It is increasingly suggested, including by the US CDC, that widespread use of simple (non-medical grade) masks may have a role in reducing the spread of COVID-19. But the WHO still does not recommend medical mask use by healthy people or cloth mask use by anyone. There is uncertainty on the effectiveness of mask use by the general population, for a variety of reasons: the ability to wear them properly, the potential to induce riskier behaviors, and the risks of wearing the same mask for several days. Additionally, there is the risk of diverting an insufficient supply of medical masks, when there are already too few for medical staff.
Were WHO guidance to change, non-medical masks are a comparatively affordable intervention that could be rolled out at scale in developing countries. At the moment, apparel firms in developing countries have considerable spare capacity because of cancelled orders. Asif Saleh, Richard Cash, and Mushfiq Mobarak have all suggested putting that capacity towards making masks to potentially ease the economic impact of COVID-19 and simultaneously the mask shortage. Taking all of this into account, we propose donor support for local cloth mask manufacture and—if WHO guidance were to change—free distribution.
Manufacturing medical masks vs. cloth masks
At this point it is worth clarifying the type of mask that these firms could manufacture rapidly and at scale–cloth masks. These contrast with the surgical medical-quality mask commonly used in hospitals that use non-woven polypropylene and are capable of filtering out microscopic particles. The global demand for medical masks at the moment clearly and considerably outstrips supply, but manufacture is comparatively complex. Some apparel manufacturers in developing countries may potentially have the capacity to produce medical masks, and they might need financing to purchase the equipment, fixed capital for repurposing machines, clean rooms, and/or working capital to get raw material supplies. Development finance institutions including CDC, the US DFC, and the IFC have a potential role here—they could help with given their existing investments in the sector. Note, however, there are shortages at the stage of non-woven polypropylene manufacturing which may be the greater barrier to increasing production.
Throughout the rest of this post, we’ll be focusing on the simple cloth mask for consumer use that does not require working with non-woven polypropylene.
In countries with spare apparel capacity, we recommend that donors fund an in-country open offer for local consumer mask manufacture to heighten the supply of masks. Aid agencies could make a standard offer for any delivery of basic consumer masks, to be delivered to a set location before a set date that met basic design standards, such as new material, given dimensions, tight knit cotton. Alternatively, they could simply lay out a number of acceptable designs in agreement with local health authorities. US healthcare provider Genesis HealthCare has this pattern and instructions, for example. They would promise to buy masks at a set price up to a set total—whatever funding they have available for the project. Preferably donors would pool funds, but given the urgency, first movers should not wait.
Logistics and distribution
The masks might initially be distributed via networks working with vaccinators, bed net providers, bottling companies, mobile scratch-card vending networks, or other industries with logistics systems with reach. Building on evidence from bed net distribution, to encourage use, consumer masks would be distributed for free. As local shortages eased, additional mask supplies could be shipped to other countries.
Outreach to firms could help to ensure practicable design details, prices, and delivery schedules. And local donor agencies should have some flexibility in terms of accepting products that do not match all technical specifications but in the opinion of medical professionals will have similar efficacy as the preset designs.
Why this approach rather than simply putting out a tender for a competitive process for the same number of masks?
Speed. With a budget, a price, and specifications, a donor could create demand (and start receiving products) tomorrow.
Targeting: A competitive process selects a winner (as does emergency sole-sourcing). The open offer would be open to any firm that can meet the technical specifications. Not only would that encourage more producers into the market, it would reward the fastest producers with an immediate payment. There would be no need for formal contracting with individual suppliers—merely a payment and receipt for masks delivered to specifications.
An alternate approach might be an accelerated, abbreviated bidding process. Specifications would be set and then a one-day online auction amongst a set of (quality) pre-selected suppliers could be carried out. The auction could be segmented by delivery times: a first auction for masks to be delivered within a week; a second auction for masks to be delivered within two weeks; and so on.
A similar approach might be used for hand sanitizer, although the evidence of local excess manufacturing capacity is less clear in that case. Manufacturers of dispensers used for cosmetic, industrial, or food products (e.g., shampoo) might be able to work with distilleries to create products that meet alcohol content standards for effective sanitizer.
It is important to repeat the WHO cautions about the potential ineffectiveness, or even harm of non-medical mask use. Donors should not support free distribution until and unless WHO advice or national government guidelines promote general non-medical mask use (and there is evidence there are insufficient masks to meet demand at the local level). That said, a number of jurisdictions have already declared mandatory face covering in public buildings. Mass manufacture of basic masks distributed for free may at least take pressure off medical mask supplies and may have broader health benefits. In addition, it would help safeguard the apparel industry—a valuable employer in many developing countries.
Many thanks to Amanda Glassman, Kalipso Chalkidou, Prashant Yadav, Rachel Silverman, and Justin Sandefur for comments and advice