When WHO declared COVID-19 a pandemic, on 11 March, there was only one public diagnostic respiratory virology laboratory in Nepal - the National Influenza Centre (NIC) at the National Public Health Laboratory (NPHL). Furthermore, it was limited to testing for the influenza virus and HIV. On 13 January 2020, when the first suspected case of COVID-19 appeared in Nepal, NPHL did not have the reagents specifically required to test for SARS-CoV-2. Thus, WHO Country Office in Nepal (WCO) helped with shipping the sample taken from the patient to the WHO Collaborating Centre in Hong Kong, where tests came out positive. It was clear that in case of a widespread outbreak the country was at high potential risk because of a severe lack of necessary equipment, infrastructure, supplies and trained manpower for rapid diagnosis needed at scale.

Since mid-March 2020, WCO closely supported the Ministry of Health and Population (MoHP) in its broad effort to develop a national network of laboratories for testing and detection of SARS-CoV-2. The result of this endeavour is impressive: there are now 83 laboratories dedicated to the testing and detection of the SARS-CoV-2 virus (of which 48 are public and 35 privately owned.

The road leading up to this was difficult and started with a single first step: NPHL started testing for the virus on 15 March 2020, becoming the first and only laboratory capable of such testing. WCO contributed by facilitating a partnership among NIC and a private research organization, Centre for Molecular Dynamics (CMDN), located in Kathmandu, which provided COVID-19 rRT-PCR primers and probes to NPHL to enable quick COVID-19 testing. Subsequently, WCO facilitated the supply of COVID-19 rRT-PCR reagents to NPHL. The Sukraraj Tropical and Infectious Disease Hospital was the designated primary hospital for the treatment of COVID-19 and the country began a process of establishing isolation wards, makeshift hospitals and quarantine centres to prepare for the virus.

Anticipating the challenge of transporting samples for testing from different areas of the country to NPHL, WCO selected and provided financial support to a local courier agency to ship the samples to NPHL from all 77 districts of Nepal in the first 3 months since the first confirmed case.

WCO acknowledged the requirement of high-level technical support in molecular diagnostics that the health system needed. In mid-March 2020 the Organization deployed to NPHL a senior laboratory expert through the Global Outbreak and Alert Response Network (GOARN). By the end of March 2020 more than 20 standard operating procedures  for COVID-19 testing were developed - relating to COVID-19 testing proper, biomedical waste handling, laboratory biosafety and biosecurity, and training for NPHL staff. Also, the WHO expert supported NPHL to develop surge testing plans aimed at increasing the number of samples tested each day, operating the equipment, the procurement of reagents, and allocating staff and work shifts. Responding to the request of NPHL, WCO provided direct financial support to engage additional staff in NPHL and also coordinated the recruitment process for national and international consultants and medical officers.

WCO supported NPHL in identifying and approving the existing laboratories that were subsequently repurposed to test for COVID-19. Also, WHO consultants worked closely with various agencies under MOHP – NPHL, Epidemiology and Disease Control Division (EDCD), and Directorate of Health (DOH) to develop and issue the Interim Guidelines for SARS-CoV-2 PCR laboratories in National Public Health Laboratory Network Nepal.

WCO team supported NPHL in developing and reviewing more than thirty COVID-19 diagnostic laboratory SOPs, work instructions, assessment and audit reports referring to COVID-19 specificities[1].

A fundamental aspect in the process of building laboratory capacity for COVID-19 pandemic response was the development of a comprehensive laboratory quality assurance programme for every new laboratory in the country, which WHO coordinated[2]. Also, WCO supported the development and implementation of a COVID-19 centralised management information system (MIS) and supported NPHL in data analysis. This tool showed that as of 4 March 2021 Nepal recorded a running total of 274,488 COVID-19 cases, 270,683 recoveries, and 3,010 deaths since the beginning of the outbreak. The disease has been detected in all provinces and districts, with Bagmati Province and Kathmandu the worst hit province and district, respectively. Also, 2,179,047 real-time RT-PCR (RT-qPCR) tests have been performed in 83 laboratories across the country, with the direct help of WHO.

Looking back at the process of developing the laboratory network in addressing COVID-19, Nepal has come a long way in terms of preparedness for public health surveillance and pandemic response. Almost all laboratories were performing molecular diagnostic assays for the first time in the first phase, when WHO conducted the laboratory quality assurance programme.

Nepal’s expansion of laboratory capacity presents a struggle to obtain key resources following the identification of the first case. Following this identification of the challenges, both NPHL and WHO identified strategic locations to support laboratory expansion rollout, and ultimately resulted in 83 sites being established. From this expansion, more than 2.1 million tests have been performed. Moreover, the expansion of laboratory capacity also shows how WHO CO  worked together with the regional office, WHO Collaborating Centres associated with the WHO GISRS,  GOARN and the Ministry of Health and Population, Govt of Nepal to not only expand physical sites, but to ensure quality of capacity expansion through enabling Quality Assurance mechanisms and establishing genome sequencing.

The expansion of laboratory capacity presents many lessons learned. Government, WHO, academia and the private sector came together in support of comprehensive health systems strengthening that enabled the expansion of laboratories to every district and more. Working together, key stakeholders were able to take limited resources and manpower and strengthen the lab capacity and operations so that not only was an expansion undertaken, but it was done so in relatively short time period of less than one year. In this respect, government and WHO worked collaboratively to identify the challenges and come up with strong solutions that not only addressed immediate response needs in the wake of COVID-19 pandemic, but supported Nepal’s overall health system in strengthening and scaling up human resources, capacity and equipment. Therefore, the lessons of this expansion identify the great teamwork presented by WHO and national government in enabling strong solutions for ensuring health security and universal health coverage.