Maintaining a safe and sufficient blood supply remains a persistent global health challenge. Blood transfusions are essential for trauma care, surgery, cancer treatment, maternal health, and management of chronic conditions. Yet nearly two thirds of countries worldwide report difficulties in meeting national blood demand, with shortages particularly pronounced in low and middle income settings.
Historically, blood donation systems have relied on two dominant models. The commodity model offered direct financial compensation for blood, while the gift model promoted voluntary non remunerated donation rooted in altruism. Although the gift model improved safety and public trust, many countries now face stagnating donation rates as demand continues to rise due to ageing populations and expanding healthcare services.
A newly published study in The BMJ examines whether an alternative approach, known as the honour model, can address this challenge. Using a large quasi experimental design in China, the researchers assessed whether combining social recognition with non monetary incentives could sustainably increase blood donation without undermining blood safety.
This article reviews the study’s findings, methodology, and implications for healthcare professionals and policy makers.
Globally, approximately 118 million blood donations are collected each year. High income countries, representing only 16 percent of the world’s population, contribute about 40 percent of these donations. In contrast, low and middle income countries often struggle to meet demand, with median donation rates far below those seen in wealthier nations.
China exemplifies this challenge. Since adopting a nationwide voluntary non remunerated blood donation system in 1998, the country achieved rapid growth in donation rates. However, progress slowed after 2012, and donation levels plateaued despite rising demand driven by population ageing and advances in medical care. Around 60 percent of Chinese blood donors are first time donors, highlighting persistent difficulties with donor retention.
These trends prompted policy makers to explore new incentive mechanisms that preserve the ethical foundation of voluntary donation while improving participation.
The gift model emphasises altruism and voluntariness, discouraging financial rewards that could commodify human blood or compromise safety. While ethically robust, the model often provides limited recognition to donors, typically in the form of certificates or symbolic awards.
The honour model builds on the gift model by introducing structured social recognition and non monetary benefits. Rather than paying donors, it rewards frequent donors with honorary status and access to selected public services. These incentives are designed to be non tradable, non transferable, and difficult to monetise, thereby avoiding direct financial motivation.
In China, the honour model was piloted using an honour card granted to frequent donors, generally those who had donated blood more than 20 times. Cardholders received benefits such as free access to public transportation, park entry, and outpatient consultations. The goal was to reinforce social respect for donors and encourage repeat donation without compromising ethical standards.
The BMJ study evaluated the honour model using a staggered difference in differences design, leveraging variations in the timing of policy adoption across Chinese provinces.
The analysis covered 30 provinces in mainland China between 2012 and 2018. Tibet was excluded due to limited blood station data. Three provinces implemented the honour model during the study period:
The remaining provinces continued to operate under the gift model and served as controls.
Researchers combined multiple data sources, including:
Outcomes were aggregated from blood station data at provincial and city levels.
The study assessed both the quantity and quality of blood donation.
These outcomes reflect overall donor participation and were log transformed to account for skewed distributions.
This measure captures the proportion of donors who passed screening and were deemed eligible, serving as a proxy for blood safety.
Additional safety analyses examined markers of transfusion transmitted infections, including hepatitis B, syphilis, and alanine aminotransferase levels.
The honour model was associated with a statistically significant and sustained increase in blood donation counts.
Notably, the effect strengthened over time, suggesting that social recognition and honorary incentives may reinforce long term donor engagement rather than producing short lived behavioural changes.
The donor eligibility rate did not change significantly after implementation of the honour model. Additional analyses of infectious disease screening outcomes also showed no deterioration in blood safety.
These findings suggest that non monetary incentives and social recognition did not encourage higher risk individuals to donate blood, a concern often raised in debates about donor incentives.
To ensure validity, the researchers conducted multiple robustness checks:
Across these analyses, the results consistently showed increased donation quantity and stable safety indicators, supporting the credibility of the findings.
The study provides evidence that incentive design matters as much as incentive presence. Financial rewards may risk crowding out intrinsic motivation or raising safety concerns, while purely symbolic recognition may be insufficient to change behaviour at scale.
The honour model occupies a middle ground. By offering benefits that signal respect and gratitude rather than direct payment, it appears to motivate repeat donation without eroding the ethical foundation of voluntary blood donation.
Many countries with constrained resources cannot afford extensive financial incentives or paid leave schemes. The honour model offers a potentially scalable alternative, particularly where public services can be leveraged as honorary benefits.
Importantly, the study emphasises that incentives should remain non tradable and non transferable to preserve safety and public trust.
Clinicians, transfusion specialists, and public health professionals play a critical role in shaping donor recruitment strategies. Understanding the behavioural mechanisms behind donor retention can inform advocacy for policies that balance ethical integrity with practical effectiveness.
Despite its strengths, the study has limitations:
While robust analytical methods mitigate some concerns, further research is needed to assess generalisability in other cultural and health system contexts.
The BMJ study provides compelling evidence that China’s honour model increased blood donation volume by up to 7.7 percent over five years without compromising blood safety. By combining social recognition with carefully designed non monetary incentives, the model offers a promising framework for addressing persistent blood shortages.
For healthcare professionals and policy makers, the findings highlight the value of incentive structures that reinforce altruism rather than replace it. As global demand for blood continues to rise, innovative yet ethically grounded approaches such as the honour model may play an increasingly important role in securing safe and sustainable blood supplies.
Liu Y, Pan Y, Zheng Z, et al. Impact of shifting blood donation policy from gift to honour model: staggered difference-in-differences analysis in China. BMJ 2026;392:e084999. Published 21 January 2026. doi: 10.1136/bmj-2025-084999
This article is intended for healthcare professionals only. It is for informational and educational purposes and should not be interpreted as policy guidance or clinical instruction. Decisions regarding blood donation systems and incentives should be made in accordance with local regulations, ethical standards, and professional judgment.
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