Putting Covid-19 tests to the test
The pandemic has exposed the chronic weakness of testing capacities and calls for diagnostic strategies at the national level.
More than two years after the start of the Covid-19 pandemic, the health crisis continues to unfold in many parts of the world. As Europe continues to lift restrictions despite another impending wave, parts of Asia, including China’s Jilin province, are experiencing lockdowns. The week of March 7-13, 2022 saw the first spike in new infections worldwide since late January 2022, with 11 million new cases and just over 43,000 new deaths, according to the WHO. Even though we now have better access to vaccines and want to live with Covid-19, these figures tell us that we are not out of the woods yet.
Large-scale testing and rapid diagnosis remain essential for continued pandemic control and preparedness. In fact, regular testing and monitoring of wastewater can help us identify surges and emerging variants, assess vaccine effectiveness, and support testing and treatment strategies. Yet, testing shortages in many countries have been a major contributing factor to the sloppy early response to the pandemic.
The Covid-19 pandemic has highlighted the chronic weakness of testing capacities, particularly in resource-limited countries, and calls for diagnostic strategies at the national level.
Putting governments and industry to the test
Scientists have developed tools to fight Covid-19 at unprecedented speed. This would not have been possible without collaboration, strong public and private investments and effective coordination. Along with the race to develop effective vaccines, the race to develop and deploy new testing approaches and new therapies for the SARS-CoV-2 virus is ongoing. While vaccine development and deployment has been handled with great determination, efforts to improve testing capacity have not received as much attention.
The screening gap has not only been observed in low- and middle-income countries (LMICs), as described in “The silent and dangerous inequality around access to Covid-19 testsbut also in advanced countries such as the United States, the United Kingdom, France, Australia and Singapore.
In one INSEAD Knowledge article in 2020, I had highlighted the need for governments to focus their efforts on managing a testing market with a variety of tests for different use cases. Unfortunately, many countries, including the United States, were overly reliant on polymerase chain reaction (PCR) testing and did not pivot to rapid antigen testing (RAT) fast enough. PCR tests were the mainstay of Covid-19 testing until last year. With the emergence of the more transmissible Omicron variant and its BA.2 subline, the appropriateness of a testing strategy relying almost exclusively on PCR testing has been tested.
More affordable tests with short turnaround times were needed to scale up testing to large populations. Rapid antigen tests have shown promise because they can be performed at home or in community settings at relatively lower cost. More importantly, with a turnaround time of just 15 minutes, they can speed up detection and responses to Covid-19. However, due to the time required to scale up production and the limited number of approved suppliers worldwide, production fell well below demand. The US FDA has been criticized for not approving faster test providers faster. For the self-testing industry – which was best known for pregnancy tests in high-income countries and self-testing for malaria and HIV in LMICs – such surges in demand were unprecedented.
Waves of Covid-19 have hit supply chains hard and most countries have been unable to respond to fluctuating demand for testing. Unfortunately, unlike vaccines, advanced contracts for test kits were not prioritized. In times of high demand, manufacturers increased capacity by adding production lines, running existing ones 24/7, and seeking new suppliers. Yet prices for tests provided to governments and companies in European countries such as Denmark, Germany and the UK collapsed after an upsurge in infections in 2021. Understandably, suppliers have been reluctant to ramp up production due to fluctuating demand.
Role of governments and global agencies in a healthy testing market
Investing in testing capacity should be seen as an investment in readiness. Governments and global organizations can take the lead in organizing the global testing market to achieve a higher level of preparedness. Amid the ups and downs of the Covid-19 waves, governments must not only ensure that production meets immediate demand, but also maintain stocks even in times of low demand for future waves.
Fluctuations in demand tend to prevent manufacturers from investing enough in expanding production and finding new cost-effective testing approaches. Governments should help stabilize demand and provide some degree of financial assurance by sharing manufacturers’ risk rather than exposing them to a “feast or famine” demand pattern. For test producers to invest in building additional manufacturing capacity, and for the domestic private sector to build more capacity to deploy such tests, they need contractual models that include some degree of risk sharing with governments. .
Supply commitments, such as the UK’s commitment at the end of 2021 to triple its testing program and the US government’s funding of free testing earlier this year, send vital demand signals but do not always result in demand. However, the U.S. government’s purchase and distribution of one billion at-home Covid-19 rapid test kits directly to U.S. households was a small step toward stabilizing the rapid test market. Additionally, firm commitments on the future use of new Covid-19 test manufacturing capacity would not only enable governments to meet Covid-19 testing needs, but would help strengthen the surveillance model for endemic diseases and future pathogens.
Ultimately, governments need to think about how much excess testing capacity they are willing to invest in, fully recognizing that all of this cannot be used when things are going well. But this capacity must be available when the next wave hits. This would involve large investments by the government, not only to buy more tests, but also to systematically solve bottlenecks in the test supply chain.
Global agencies and national governments need to take geographical diversification of test manufacturing capacity seriously by investing in production in regions where test production is limited. This can contribute to regional preparedness and resilience, and more generally to more equitable access and global health security.
At the global level, leaders must define a global diagnostic agenda for emerging pathogens as part of overall pandemic preparedness. This should be linked to global collaborations and investments to build infrastructure for molecular testing, especially in LRICs. To better coordinate global supply chains, integrated platforms can help improve resource mobilization, allocation and collaborative purchasing mechanisms.
Global coordination is also needed to define research priorities and policy applications of current and future diagnostic options. For example, to ensure that tests are applicable to diverse population profiles in a variety of settings, investments can be channeled into multi-country validation studies. Ultimately, multi-stakeholder collaboration is needed to gain regulatory approval and enable rapid testing adoption.
In addition to individual tests, scientists and industry continue their R&D efforts to develop new solutions. New monitoring methods such as blood tests Covid-19 virus in wastewater to provide early warnings have been developed on a scale never seen before in wastewater monitoring. New therapeutic options for early treatment of Covid-19 may further amplify the need for a healthy testing market.
Ultimately, we have to accept that there is considerable uncertainty in the demand and supply landscape of the Covid-19 testing market. Test developers, manufacturers, governments, and global organizations need to stay nimble and collaborative so they can quickly change strategy as new developments unfold. Operational flexibility, diversity of testing approaches, and more effective ways to share demand risk will be important attributes for managing uncertainty in the testing market.
Prashant Yadav is an Affiliate Professor of Technology and Operations Management at INSEAD and Academic Director of INSEAD Africa Initiative. His work focuses on improving healthcare supply chains and designing better supply chains for employee benefit products.
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