores, issues, transports and
distributes units of whole blood and/or blood products to hospitals and other health
facilities.

D. BLOOD COLLECTION UNIT (BCU) – a blood service facility, duly authorized by

the DOH-Regional Office 3 (RO3), whose main function is to collect blood from
volunteer non-remunerated blood donors. It advocates and promotes voluntary blood
donation and healthy lifestyle. It recruits and cares as well as screens and selects for
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REGIONAL OFFICE III

DEPARTMENT OF HEALTH
City of San Fernando, Pampanga
www.ro3.doh.gov.ph

voluntary blood donors and conducts health education and counselling services. It
transports blood to BC for testing and processing. It can also perform compatibility
testing of red cell units if hospital based.

E. BLOOD DONOR REGISTRY – a list of individuals who are registered as blood

donors with their ABO group and Rh type, identity and content information
(complete name, address, telephone number, email-address). Blood donors who have
donated at least once and have committed themselves to be called upon are enrolled.

F. BLOOD SERVICE NETWORK (BSN) – an informal organization established to

provide for the blood needs of specific geographical areas or catchment population. It
is composed of the lead blood service facility/ies, designated blood center, hospital
blood banks, blood collection units, blood stations and end-user hospitals/non-
hospital health facility/ies.

G. BLOOD STATION (BS) – a blood service facility, duly authorized by the DOH-
Regional Office 3 (RO3), whose main function is the storage, issuance, transport and
distribution of whole blood and packed red cells. It advocates and promotes voluntary
blood donation and healthy lifestyle.

H. Comprehensive Emergency Obstetric and Newborn Care Facilities (CEmONC)-

Can perform the 6 signal obstetric functions of a BEmONC and in addition, perform
caesarean section and provide blood banking and transfusion services along with
other highly specialized obstetric services. It is also capable of providing the
following neonatal emergency interventions which include at the minimum:

1. Newborn resuscitation;
2. Treatment of neonatal sepsis/ infection; and
3. Oxygen support; and
4. Management of low-birth weight or premature newborn along with
other specialized neonatal services.

I. END-USER HOSPITAL (EU) – a hospital with a licensed clinical laboratory

capable of red cell typing and cross-matching and which does not have any blood
service facility but which only receives blood and blood components for blood
transfusion as needed.

J. End-User Non-Hospital Health Facility – a licensed/accredited non-hospital health

facility without a licensed clinical laboratory but which administers blood transfusion.

K. FAMILY/REPLACEMENT DONORS - Are those who give blood when it is

required by a member of their own family or community. In most cases, the patient’s
relatives are requested by hospital staff to donate blood, but in some settings it is
compulsory for every patient who requires transfusion to provide a specified number
of replacement donors on emergency admission to hospital or before planned surgery.
Although donors are not paid by the blood transfusion service or hospital, there may
be a hidden paid donation system in which money or other forms of payment are
actually provided by patients’ families. (WHO)

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REGIONAL OFFICE III

DEPARTMENT OF HEALTH
City of San Fernando, Pampanga
www.ro3.doh.gov.ph

L. HAEMOVIGILANCE-
1. It is the identification and prevention of the occurrence and recurrence of
transfusion related unwanted events- to increase the safety, efficacy and efficiency
of blood transfusion, covering all activities of transfusion chain from donor to
recipients (WHO).
2. Defined as the detection, gathering and analysis of information regarding untoward
and unexpected effects of blood donation and transfusion. (Manual of Standards`-
NVBSP).

M. HOSPITAL BLOOD BANK ( HBB) – a blood service facility in a hospital, duly

licensed by the HFSRB/DOH-RO 3 whose service capabilities are storage and
issuance of whole blood and blood components obtained from a Blood Center. It
advocates and promotes voluntary blood donation and healthy lifestyle. It also
provides compatibility testing of red cell units, direct Coomb’s test, red cell antibody
screening, investigation of transfusion reactions, and assist the hospital blood
transfusion committee (HBTC) in the conduct of post-transfusion surveillance
(haemovigilance).

N. HOSPITAL BLOOD BANK WITH ADDITIONAL FUNCTION – a blood

service facility in a hospital, duly licensed by the DOH-HFSRB whose service
capabilities is similar to a BC, provided that the facility meets the requirement for a
BC. It also provides compatibility testing of red cell units, direct Coomb’s test, red
cell antibody screening, investigation of transfusion reactions, and assist the hospital
blood transfusion committee (HBTC) in the conduct of post-transfusion surveillance
(haemovigilance).

O. HOSPITAL BLOOD TRANSFUSION COMMITTEE (HBTC) – a hospital

committee primarily responsible for the formulation of the blood bank and blood
transfusion policies and guidelines, monitoring and audit of the use of blood and
blood components within the facility in accordance with the Manual of Standards for
Blood Service Facilities issued by the DOH. A functional HBTC is a prerequisite for
the licensing or authorization of a blood service facility by the DOH and accreditation
by the Philippine Health Insurance Corporation (PhilHealth).

P. LEAD BLOOD SERVICE FACILITY (LBSF)- a hospital-based or non-hospital-

based facility designated by NVBSP to collect, test, process and supply blood to
hospitals under its network and highly capable of producing large scale blood and
blood products, also tasked with other internal and external functions relative to blood
services as per Department Circular 2012-0359.

Q. LOCAL BLOOD COUNCIL (LBC) – a non-profit, non-governmental, multi-

sectoral group whose members come from government and private sector in the local
community committed to support the blood program. Its objective is to plan and
implement a local blood donation program in accordance to DOH policies and
guidelines as Local Blood Councils

R. MOBILE BLOOD DONATION (MBD), COMMUNITY-BASED BLOOD

DONATION - a blood donation session conducted in a temporary site away from the
location of the Blood Collection Unit or Blood bank/Center.
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 Republic of the Philippines

REGIONAL OFFICE III

DEPARTMENT OF HEALTH
City of San Fernando, Pampanga
www.ro3.doh.gov.ph

S. NATIONAL BLOOD BANKING NETWORKING SYSTEM (NBBNetS) –

electronic health information system that will strengthen a nationally coordinated
network of BSFs.

T. “SAFE” BLOOD DONOR – individual from low-risk population group who

provided a blood donation that was negative on all laboratory screening tests and who
subsequently reported no behavioural risks and donated blood once or more than
twice without receiving any form of cash or in kind.

U. VOLUNTARY NON-REMUNERATED BLOOD DONORS (VNRBD) – donor

gives blood, plasma or cellular components of his or her own free will and receives
no payment, either in the form of cash or in kind which could be considered a
substitute for money. This would include time off work other than that reasonably
needed for the donation and travel. Small tokens, refreshments and reimbursements of
direct travel costs are compatible with voluntary, non-remunerated donation (WHO).

V. STRUCTURAL ORGANIZATION (AO 2005-0002)

1. Regional Blood Service Network shall consist of:

a. DOH- Regional Office III -Regional Voluntary Blood Program Coordinator

b. Provincial/ Municipal Blood Program Coordinators
c. Provincial/Municipal/Barangay Blood Councils and their committees
d. Lead Blood Service Facilities
e. Authorized blood collection units and apheresis facilities: Government, the
Philippine Red Cross ( PRC), or Non-Government Organizations
f. Hospital Blood Banks and blood stations, both government and private
g. Non-hospital based blood stations: government or the PRC
h. End-user hospitals and Non-hospital based health facilities, both government
and private.
i. National Reference Laboratories for Immunology and Immuno-Hematology
and testing of Blood Transfusion Transmissible Infection for blood units.

VI. GENERAL GUIDELINES

a. All provinces shall establish/ operate their Provincial Blood Service Network and use
these guidelines for their operationalization (AO 2010-0001).
b. All Provincial Blood Service Networks shall organize into a Regional Blood Service
Network and shall follow all the provisions of this RBSN Guidelines in their
operation.

VII. SPECIFIC GUIDELINES

A. Inclusion in the Blood Service Network

1. Designated Lead Blood Service facilities (LBSFs) namely Dr. Paulino J. Garcia
Memorial Research and Medical Center, Jose B. Lingad Memorial Regional
Hospital, Bulacan Provincial Blood Center and James L. Gordon Memorial

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 Republic of the Philippines

REGIONAL OFFICE III

DEPARTMENT OF HEALTH
City of San Fernando, Pampanga
www.ro3.doh.gov.ph

Hospital as the LBSFs in Region 3, shall have the overall supervision of all the
blood service facilities within their Zonal Network:
a. Dr. Paulino J. Garcia Memorial Research and Medical Center – Aurora,
Nueva Ecija and Tarlac
b. Jose B. Lingad Memorial Regional Hospital- Pampanga and Angeles City
c. Bulacan Blood Center- Province of Bulacan
d. James L. Gordon Memorial Hospital - Olongapo , Bataan and Zambales
2. By virtue of Department Circular No. 2012-0359, the four (4) facilities shall
supply blood to other hospitals and shall perform their internal and external
functions as the lead blood service facilities in the region. Memorandum of
Agreement (MOA) (ANNEX B) shall be instituted between the LBSFs and the
Satellite Blood Service Facilities to clarify accountabilities/responsibilities of both
parties.
3. Issuance of Certificate of Inclusion shall be issued by the DOH-Regional Office 3
upon the recommendation of the Lead BSF, only if the facility has met the
requirements for the inclusion in the Provincial/ Zonal Blood Service Network
(BSN). For uniformity of implementation, the requirements will be standardized
in the annexes of RBSN Guidelines. Recommendation for inclusion shall be
issued by the Provincial Blood Program Coordinator using the Certificate of
Inclusion Checklist (ANNEX A) in coordination with the Lead Blood Service
Facility and Philippine Red Cross.
4. Blood Service facilities with great capacity to produce as determined by the
provincial BSN may also supply blood to other BSFs within their catchment areas
provided a MOA is established.

B. Operation of Blood Service Network

1. Blood and blood products shall be made available at all times. The availability of
blood is the shared responsibility among the attending physician, the
community and the management and staff of the health facilities (hospitals and
blood service facilities).
2. All BSFs (government, private, or PRC) shall provide adequate, safe and quality
blood and blood products at all times and shall conduct quality assurance in all
aspects of its operation.
3. All Blood Service Facilities shall develop and implement policies and
procedures on blood collection from voluntary non-remunerated healthy blood
donors only.
4. All BSFs are mandated to follow AO 2015-0045 (New Maximum Allowable
Service Fees for Whole Blood and Blood Components in Blood Service
Facilities).
5. Provincial BSN meeting shall be conducted quarterly, spearheaded by the LBSF,
while the Regional Blood Service Network shall be conducted annually,
spearheaded by the Regional Voluntary Blood Program Coordinators.

C. Community Mobilization

1. Community Mobilization through Local Blood Councils (AO 2010-001) (AO

2010-0002) (DC 2010-0013)

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 Republic of the Philippines

REGIONAL OFFICE III

DEPARTMENT OF HEALTH
City of San Fernando, Pampanga
www.ro3.doh.gov.ph

1.1. Every Province through their Local Blood Councils/ILHZ Blood Council
shall formulate their Local Blood Donation Program that fulfils the needs
for blood transfusion in the community.
1.2. Every province and highly urbanized city shall establish a Local Blood
Council that shall support the Regional Blood Service Network
1.3. Local Blood Councils are encouraged to be formed in component cities,
districts, municipalities and barangays.
1.4. The Local Blood Council or established ILHZ Blood Council shall assist
the Provincial Blood Services Network in the following:
a. Participates/Coordinates/ Monitors the implementation of the Local
Blood Donation Program of the province.
b. Plans and implements in public education, advocacy and donor
recruitment activities to promote voluntary blood donation.
c. Conducts an organized and sustained public information campaign to
promote voluntary blood donation.
d. Assists in the recruitment and retention of regular volunteer blood
donors
e. Organizes Mobile Blood Collection activities in coordination with the
Blood Centers, and authorized Blood Collection Units; Government
and Private Hospital and PRC Chapters.
f. Spearheads/ assists in fund-sourcing/ fund raising from within the
community and from external governmental and non-governmental
organizations, financial institutions or agencies.
g. Strengthens the linkages of local hospitals, BEmONC/CEmONC
facilities and Health Facilities with the Lead Blood Service Facilities.

2. Community Mobilization through Local Government Units

2.1. To mobilize all sectors of the community, all LGUs shall endeavour to
attain the criteria/data set by the LGU Scorecard for Blood Voluntary
Program of collecting Blood Donation Rate of 1% (using latest statistics
issued by the National Statistics Office) of the total population in
accordance to Department Memorandum No. 2014-0147. (II. Governance
for Health-Internal Management Support System, letter E, page 8 of 21).
2.2. Municipal and City Blood Program Coordinators shall conduct community
blood donation activity at least two times (2x) a year ,until they meet
the target for Blood donation rate of 1% of the total population (10 blood
donations per 1,000 population) as stipulated in LGU Scorecard.
2.3. The Provincial/Municipal/City Blood Program coordinators shall ensure
that a regular, equitably scheduled community blood donation activities
are conducted by closely coordinating/collaborating with their respective
LCEs, LBSF, PRC, and other BSFs.
2.4. Municipal/City Health Officer shall act as the municipal/city blood program
coordinator with the following functions:
a. To work for the signing of Memorandum of Agreement between LGU
and the identified LBSF.
b. To formulate plan and submit target date of Community Blood
Donation activities to their respective Local Chief Executive
copy furnishing the Provincial Health Office/Provincial Blood
Program Coordinator.
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REGIONAL OFFICE III

DEPARTMENT OF HEALTH
City of San Fernando, Pampanga
www.ro3.doh.gov.ph

c. To encourage their respective Municipal/City/Barangay Health

Council to actively support the program
d. To facilitate manpower assistance for the initial donor’s screening,
interview & physical examination.
e. To facilitate the request for Mobile Blood Donation Activity to Lead
BSF or other authorized BCUs, Blood Center and other hospital
Blood banks with additional function.(ANNEX C- REQUEST
FOR MBD TEMPLATE)
f. That during MBD shall create a system that will register regular
repeat blood donors (ANNEX D-DONOR ENROLLMENT CARD),
by assigning 1-2 staff as Blood Donor Registry Team.
2.5. The Local Blood Donation Program shall be included in the Work and
Financial Plan of the Local Government Unit (LGU) (DILG Memo
Circular No. 99-133, dated August 4, 1999). Resources- financial, human
and material-shall be provided to the Local Blood Council and
implementing organizations in accordance to the approved budget granted
by the LGU.( AO 2010-0002. VIII.e)

D. Donor Recruitment and Retention

1. LBC Committee on Donor Recruitment and Retention of each

province/municipality/city/barangay shall be responsible in the scheduling of
donor recruitment in coordination with the Provincial Blood Program
Coordinators, Blood Service Facilities, agencies and prospective potential blood
donors.
2. The LBC committee on public education and campaign shall formulate an
operational plan for effective education and marketing campaigns to promote
voluntary blood donation yearly. Implementation of such plan shall be carried out
by authorized and trained Donor Recruitment Officers/Teams of its respective
LGUs.
3. The DOH-RO 3 RVBSP shall provide technical assistance and may provide
logistics to support donor recruitment activities. Documented donor recruitment
and retention programs and accomplishments shall be one of the basis of the
DOH-RO 3 RVBSP in planning and determining the support to be extended to a
particular province.
4. Trained donor recruitment officers shall target volunteer blood donors from the
low risk population who meets defined selection criteria.
5. The blood council in each barangay, municipality, city and province shall
endeavour to recruit at least 2% of the total population by authorized and trained
Donor Recruitment Officers/Team of LGUs and blood service facilities.
6. The Provincial/Municipal Blood Program Coordinator shall keep a registry of
recruited donors to determine and to document whether achievement of Donor
Recruitment target has been met (2% of the total population as well as to
determine the success and deferral rate).
7. All Blood Service Facilities shall participate in the donor recruitment and
retention activities of the Province.
8. A continuing education program centered on social marketing and research shall
be undertaken for authorized and trained Donor Recruitment Officers/Teams of
LGUs.

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REGIONAL OFFICE III

DEPARTMENT OF HEALTH
City of San Fernando, Pampanga
www.ro3.doh.gov.ph

9. The training and establishment of association of Blood Donor recruitment

Officers (at BSFs, PDO, Provincial, Municipal/City and Barangays) may be
encouraged and facilitated by the DOH-RO 3 RVBSP.
10. All blood service facilities shall maintain registry of blood donors with rare blood
types, and shall submit a copy to their designated lead blood service facilities
through the Provincial Health Office Blood Program Coordinator.
11. All Blood Collecting Units/BSFs are required to build a pool of regular voluntary
blood donors utilizing effective database management system. The enlisted names
shall be forwarded to the Provincial Health Office for consolidation. (SEE
ANNEX E AS TEMPLATE)

E. Donor Screening, Counselling and Collection of Blood

1. Donor screening shall include medical interview, pre-donation counselling and

physical examination of donors following the standards on Donor Selection and
Counseling Manual by trained Donor Recruitment Officers.
2. Blood shall be collected from healthy, properly interviewed, examined and
screened prior to blood donation by trained phlebotomist (either a licensed
medical technologist, nurse, midwife, or allied medical personnel).
3. Collection of blood shall be conducted in the premises of a licensed Blood Center,
Lead Blood Service facility/Hospital Blood Bank with additional function/Blood
Collection Unit only from walk- in voluntary blood donors, except during MBDs.
4. For Blood Sufficiency and efficiency, organized Community Based Mobile blood
Donations (MBD) shall be systematically scheduled by the LGU in coordination
with the Provincial Blood Program Coordinator and Blood Center/Lead Blood
Service facility/Hospital Blood Bank with additional function/Blood Collection
Unit nearest to the area where target blood donation will be conducted. MBD may
be conducted in schools/universities, government or private agencies, shopping
malls, business establishments, factories, barangays, churches, communities,
among others.
5. The Municipal Coordinator where MBD was initiated shall keep a copy and
submit the Reports of Blood Collection and Donor Registry to the Provincial
Health Office Blood Program coordinator monthly, for data analysis.( ANNEX F)
These data may also be used to validate LGU Scorecard accomplishment for
Blood program Indicator.
6. To ensure that sufficient stocks of blood are sustained and periods of
oversupply/shortage are avoided, inventory of Blood Usage including components
by all Hospital Blood Banks, Blood Stations and other facilities administering
blood transfusion
(ANNEX G) shall be reported monthly to the Provincial Health Office Blood
Coordinator. The Provincial/municipal coordinator together with the LBC Team
and Lead Blood Service facility shall regularly analyze the balance between
production and usage, so that MBDs shall be regularly and properly organized.
7. Persons who screen blood donors and collect blood shall undergo sufficient
regular training to assure the quality of blood collected.

F. Testing of Blood Units

1. Blood typing (forward and reverse test tube typing) must be done on each unit of
blood for transfusion. And when applicable, antibody screen should be done.
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REGIONAL OFFICE III

DEPARTMENT OF HEALTH
City of San Fernando, Pampanga
www.ro3.doh.gov.ph

2. All whole blood and apheresis donations shall be tested for evidence of
Transfusion-Transmitted Infections (TTIs) prior to release for cross-matching and
transfusion.
3. Testing of all blood donations shall be mandatory for the following infections and
shall be run simultaneously or in parallel using the methodology and
recommended assays (DC 2013-0132):
a. HIV-1 and HIV-2: either a combination of HIV antigen-antibody or HIV
antibodies
b. Hepatitis B: Hepatitis B surface antigen (HBsAg)
c. Hepatitis C: preferably a combination of HCV antigen-antibody
d. Syphilis (Treponema pallidum): screening for specific treponemal antibodies
e. Malaria: screening for antigen or antibody or demonstration of the parasite in
a thick and thin blood smear
4. All testing of blood donations for TTIs shall be carried out only on samples taken
from the blood unit and in a quality controlled environment.
5. If found initially reactive to any of the TTIs and the test is valid, the blood unit
shall be referred to National Voluntary Blood Services Program-National
Reference Laboratory (NRL- Research Institute for Tropical Medicine) for
confirmatory testing.
6. If the testing is performed following strict guidelines and under quality-assured
conditions, there is no need for the receiving facility to repeat test in duplicate.
7. Only licensed Blood Center/Hospital Blood Bank with additional Function shall
be allowed to test blood for the five (5) mandatory TTIs. Where feasible, blood
testing shall be centralized in identified Lead Blood Service Facilities to achieve
uniformity of standards, increased safety and economies of scale.
8. The minimum evaluated sensitivity and specificity levels of all assays used for
blood screening shall be as high as possible and preferably not less than 99.5%
with Certificate of Product Registration from Food and Drug Administration
(FDA) and proof of Kit Evaluation from STD AIDS Cooperative Central
Laboratory (SACCL). Only reagent kits with current and valid certificates of
product registration and SACCL evaluation shall be used in screening blood units
for TTIs.
9. Since it is recognized that there is no system that will ensure absolute safety in
blood transfusion, the issuing BSF shall not be liable for any transfusion-
associated infections provided that all quality standards and requirements and
technical operating procedures have been complied with and documented.
10. Only blood and blood components that are nonreactive in all five (5) mandatory
TTIs shall be released for cross-matching and transfusion.
11. All blood unit tested reactive to TTIs shall be properly labelled and stored
separately It should be discarded safely within 48 hours and appropriately sent to
NVBSP-NRL for confirmatory testing. Furthermore, blood units tested reactive
for HBsAg under the following test kits and criteria shall no longer be sent to
NVBSP-NRL for further testing: (D.C. No. 2012-0198)
a. Abbott Axsym HBsAg with Optical Density (OD) reading of equal to or
greater than 34.9 (>34.9)
b. Roche Elecsys HBsAg with Optical Density (OD) reading of equal to or
greater than 20.46 (>20.46)
c. Abbott Architect HBsAg with Optical Density (OD) reading of equal to or
greater than 34.3 (>34.3)

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REGIONAL OFFICE III

DEPARTMENT OF HEALTH
City of San Fernando, Pampanga
www.ro3.doh.gov.ph

d. Biorad Monolisa HBsAg ULTRA with Optical Density over Cut-Off Value
(OD/COV) reading of equal to or greater than 20.11 (>20.11)
12. Blood units tested reactive to syphilis shall not be referred nor sent to NVBSP-
NRL for further testing.
13. Blood unit tested reactive by methods that do not conform to the guidelines herein
shall not be accepted for further testing by the NVBSP-NRL.
14. To eliminate unnecessary blood service fees and to decrease the financial burden
among patients, blood units issued by a licensed facility within the network ,shall
no longer be retested by transfusing facility or by other BSF provided that the
result of TTIs Testing is issued and the BSF tested the blood units in conformity
with the guidelines herein. MOA for referral shall be in place to protect both
parties from legal disputes and to clarify accountabilities.
15. Collection of Blood Service fees shall not exceed the maximum allowable fees
issued by the DOH and shall follow strictly the guidelines on AO 2015-0045
(New Maximum allowable Service Fees for Whole Blood and Blood Components
in Blood Service Facilities.)
16. Staff performing TTI testing shall have undergone training and passed
proficiency testing offered by the NVBSP-NRL-RITM. Only trained and
proficient staff shall perform testing of donated blood units for TTIs.

G. Handling, Storage and Transport of Blood Components

1. It shall be the responsibility of issuing facility to ensure that the storage and
transport of blood components is maintained at optimal condition to prevent or
delay physical, chemical or mechanical changes detrimental to blood components;
and to prevent or minimize microbial contamination and proliferation.
2. Handling , Storage and Transport of Blood Components shall follow the
provisions stated in Department Circular 2010-0013 Section 6.D
3. Availability, handling, transport and care of blood units shall be the responsibility
of either the issuing or transfusing facility, therefore, transactions shall only be
made between the Blood Service Facilities and not the relatives of patients. These
may be embodied in the MOA, for clearer accountabilities between parties.
4. Upon arrival of the units of blood/blood products to the hospital or end user health
facility, the receiving trained staff shall check the condition of the Cold Chain.
The following conditions may indicate improper storage during transport:
a. Direct contact of blood bag with ice or ice water
b. Complete melting of ice due to temperature over +10 oC
c. Insufficient number of cold packs/ice packs or not proportional to the
number of units of blood in thermo box
d. Plasma not in frozen state
5. If the units of blood are not acceptable, the issuing authorized blood service
facility shall be notified to arrange for the return of the unit of blood. Upon return,
the component shall be quarantined, properly labelled and recorded for the
information of all concerned staff and proper disposal.

H. Rejection and Return of Unit of Blood (Use form at ANNEX H)

1. Probable causes for rejection and return of unit of blood by End-User Blood
Service Facilities(EU- BSF )are the following:
a. Mislabelled blood type
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REGIONAL OFFICE III

DEPARTMENT OF HEALTH
City of San Fernando, Pampanga
www.ro3.doh.gov.ph

b. Wrong component issued

c. Improper storage of blood unit during transport
d. Defects in the blood bag
2. Incompatible cross match may also be a cause for rejection and return of unit of
blood provided that it is not due to clinically significant antibody/ies identified
from the patient’s blood. In such cases, instead of dispensing the units, segments
coming from 5 units are dispensed for cross-matching to avoid open-system
procedure and exposure of blood units to higher temperature.
3. The EU-BSF shall notify the releasing BSF before the unit of blood is shipped
back with accompanying documents stating the reason/s for rejection.
4. The releasing authorized BSF shall verify for inconsistencies in all documents
such as request form, issuance record of the blood unit, among others, which
could have resulted from a clerical error such as mislabelling of blood. The
releasing authorized BSF shall check/investigate for discrepancies and shall
properly document the physical condition of the returned blood unit.
5. The returned unit of blood shall be immediately replaced with the same
component requested without additional cost after the authorized BSF had
properly validated and documented the cause for rejection.
6. The releasing licensed/authorized BSF shall institute appropriate corrective and
preventive measures relative to the findings of the investigation.

I. Issuance/ Provision of Blood Units

1. Request for blood units and its issuance shall be directly between the requesting
hospital/EU health facility authorized Blood Station and licensed Blood Center/
Lead BSF.
2. Hospitals and non-hospital based (ie renal dialysis centers, ambulatory surgical
clinics, and emergency obstetrical care facilities) health facilities administering
blood transfusion shall determine and submit their recent average weekly blood
usage to issuing BSF. This will serve as one of their basis for maintaining proper
audit and inventory system of blood and blood components to ensure adequate
and safe supply of blood to patients
3. All transactions on issuance and transport of blood/blood components should be
in accordance with the agreement made between the issuing party and the end-
user health facility as reflected in the MOA.
4. Blood and blood components shall be available 24 hours. Every hospital shall
determine their minimum blood stock inventory level and have a ready stock of
unassigned tested blood units available at all times for emergencies.
5. Each Blood Service Facility shall operate in accordance with the Manual of
Standards for Blood Service facilities.

J. Blood Supply, Storage and Distribution

1. Taking into account the terrain and distance among BSFs and the hospital,
communication and transport facilities equipped with appropriate temperature,
control shall be established to ensure accessibility, availability of quality blood
and blood products.
2. All National and local government hospitals ( level 2-3) shall have the appropriate
BSFs (HBB or at least BS) within the premises to ensure timely access to needed
blood. If a level 1 Hospital is identified as provider of Basic Emergency Obstetric
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REGIONAL OFFICE III

DEPARTMENT OF HEALTH
City of San Fernando, Pampanga
www.ro3.doh.gov.ph

and Neonatal Care( BEmONC) services, it shall likewise have the appropriate
blood service facility( either BB or BS).
3. All BSFs licensed and authorized to store blood shall have appropriate cold
storage equipment.

K. Submission of Reports

1. All BSFs shall submit reports to the LBSF through the Provincial Blood Program
Coordinators for consolidation. (Annual Blood Safety Indicator (BSI) Report and
the prescribed NVBSP forms quarterly (Blood Monitoring forms, Dec 2000). The
LBSF, together with the PHO Blood Coordinator consolidates and analyse the
consolidated reports to determine degree of needs of Blood supply in their Zonal
Assignments.
2. The Lead BSF shall submit the report to RVBSP for final consolidation and
analysis of the Regional performance. This shall serve as basis for planning in the
RVBSP.
3. All BSFs shall facilitate and endeavor the use of National Blood Bank Network
System (NBBNetS) or its equivalent as agreed within by the respective provincial
blood service network for information sharing of available blood units.
4. All BSFs conducting collection from MBD session shall submit properly sealed
TTI result

L. Monitoring

1. To monitor effective implementation of the Regional Blood Service Network

Guidelines, Monitoring team shall be created by the DOH-Regional Office 3, to
be issued in a separate Regional Special Order.
2. The monitoring team shall be composed of the following :
a. RVBSP Coordinators
b. Representative/s from Regulation Licensing and Enforcement Division
c. Lead Blood Service facilities( under the Zonal Network being monitored)
3. All reports generated from monitoring shall be submitted to the DOH-RO3
Director, copy furnishing the PHO Blood Program coordinator from where the
inspected BSF is located, for appropriate action.

VIII. SUMMARY OF ROLES AND RESPONSIBILITIES

A. Philippine Red Cross within the Region

1. Consults and coordinates with Provincial Blood Program Coordinator in planning

and implementation of various projects and activities especially on public
education and advocacy on voluntary blood donation;
2. Establishes/maintains and continually improve the Philippine Red Cross blood
service facilities in the region or among provinces following the set standards and
procedures;
3. Facilitates the networking of Philippine Red Cross blood service facilities in the
regional blood service network;
4. Promotes voluntary blood donation through public education campaign to the
community to instil public consciousness of the principle that voluntary blood
donation is a humanitarian act and a social responsibility;
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REGIONAL OFFICE III

DEPARTMENT OF HEALTH
City of San Fernando, Pampanga
www.ro3.doh.gov.ph

5. Informs the public of the need for voluntary blood donation to curb the hazards
caused by the commercial sale of blood;
6. Establishes and promotes the collection of blood in various areas in the
community, such as but not limited to schools, business enterprises, barangays
and military camps;
7. Maintains and updates the rare blood type registry and provide data to those who
need them.
8. Facilitates and Coordinates the provision of the Rh negative blood/blood
products by the patient in Region 3
9. Submits quarterly, annual report to the regional blood program coordinator
through designated lead blood service facilities.

B. Local Blood Councils/ Inter Local Health Zone

1. Participate in the formulation of the Local Blood Donation Program that fulfils
the needs for blood transfusion in the community;
2. Plan and implement public education, advocacy and donor recruitment activities
to promote voluntary blood donation;
3. Conduct an organized and sustained public information campaign to promote
voluntary blood donation through:
a. Flyers, brochures, comics
b. Posters, billboards
c. News articles, features, press releases
d. Radio/TV spots, talk shows
4. Assist in the recruitment and retention of regular volunteer blood donors through:
a. Community meetings and seminars
b. Door to door campaigns
c. Blood Donor Club membership
d. Blood Donor Panels in
i. Barangays
ii. Schools
iii. Business firms
iv. Others
5. Organize mobile blood collection activities in coordination with the authorized
blood service facilities in strategic sites:
a. Barangays
b. Shopping malls
c. Business offices
d. Schools
e. Churches
f. Factories
g. Military camps
h. Media and Telecommunication Company
i. Others
6. Spearhead/Assist in fund-sourcing/fund-raising from within the community and
from external governmental and non-governmental organizations, financial
institutions or agencies.
7. To propose budget allocation for the blood program to local government units

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REGIONAL OFFICE III

DEPARTMENT OF HEALTH
City of San Fernando, Pampanga
www.ro3.doh.gov.ph

8. Strengthen the linkages of local hospitals, BEmONC/CEmONC facilities and

health services with the designated lead Blood Service facility; coordinate and
monitor the implementation of the Local Blood Donation Program.

C. Lead Blood Service Facilities

1. Internal
a. Advocacy, donor recruitment, retention and care
b. Donor screening and counselling
c. Collection: in-house and mobile blood collection (LGUs, offices, schools,
churches, etc)
d. Testing and processing units of blood
i. Administrative and technical procedures
ii. Quality assurance of blood and blood products
e. Distribution of blood and blood products to hospitals and other health
facilities
i. Administrative procedures for distribution, issuance and transport
ii. Administrative procedure for rejection and return of blood
products
iii. Cold chain management/transport service
iv. Training of HBB/Lab staff on blood stock inventory
v. Medical specialist to liaise with HBB/Lab (Pathologist)
vi. All hospitals and end users obtain blood needed and ensure no
wastage
f. Quality assurance program
g. Monitoring rational and efficient use of blood products
i. Medical specialist to liaise with HBB and HBTC (preferably
Hematologist or Pathologist)
ii. Medical specialist to participate in Regional/Zonal BSN meetings
iii. Training of hospital medical staff in the rational use of blood
through HBTC
iv. Monitoring of utilization of blood products through HBTC reports
h. Financial management – management of income and expenses for
operation by lead BSF
i. Collection of blood processing fees
ii. Procurement of reagents for testing and equipment for processing
and storage
iii. Utilization report of trust fund
iv. Preparation of procedure for monthly collection from blood service
facilities
v. Preparation of monthly billing statement
vi. Record keeping of financial transactions
vii. Preparation of monthly and annual financial report
viii. Review of financial performance
i. Submission of reports to Regional Office 3 and NVBSP

2. External
a. Regional blood program coordination
i. Public education campaign through local blood council

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REGIONAL OFFICE III

DEPARTMENT OF HEALTH
City of San Fernando, Pampanga
www.ro3.doh.gov.ph

ii. Coordinate with Local Government Unit (LGU) and Local Health
Services (LHS) – Blood Program Coordinators
iii. Participate in Zonal Blood Services Network meetings
iv. Train Donor Recruitment Officers (DROs)
v. Train Donor Interviewers and Phlebotomists (MBD Teams)
vi. Procure blood bags and other supplies for MBD
vii. Conduct Mobile Blood Donation Sessions
viii. Supervise BCUs and MBD Teams

D. DOH-Regional Office 3

Regional Voluntary Blood Service Program ( RVBSP)

1. Implements the NVBSP strategic plan in the region.

2. Conducts advocacy visits to local chief executives and other major stakeholders
for the promotion of voluntary blood donation in their respective localities/service
areas.
3. Designs and organizes training program on Voluntary Blood Donation Program
Management for Provincial and Municipal Blood Program Coordinators; and on
Effective Donor Recruitment, Retention and Care for local blood donor
recruitment officers.
4. Provides technical assistance to LGUs and NGOs in the selection of local blood
donor Recruiters, capability building and other NVBSP activities.
5. Designs IEC materials for distribution to potential blood donors.
6. Assists provincial and municipal blood program coordinators in lobbying for fund
support from LGUs, donor agencies, business and the private sector to share in
financing the Local Blood Program.
7. Monitors the Regional implementation of the Blood Program.
8. Collects, collates and analyses statistical data on the status of performance
indicators of Voluntary Blood Donation Program.
9. Organizes training of concerned personnel on the SOPs in Blood Services
(relative to all the links in the transfusion chain).
9. Prepares information materials for blood end-users and the general public on the
importance of cost recovery in sustaining quality blood services through
collection of blood processing fees.
10. Organizes training on Quality Management for personnel of various types of
blood service facilities (including hospital blood banks).
11. Advocates to existing blood service facilities (including hospital blood banks)
subscription/participation in the nationwide NBBNeTs or its equivalent.
12. Monitors the institutionalization of quality systems in blood service facilities with
trained personnel.
13. Promotes the organization of functional HBTC.
15. To develop/strengthen blood services network in the region through development
of policies and guidelines and regularly reviewing them for consistency and
suitability and by closely coordinating with the National and Licensing Office.

Regulation Licensing and Enforcement Division (RLED)

1. Monitors the compliance of blood service facilities and end-user hospitals to the
licensing requirements.
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REGIONAL OFFICE III

DEPARTMENT OF HEALTH
City of San Fernando, Pampanga
www.ro3.doh.gov.ph

2. Facilitates issuance of LTO/ATO of blood service facilities in the region upon full
compliance of BSF/s to licensing requirements.
3. Coordinates with the RO3 Regional Blood Program Coordinators for the status of
licensed or authorized Blood Service Facilites.

Provincial DOH Office ( Development Management Officers)

1. Presents Blood Program Mechanics to Local Health Board

2. Provides technical assistance to LGUs through the promotion of voluntary blood
donation, development and strengthening of blood service network and blood
donor selection and management.
3. Facilitates submission of quarterly/annual reports from the municipalities

E. Provincial/ HUC Health Office (PHO)

1. Helps establish blood donor recruitment centers in their respective areas and
coordinate Mobile Blood Donation activities.
2. Oversees that regular MBDs are conducted and equitably scheduled
3. Acts as Provincial Blood Program Coordinator
4. Prepares supporting documents for their respective potential LCE awardees
5. Identifies and designates staffs as Blood Donor Retention and Recruiting
Officers.
6. Includes in the Work and Financial Plan of the province the operations of the
Local Blood Donation program and cascading it to each Municipality/City Health
Office.
7. Collects and consolidates quarterly and annual provincial blood program reports
from different blood service facilities.
8. Submits reports to DOH-ROIII Blood Program Coordinators on time.

F. City Health Office/ Municipal Health Office

1. Establishes mobile blood donation teams in their respective areas

2. Acts as blood program coordinators
3. Prepares supporting documents for their respective LCE awardees
4. Assigns or designates a trained nurse or medical technologist as blood donor
recruitment officer (DRO) in coordination with the trained midwife and Barangay
Health Worker (BHW).
5. Includes the operations of the Local Blood Donation program in the Work and
Financial Plan of the city/ municipality
6. Submits quarterly and annual reports to Provincial Blood Program Coordinator on
time.
7. Submits quarterly (bi annual, if feasible) Mobile Blood Donation schedule to
Provincial Blood Program Coordinator ,through AMHOP meeting, a month ahead
of time of the scheduled activity.

G. Barangay Health Stations

1. Designated as the centers for advocacy and social mobilization

2. Midwife and BHW after properly trained, shall be designated as blood donor
recruitment officer (DRO).
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