“Voluntary, Unpaid, and Handsomely Rewarded: Donor Benefits in the World's Whole-Blood Systems,” by Krawiec and Roth

 Around the world, "non-compensation" of blood donors allows for a variety of incentives.

Kimberly D. Krawiec and Alvin E. Roth, “Voluntary, Unpaid, and Handsomely Rewarded: Donor Benefits in the World's Whole-Blood Systems,” SSRN, Virginia Law and Economics Research Paper No. 2026-12,  1 July 2026, https://papers.ssrn.com/sol3/papers.cfm?abstract_id=7030818  

 Abstract
The ideal of the unpaid blood donor is nearly universal; the practice is more complicated. Whole-blood systems around the world preserve a formal commitment to voluntary, nonremunerated donation-and then provide donors with gift cards, sweepstakes entries, cash "expense allowances," paid leave, tax relief, priority service, medals, and, in some places, extra points on a child's school exam. This Essay maps the gap between label and practice. Drawing on examples from thirteen countries spanning five continents, it organizes donor benefits by institutional mechanism: gift cards and sweepstakes; direct monetary transfers; paid work leave; other material and recognition-based benefits; and replacement donation and the informal cash markets it can generate. We demonstrate that "voluntary, nonremunerated donation" frequently coexists with substantial material benefits. Whole-blood donors nearly always receive something of value in exchange for their generosity; what varies is how those benefits are structured, funded, routed, and legally classified. 

 

Jurisdiction	Representative donor benefits	Legal classification / routing
United States	Nontransferable gift cards; sweepstakes (e.g., Super Bowl LX trip; $5,000–$7,000 raffles); promotional items (shirts, mugs, bags, movie tickets).	“Volunteer donor” label retained where benefits are not readily convertible to cash; sweepstakes framed as “no donation necessary.”
South Korea	Promotional K-pop photo cards; vendor and restaurant vouchers (5,000–8,000 won); merchandise; transferable blood-donation card.	Prohibited “consideration” distinguished from “commemorative gifts” and donor encouragement.
Kazakhstan	~$18.75 (2 MCI) for reimbursable donation; ~$2.34 meal equivalent for gratuitous donation.	Categorized as payment; reimbursable donation invited for shortages and rare types.
Bulgaria	Payment in narrow statutory cases (shortage, vaccine/serum/immunoglobulin production, research/diagnostics).	Voluntary/unremunerated rule with “against payment” exceptions.
Germany	Direct monetary transfers at some collection centers; refreshments and health checks only at DRK.	“Aufwandsentschädigung” (expense allowance), set per collection service.
China	Family exam-point awards (Pujiang: 1–3 points); platelet shopping cards $31–$386; paid leave, tax benefits; prepaid phone/transport cards, movie tickets.	“Gratuitous” system plus “appropriate subsidies”; tolerated monetary-equivalent and family-directed rewards.
South Africa	Data/streaming vouchers, raffles, merchandise; private wellness rewards (Discovery Vitality, Momentum, Bonitas).	Donor benefits supplied through blood-service promotions and private wellness programs.
Brazil	One paid day off per 12 months (private employees); donation-day leave (public servants); 120-day priority service at banks, hospitals, etc.	Donation converted into paid-leave entitlement and legally recognized priority status.
Spain	Donor medals, honors, and milestone recognition.	Recognition-based; no direct monetary transfer.
India	Replacement donation; illicit “professional donor” cash market.	Patient-side payment associated with replacement donation.
Nigeria	Tokens, certificates, badges, transport refunds; in practice 68% family replacement and 12.2% commercial donors.	Patient-side payment associated with replacement donation; commercial donors openly reported in donor categories.
Sierra Leone	Predominantly family replacement donors (~90%); paid donors recorded as replacement donors.	Patient-side payment associated with replacement donation; paid donors recorded as family replacement donors.
Argentina	Post-donation meal; medical certificate; 24-hour work-absence justification; 2026 shift away from replacement model.	Statutory donor benefits plus replacement-donation phase-out.

 

"If there is a lesson in this tour of the world’s whole-blood systems, it is that “voluntary, nonremunerated donation” is a phrase asked to carry a great deal of freight. It accommodates a $7,000 gift card, so long as the gift card is offered through a sweepstakes that does not require a blood donation to enter. It accommodates €60 in cash, so long as the cash is legally categorized as an expense allowance. It accommodates extra points on a child’s high-school entrance exam, paid leave, free public transit, priority service at the bank, and a tote bag—often all while the governing statute insists that blood may not be given for reward. "

Australia has more unpaid beekeepers than blood donors

 If only there were some way for Australia to become self-sufficient in blood plasma, so it could stop having to buy it from the US...

The Financial Times has the story:

Australia’s drive to get more blood flowing
The country has more recreational beekeepers than regular donors and is forced to rely on imports  by Nic Fildes 

" Australia needs 100,000 new donors every year to meet its need for blood and plasma. But there are more recreational beekeepers in Australia than people who have actively donated their blood three times or more.

"This is not only an Australian challenge. Most countries have a supply gap. One problem is that the legion of older donors that has kept donations flowing for decades is dwindling and younger generations are not donating or do not return after they’ve tried it once. 

...

"The situation is particularly acute for plasma — the yellow-coloured component of blood sometimes called liquid gold — which is a vital ingredient for 18 different life-saving procedures ranging from immune deficiency treatment to heart surgery. 

Australia supplies only 38 per cent of its own plasma and spends about A$600mn a year to import it — more than double what was spent a decade ago. A report published by the state of New South Wales suggests imports needed could rise to 66 per cent of the total by 2030, meaning taxpayers are set to foot an even larger plasma bill.

For now, Australia relies on the US, where people earn up to $70 per donation, which supplies about 70 per cent of the world’s plasma."

 

Paid plasma donations are becoming more middle-class

 The NYT has the story:

The Middle-Class Suburbanites Who Sell Their Blood Plasma to Get By.  Across the United States, plasma centers are opening in wealthier areas as more people struggle with the high cost of housing, groceries and health care.   By Kurtis Lee and Robert Gebeloff   March 20, 2026

"Every day, an estimated 215,000 people donate plasma, the yellowish liquid component of blood. Mr. Briseño is among them. He is not jobless or facing eviction, but, like many in the American middle class, he is caught in the vise of rising expenses and wages that aren’t growing fast enough to cover them. So he is turning to a method more commonly associated with the lowest-income Americans. For people like him, an extra $600 or so a month can mean making a mortgage payment or covering increased health-insurance costs.

"A recent study by researchers at Washington University in St. Louis and the University of Colorado, Boulder, observed that while older plasma centers are clustered in low-income areas, newer centers were increasingly likely to open in middle-class neighborhoods. A New York Times analysis shows the trend has continued: Centers have sprung up in more than 100 such neighborhoods, in suburbs and wealthier sections of cities, since researchers finished collecting their data in 2021."

 

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Here's an earlier post on the study that sparked the NYT report:

Wednesday, November 16, 2022  Blood Money, by John Dooley and Emily Gallagher

 

International statistics on plasma donation show that it is quite safe

 Peter Jaworski collects the statistics from Europe and North America:

Plasma donation is safe
And commercial plasma donation is not less safe than non-commercial donations
Peter Jaworski
Mar 16, 2026 

"Source plasma donation (also called “plasmapheresis”) is inordinately safe (so is whole blood donation). And the best publicly-available donation safety data give us no reason to think that commercial plasma collection is less safe than non-commercial plasma collection.

" That claim may be surprising in light of the recent heartbreaking deaths reported after plasma donations in Winnipeg. These tragedies have raised questions about the safety of plasma donation in general, with some critics suggesting that commercial plasma donation is inherently less safe than non-commercial plasma donation.

"The evidence for the claim that plasmapheresis, including commercial plasmapheresis, is safe can be found in countries with the largest plasmapheresis programs, which publish annual reports on serious donor adverse events. Some of these countries have exclusively non-commercial plasma collection, while others have predominantly commercial systems. "

How safe is plasma donation?

 Here's a story from the NYT, about the recent regularization of paid plasma donation in (some provinces of) Canada.

How Safe Is Plasma Donation?
Two recent deaths tied to for-profit clinics in Canada raised concerns about the health effects of having plasma drawn as often as twice a week. By Roni Caryn Rabin and Vjosa Isai

"Donating plasma, which is used to make lifesaving medicinal products, is widely perceived as low-risk. But questions about the safety of the practice arose this week when Canadian health authorities confirmed they were investigating two recent deaths of people who gave plasma at for-profit clinics in Winnipeg operated by Grifols, a Spanish health care company. 

"Millions of people donate frequently in North America. An estimated 60 to 70 percent of plasma-derived medicinal products worldwide are made from plasma donated in the United States.

And demand for plasma is growing. The market for plasma-derived medicinal products is valued at $40.35 billion and is expected to double over the next eight years, as the products are used to treat an expanding number of conditions, including immune deficiency syndromes and bleeding disorders.

But the health impact of frequent plasma donation on the donors themselves has not been well studied, and there is no consensus among health regulators about how long donors should wait between plasma draws.

In both Canada and the United States, companies can pay people an honorarium for donating their plasma, and health regulations say that people can donate up to twice a week.  

...

"A 2020 investigation by the F.D.A. into 34 deaths reported as being associated with plasma donation did not determine that donation was the cause of death in any of the cases. It ruled donation out entirely as a cause in 31 cases. "

 

WHO Says Countries Should Be Self-Sufficient In (Unremunerated) Organs And Blood by Krawiec and Roth (now open source)

The published version of our paper is now widely available:

Kimberly D. Krawiec and Alvin E. Roth, “WHO Says Countries Should Be Self-Sufficient In (Unremunerated) Organs And Blood,” in James Stacey Taylor and Mark J. Cherry, eds., Markets in Human Organs for Transplantation: Controversy and Contention., Routledge, November 2025 (open source) https://www.taylorfrancis.com/reader/download/5885e1ba-c9af-4547-941c-821a2afaa7ee/chapter/pdf?context=ubx  

From the introduction:

[The nonremuneration principle] is only half of a WHO policy, broadly accepted around the world, that mandates both national (or sometimes only regional) self-sufficiency and an absence of remuneration for both blood products and transplantable organs (hereafter, the “twin principles”) (WHO 2009, 2023). This self-
sufficiency mandate, though less examined than the ban on  remuneration, presents a real hurdle to progress in transplantation, especially for smaller and low and middle income (LMIC) countries. 

"WHO’s insistence on self-sufficiency inhibits cooperative kidney
exchange efforts (as well as other innovations) among countries that
would benefit all concerned, especially the LMIC that the policy is purportedly designed to help. As will be discussed, the policy’s effect on blood products, especially when combined with the no remuneration rule, is even more stark – no country that fails to compensate donors is self-sufficient in plasma collection and few LMIC collect sufficient supplies of whole blood.
 

"This chapter critiques these twin principles, making several central points. In Section 2.2, we discuss the twin principles as applied to blood products, noting the particularly pernicious effects on plasma supply and availability, especially in poorer nations. In Section 2.3, we turn to transplantation, emphasizing the numerous benefits of international cooperation and cross-border transplantation – benefits that would be undermined by self-sufficiency, especially in smaller countries and those without well-developed domestic exchange programs. We illustrate this point with examples drawn from several noteworthy instances of cross-border kidney exchange.
 

"In Section 2.4, we argue that the current discourse around remuneration and organ donation is frequently overdramatic and unhelpful. Although nearly every effort to increase organ donation and transplantation presents ethical challenges, not every such effort amounts to “trafficking” or “a crime against humanity.” These labels stifle helpful deliberation, progress, and consensus. Section 2.5 concludes with recommendations for a saner approach to the scarce resources of blood products and transplantable organs – one that is focused on international cooperation, rather than self-sufficiency; evidence-based policies, rather than a reliance on decades-old
assumptions and understandings; and the use of pilot studies and trials to test the ethics, safety, and efficacy of incentives in various settings."

######

Here's the book:

 

Commercial plasma collection in the US: the Jaworski report for 2025

 Peter Jaworski, a tireless student of blood donation around the world, has published a report on the plasma industry.  It's full of interesting facts, a few of which are highlighted below.

America’s Plasma Contribution to the World: 2025
Launching the Georgetown Blood and Plasma Research Group and the annual state of the U.S. plasma industry report  by Peter Jaworski 

"I am proud to announce the official launch of the Georgetown Blood and Plasma Research Group. Housed at Georgetown University, this initiative will serve as a dedicated academic hub for research on the ethics and economics of global supply chains for not only blood plasma, but blood, bone marrow, and other medically-useful substances of human origin. Our goal is to provide data-driven insights, foster serious philosophical discussion, and be a home for interdisciplinary research.
 

"This 2025 Annual Report is the first contribution to that mission. 

...

"As of December 31, there are 1,247 plasma collection centers in the United States (including four centers in Puerto Rico).

"To put this into perspective: The U.S. is now home to more plasma centers than community colleges (just over 1,000) or Kohl’s department stores (around 1,175). There are almost as many plasma collection centers as Denny’s restaurants (around 1,300). 

...

"we can look at the economics of independent plasma companies. Their business is to sell plasma to fractionators, not to make medicine from the plasma.

"The current selling price of a liter of plasma is around $190, give or take $10.

• Donors receive between 30-40% of that revenue, or around $70 (an average donation is 850 - 880 mL, requiring more than one donation to equal a liter).
• The center spends a majority of the remaining revenue on costs like employees, supplies (“softgoods”), testing, and facility overhead.
• The plasma center will pocket around 8-12%, or around $15 in profit. 

...

"The U.S. plasma industry does more than save American lives, it provides the material for life-saving therapies for patients around the world.

"The 62.5 million liters collected in the U.S. in 2025 represents around 68% of global plasma collections for the manufacture of medicines. About 52% of those collections will end up in medicines to treat American patients, while the remaining 48% will end up treating patients in the rest of the world."

Blood transfusion for dogs and cats

 Somewhat as in human donation around the world, blood donors for veterinary transfusions of cats and dogs are both volunteers and professionals. (Of course all these donors are themselves dogs and cats.)

Here's the NYT on the story:

 The Pet ‘Superheroes’ Who Donate Their Blood.
Transfusions have become an important part of veterinary medicine, but cat and dog blood is not always easy to come by.  By Emily Anthes

 "All kinds of ailments — including injuries, infectious diseases, immune conditions and cancer — can leave a pet in desperate need of blood, and transfusion has become an increasingly routine part of veterinary care.

“It is just as important a part of veterinary medicine as it is for human medicine,” said Dr. Dana LeVine, a small-animal internist at Auburn University and the president of the Association of Veterinary Hematology and Transfusion Medicine.

...

"There is no canine Red Cross. Instead, there are hospitals with in-house blood donation colonies, veterinary clinics with a roster of ad hoc donors on call and a small number of commercial blood banks, with wait lists that can stretch for months. There is also a growing community of pet owners who are signing their animals up to provide blood for other pets in need 

...

"Commercial blood banks for animals began emerging in the 1980s. Some rely on “closed colonies,” a group of cats or dogs that live on site, providing blood for several years before they are put up for adoption.

"Closed colonies have been a critical source of animal blood and can be run humanely, experts said. “I know many places that have fabulous cat rooms for cat donors,” said Dr. LeVine, who adopted her previous cat, Salt, from a blood donation colony.

"But animal rights activists have also exposed mistreatment and abuse at some commercial blood banks with closed colonies, and demand far outstrips the volume of blood they can provide.

"These factors have helped fuel interest in an alternate model, which recruits local pets to become regular donors. At DoveLewis, roughly 90 dogs and 40 cats serve as regular donors, or what the hospital calls “superheroes.”

...

"Community blood banks don’t pay pet owners for blood, but they do offer other perks, which often include free veterinary exams, blood work and flea and tick preventatives. The animals are rewarded, too. At DoveLewis, donor dogs get a jar of chicken or beef baby food. “It’s just the perfect size jar of smelly meat,” said Kelsey Reinauer, the blood bank director. “And then they get to pick out a toy from our toy bucket.”

########

See also

California Animal Blood Banks Program

“Historically, California required commercial blood banks for animals to be closed-colony establishments. On January 1, 2022, Assembly Bill 1282, the California Pet Blood Bank Modernization Act, went into effect. This law aims to address the shortage of animal blood available for veterinary transfusion medicine in California and transition the state from closed-colony blood banks to community blood banks.”

Blood supply in West Africa

 Here are some thoughts on blood shortages in West Africa by Jappah and Tao. (Jappah has just returned from Sierra Leone...)

To meet demand, blood donation should not rely solely on volunteers
A misalignment between supply and demand especially hurts people in low-income nations. by Jlateh Vincent Jappah and Ruoying (Carol) Tao, Harvard Public Health, December 4, 2024

"The World Health Organization advocates for 100 percent voluntary, non-remunerated blood donation—a position that was more defensible in the 1970s, before widespread screening for bloodborne diseases like hepatitis. Today, two-thirds of the world face shortages of blood and blood products, leading to many preventable deaths, especially among women and children. More than 80 percent of the world’s population has access to only 20 percent of the global blood supply. These global inequities in blood and blood product supplies are unacceptable.

"Africa, in particular, faces a disproportionate demand for blood and blood products. The continent relies heavily on family-based donation, which is not sustainable. Policies about blood supply in Africa, meanwhile, are generally based on research generated outside the continent—and in that research field, the idea of addressing blood shortages in Africa by providing adequate incentives and compensation to blood donors is met with skepticism.

"We are conducting research with nonprofit organizations such as Lifeline Nehemiah Projects and with government agencies in West Africa, and shortly we will begin field experiments, to study whether non-cash incentives increase blood donation.

...

"The misalignment between blood supply and demand is especially acute in low-income countries, where the demand for blood is high due to disease burdens, traumatic injuries, and medical conditions that require transfusions. Blood shortages in these regions are also driven by factors such as a higher prevalence of sickle cell anemia and bloodborne pathogens. And yet problems such as poor nutrition limit people’s ability to donate blood voluntarily.

...

"Blood donation should not rely solely on charity but also on empowering individuals and communities to meet their own needs. In Sierra Leone, for instance, humanitarian organizations provide food and transportation to blood banks, to encourage blood donations. These incentives have significantly increased donation rates, though blood banks sometimes struggle with supply shortages, such as blood bags and needles."

Jlateh Vincent Jappah is a physician and a Ph.D. candidate in health policy at Stanford University. He is a fellow at the McCoy Family Center for Ethics in Society at Stanford.

Ruoying (Carol) Tao
Ruoying (Carol) Tao is a Ph.D. student in health care management and economics at The Wharton School at the University of Pennsylvania. She previously worked in health care management consulting.

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Earlier:

Wednesday, August 28, 2024 WHO Says Countries Should Be Self-Sufficient In (Unremunerated) Organs And Blood, by Krawiec and Roth

 

Kim Krawiec interview about WHO demands for national self sufficiency in blood donation and kidney exchange

 The University of Virginia takes note of the recent Krawiec & Roth paper I blogged about in August.

Here is their interview with Kim about the paper:

WHO Stifles International Blood and Organ Donations, Argue Professors. Professor Kimberly Krawiec, Nobel Prize Winner Alvin E. Roth of Stanford Argue World Health Organization Policies Need Revision

Here are the first two Q&As

"What motivated you to critique the WHO principles of self-sufficiency and nonremuneration in organs and blood? ​

"The severe shortage of both blood products and transplantable organs, especially kidneys, was our motivation and has motivated much of our other work, both together and separately. In the United States alone, the organ transplant waiting list is approximately 100,000 people, and if current trends continue, it will only grow in the coming years.

"Shortages of blood products present a similar challenge. Although wealthy countries are typically able to satisfy domestic whole blood needs, the vast majority of low- and middle-income countries (LMIC) are not. As a result, in many LMIC, shortages of blood for transfusion contribute to maternal death, death from traffic accidents and complications from childhood anemia. Moreover, even wealthy countries experience seasonal shortages of whole blood or deficiencies in some blood components, such as platelets, which are harder to collect and have a shorter shelf life.

The shortage of plasma-derived medicinal products (PDMPs) is particularly severe and entirely preventable. PDMPs are life-saving treatments for multiple acute and chronic conditions for which there are no alternative treatments. Yet these life-saving therapies are unavailable to much of the world’s population. The United States, one of the few countries to pay plasma donors, supplies 70% of the world’s plasma needs, with Germany, Austria, Hungary, Czechia and Latvia (which also permit some form of payment for plasma donors) supplying another 20% of the world total. In other words, a handful of countries supply plasma to the rest of the world, including other wealthy countries. Meanwhile, LMIC who can neither collect and process their own nor afford to purchase blood products on the open market (or are prevented from doing so under the terms of the foreign aid that supports their health system) simply do without, to the detriment of their citizens.

"How do current WHO policies on organ and blood donation contribute to this problem?

"WHO policy mandates both national (or sometimes only regional) self-sufficiency and an absence of remuneration for both blood products and transplantable organs — what we refer to in the paper as “the twin principles.” These twin principles are unhelpful separately and unworkable together. Their effect on blood products is particularly stark — no country that fails to compensate donors is self-sufficient in plasma collection and few LMIC collect sufficient supplies of whole blood.

"The self-sufficiency mandate presents a real hurdle to progress in transplantation, especially for smaller countries and LMIC. This is especially the case because some of the most exciting and promising developments for increasing the availability of transplants have been in kidney exchange, a mechanism that leverages in-kind exchange, rather than financial compensation, to encourage and facilitate donation among those with willing but incompatible partners. But kidney exchange works best when a large pool of patient-donor pairs can engage with one another. So, requiring that transplantation be contained within national boundaries unnecessarily limits access to transplants that could be achieved only by cross-border exchange."

IV fluid shortages in the U.S.--perhaps we should allow international imports?

There's a hurricane-induced shortage of intravenous (IV) fluid.  Maybe we should import some? (But...international borders...)

An obstacle is that FDA approval of the factories is usually needed, but can be (and in the past has been) suspended, to allow imports from places that do their own high quality inspection (like Australia and Ireland in 2017--I guess it's good that the labels are in English) .  

More generally, after the Covid pandemic we learned of the fragility of supply chains that have concentrated overseas sources (like surgical masks from Wuhan).  The reaction has been to onshore more production. But concentrated domestic production also makes for fragile supply chains, and being able to diversify to overseas producers could strengthen them.

Statnews has the story:

White House should declare national emergency over IV fluid shortages caused by Helene, says hospital group. Hurricane Helene shuttered a Baxter plant that manufactures 60% of IV solutions for the U.S.  By Brittany Trang 

"Amid Hurricane Helene shuttering a major IV solution manufacturing plant and Hurricane Milton now barreling toward other IV manufacturing facilities in central Florida, the American Hospital Association on Monday asked the Biden administration to declare a shortage of IV solutions and invoke national emergency powers to ease the crisis. 

'In late September, Hurricane Helene shut down a Baxter plant in Marion, N. C., which manufactures approximately 60% of the IV solutions for the U.S. Both Baxter and “all other suppliers” of IV solutions have restricted how much their customers can order and have stopped taking new customers, AHA president Rick Pollack wrote in the organization’s letter to Biden. As a result, hospitals have declared internal shortages and restricted IV use. 

...

"In addition, the letter asked for the government to declare a national emergency and public health emergency so that Medicare and Medicaid rules around IV infusions can become more flexible, and to invoke the Defense Production Act to expand the production of IV solutions and bags. The AHA also suggested the government put the Federal Trade Commission and Department of Justice on alert for price gouging during the shortage.

Another step the FDA could take is to allow the importation of IV bags from other countries,* as it did when Hurricane Maria shut down Baxter’s Puerto Rico-based IV saline plants in 2017. That shortage mostly affected small IV bags. According to Vizient, a health care performance improvement company, the North Carolina Baxter plant is largely a producer of large IV bags, including saline, dextrose, and Ringer’s lactate solutions.

#####

*In 2017: "To address a shortage of intravenous solution bags exacerbated by Hurricane Maria, the Food and Drug Administration has granted permission for a health supply company to import certain products to the United States from Australia and Ireland."

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Related:

Wednesday, August 28, 2024

WHO Says Countries Should Be Self-Sufficient In (Unremunerated) Organs And Blood, by Krawiec and Roth