Systematic Analysis of factors required for achieving 100% voluntary non-remunerated blood donation: A qualitative interview-based study of international experiences using the PESTELE framework

This international study provides the first systematic analysis of factors required for achieving 100% voluntary non-remunerated blood donation (VNRD). Semi-structured interviews with 15 experts from 12 countries using the PESTELE framework examined P olitical, E conomic, S ocial, T echnological, E nvironmental, L egal, and E thical factors influencing VNRD implementation. Countries were classified as achieving (≥90%) or underachieving (<90%) VNRD based on reported rates. Analysis identified 41 distinct elements across seven PESTELE domains, with only 16 shared between groups. Achieving countries exhibited focused strategies with fewer unique elements, whereas underachieving countries showed fragmentation with greater element variation, revealing an inverse relationship between factor complexity and implementation success. Modeling suggested a three-tiered hierarchical structure positioning political and legal factors as foundational enablers, economic factors as resource providers, and social, technological, environmental, and ethical factors as implementation mechanisms. Three developmental pathways were identified: crisis-driven transformation, economic development integration, and systematic international framework adoption. Findings indicate that successful VNRD implementation depends on sustained political commitment, integrated financing, and context-specific cultural adaptation through focused and sequential rather than simultaneous interventions across the PESTELE domains. These insights may help to advance globalization of VNRD through adoption of evidence-based strategies and international development assistance more targeted to hierarchical stages of development.