Access to medical personal protective equipment (PPE) is essential for routine healthcare delivery, and a critical tool for containing outbreaks, as well as preventing and responding to pandemics. It is one of our most effective tools against COVID-19, and an undervalued tool more generally in infection control.
Healthcare workers who put themselves at risk to protect our communities have a right to be protected. Ensuring access to the PPE needed to stay safe is essential; it reduces the risk of infection during a pandemic by an estimated 60-95%. PPE is also one of the most cost-effective health interventions. The cost-effectiveness of protecting healthcare workers (HCWs) with PPE in low-income countries (LICs) and lower-middle-income countries (LMICs) over a one year period during the early phase of the COVID-19 pandemic was $59 per infection averted. The societal return is nearly 100 times the initial investment, considering losses of future productivity alone. Crucially, protecting HCWs also helps protect the communities who depend on them. Despite this, some countries have been underinvesting in medical PPE – both before and during the pandemic. In some countries, fewer than 15% of healthcare facilities have access to the PPE they need.
The COVID-19 pandemic revealed several issues in the PPE ecosystem, including acute shortages which induced steep price shocks and gaps in access. For example, the price of gloves surged by 500% over a matter of weeks during 2020, with lead times of up to 9 months. These disruptions severely compromised HCW protection across the world. Inequities in PPE availability were also observed, with remote areas often subject to shortages or suboptimal quality. While these issues have progressively eased, most aspects of the PPE ecosystem are still broken; many are the result of market failures which predate the current crisis. Together, they point to the importance of greater public investment and multipronged efforts to improve the PPE ecosystem.
Transforming the PPE ecosystem will require five coordinated shifts. Executed together, these will help us provide HCWs with effective and affordable PPE.
Catalysing PPE innovation: Today, there is no systemic approach for catalysing PPE innovation that meets HCW needs, and approaches to improving wearability, fit and environmental impact are still rudimentary. Most PPE products are designed for single-use, leading to enormous waste with no potential for circularity. In the future, innovation should be encouraged by offering coordinated incentives and procurement commitments, informed by deeper insights into PPE use on the ground.
Improving standards and quality: PPE standards currently vary across regions and create confusion, while testing capacity is often insufficient to ensure standards have been met. Going forward, standards for critical PPE should be harmonised, with a concerted effort to scale-up testing capacity in LMICs and globally.
Expanding and diversifying manufacturing capacity: PPE manufacturing is highly concentrated in a handful of countries; more than 60% of global production is in China and the USA. A combination of widespread supply chain disruptions and a 280% surge in demand in 2020 denied entire populations access to high-quality PPE. In the medium term, production capacity should be established in under-served regions, with support for select players who can achieve the scale required to be commercially viable and compete sustainably in the global market.
Strengthening procurement practices: Demand from countries has been highly fragmented and uncoordinated and has focused on cost at the expense of quality. Early in the pandemic 60% of respirators imported in haste fell short of their stated quality standard. Going forward, procurers should take a consistent approach to PPE procurement that goes beyond lowest-price, carefully selecting the appropriate procurement approach that best fits their context.
Improving usage and disposal. As it stands, PPE is not being recognised as a critical health tool in countries, leading to large gaps in availability and training. Disposal is also an issue; every single day disposable masks alone generate 1.6 million tons of plastic waste. Going forward, the importance of PPE should be reflected in sustained investments, ranging from procurement to waste management.
While the case for transforming the medical PPE ecosystem is clear, and some initiatives are already underway, correcting these market failures will require joint action and commitment:
Governments need to recognise the critical role of PPE alongside infection prevention and control (IPC) and water, sanitation, and hygiene (WASH) tools and prioritise accordingly. They should support and steer the establishment of at-scale regional manufacturing (rather than sub-scale local manufacturing that cannot be commercially viable globally). These efforts should be supplemented by national buffer stocks of PPE, large enough to cover any gaps in availability brought about by large supply chain disruptions. Finally, they should take a more holistic approach to PPE procurement, moving beyond lowest-price to encourage the development of high quality and innovative PPE.
WHO should consider adding ‘access to PPE’ as one of the key elements of any future country-by-country evaluation of preparedness such as the IHR M&E Framework. It should also convene regulators and standards organisations to harmonise medical PPE standards. Finally, it should elaborate target product characteristics for PPE to help direct future innovation.
Funders like the Global Fund or USAID should jointly develop and deploy new ‘pull’ and ‘push’ incentives to catalyse innovation around unmet needs which are informed by users. To enable this, they should establish mechanisms to create better visibility on the needs of HCWs in LICs/LMICs, as well as on emerging PPE innovations which could help protect them.
Development banks and finance institutions need to support at-scale local manufacturing and testing capacity by providing access to financing solutions and guidance. Development banks should support the development of national procurement processes, quality assurance mechanisms and last mile delivery systems for PPE. They should also facilitate greater investment in PPE.
Manufacturers need to engage with governments and public health stakeholders to enable this transformation, and actively engage in innovation to develop affordable, safe, high-quality products that meet the needs of healthcare workers.