The problems with management of haemophilia in developing countries are poor awareness, inadequate diagnostic facilities and scarce factor concentrates for therapy. The priorities in establishing services for haemophilia include training care providers, setting up care centres, initiating a registry, educating affected people and their families about the condition, providing low-cost factor concentrates, improving social awareness and developing a comprehensive care team. A coagulation laboratory capable of reliably performing clotting times with correction studies using normal pooled, FVIII and FIX deficient patient plasma and factor assay is most essential for diagnosis. More advanced centralized laboratories are also needed. Molecular biology techniques for mutation detection and gene tracking should be established in each country for accurate carrier detection and antenatal diagnosis. Different models of haemophilia care exists. In India, there is no support from the government. Services, including import of factor concentrates, are organized by the Haemophilia Federation of India, with support from other institutions. Haemophilia is managed with minimal replacement therapy (about 2000 i.u./PWH/year). In Malaysia, where the system is fully supported by the government, facilities are available at all public hospitals and moderate levels of factor concentrates are available 'on-demand' (about 11,000 i.u./PWH/year) at the hospitals. Haemophilia care in South Africa is provided through major public hospitals. Intermediate purity factor concentrates are locally produced (about 12,000 i.u./PWH/year) at low cost. The combined experience in the developing world in providing haemophilia services should be used to define standards for care and set achievable goals.

The success in the management of haemophilia in the last two decades has been predominantly due to the availability of sufficient quantities of safe factor concentrates. Unfortunately, the prohibitive cost of these products has prevented this benefit from being available to the vast majority (approximately 80%) of haemophiliacs living in the developing world. A few developing countries have established facilities for the production of low- to intermediate-purity factor concentrates locally. The infrastructure required to achieve this can be very basic. The experience in South Africa, Thailand, Cuba and Brazil, described herein, shows that this approach provides factor concentrates which are very economical in comparison with more purified commercial products. This has had a major impact on the quality of haemophilia care in these countries. Wide availability of low-cost factor concentrates has made these products accessible to a large number of haemophiliacs and even made home therapy possible. The effort to provide these products results in improvement of the blood transfusion services. This, in turn, contributes to better facilities for patients with other transfusion-dependent diseases and society in general. Installation of small plasma fractionation plants is also a viable option. This not only allows processing of large pools of plasma for greater quantities of factor concentrates but also provides albumin and immunoglobulin. The revenue generated from the sale of the other products has been used to improve and subsidize haemophilia care. It is concluded that local production of intermediate purity factor concentrates in developing countries is absolutely necessary. A well organized transfusion service is required to collect adequate quantities of plasma for fractionation.