BACKGROUND: Problems with blood supply in China in the 1990s stimulated measures to achieve 100% voluntary donation but supply remains inadequate to meet demand. STUDY DESIGN AND METHODS: Review of official policies, supplemented with observation of practice and interviews with key informants (potential and actual donors and health workers) in Guizhou province in Southern China. RESULTS: Interviewees perceived the transfusion system as a mutual social contract. However, some individuals were unwilling to donate because of concerns about health risks, the idea of transferring blood between people, wastage or profits being made from blood. Inappropriate incentives, including cash, were used to encourage donation. Recent reforms have increased confidence in donation and transfusion safety although concerns persist about misuse. There is a need to reduce unnecessary use of blood and its products. CONCLUSION: China still relies heavily on blood supplies obtained through quota, purchase or use of incentives. There is scope to expand voluntary donation further. However, as a priority it will be necessary to reduce overuse.
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