With about 143 tests/million as of April 3, Pakistan ranks among the bottom of the global list in terms of Covid-19 testing. Testing is really crucial if Pakistan wants to relax lockdowns in a way that minimises the impact of Covid-19 on healthy people, boosts the economy and helps us identify which groups and individuals need help the most.

Group testing should be considered. The idea is to test people in groups — that is, examine DNA samples drawn from several people at the same time. If the test is negative, everyone in the group is considered negative; if it is positive, then at least one person in the group has Covid-19.

A similar iteration can be done by subdividing the Covid-19 positive groups into smaller groups until the affected individuals have been identified. This approach can be more efficient than individual testing by a factor of 18.2:1 and has been used since World War II. A few countries have already started implementing this approach for Covid-19.

The first step should be to identify groups of households that we know are affected/not affected by the virus. As more tests become available, one can investigate each positive group and apply the same approach to ease the burden on other families. Furthermore, contact tracing should be practiced to monitor likely families/clusters that might get infected in the future and the next round of testing can focus on those clusters/families.

How many swabs, workers and tests may be needed for an initial mapping of the population? For 220 million individuals, assuming an average of 6.45 members/family (based on 2017 census), we will need 34.12 million swabs to test every household.

Using 113,695 workers, one can test the entire country in 2 weeks (150 households/worker/week). This is feasible given that we have around 125,000 community health workers in Pakistan. If, 35 households are sampled daily, we would need about 974,530 workers for sampling to be completed in a week.

Each worker shall require training and protective gear (PPE). If we conduct a PCR test for the pooled sample of 50-64 households, between 532,946 and 682,171 PCR kits may be needed to test the entire country in the initial round.

The optimal group size may be determined by the inverse of the prevalence ratio. The suggestion for 50 and 64 households per PCR test is based on recent trials on new methods in lab testing that reduce the number of kits needed by an order of magnitude without reducing sensitivity of test. We need Pakistani lab technicians/scientists to immediately start tests.

I assume here that a randomly selected member of any household is representative of the entire family (if one person is Covid-19 positive it’s extremely likely that the entire family is). This assumption can be tested in a pilot before scale up. Moreover, if enough testing kits are not available, one can randomly select a certain proportion of households from each region of Pakistan that allows one to identity clusters of families and selectively quarantine those clusters, until more tests arrive to dig deeper.

For the lockdown and testing to be effective we need complementary policies. First, transparency in our policy approach is critical, and we can inculcate a principle of trial and error that allows us to experiment with different ideas.

Prizes should be announced for Pakistan-specific solutions for Covid-19 by the government and the HEC grants approval mechanisms simplified. Second, safety nets are absolutely essential. The relief package announced by the prime minister is welcome but I am afraid that the amount (Rs 3,000/month) is still too little.

An alternative may be commodity transfers (adjusted to meet needs in Ramazan) and additional cash for daily wage workers conditional on individuals staying at home.

Random checks on households may be done by community workers and those not found at their homes should not be given the additional cash.This will incentivize social distancing while addressing hunger and malnutrition.

Throughout the pandemic, an authoritative independent and trusted health authority should be providing public health warnings and protocols on social distancing, hand washing etc. Education tools tailored to local languages and to different situations (e.g. those who have sick family members or those with infants/elderly) will be needed.

Addressing healthcare supply shortages will be critical.

Initially we will need to import ventilators, masks, PPE, swabs and testing kits. However, Pakistan must also cease this moment to build up capacity in surgical instrument/medical device market.

Temporary hospitals will need to be established. Healthcare workers need to be provided PPE and taken care of as first priority. A big concern here is that current hospitals will become major transmitters of disease.

Now is also the time to take telemedicine seriously. The Sehat Kahani Telemedicine App is a welcome step in this direction. We need to make sure that there is more widespread adoption of such technologies with appropriate government support.

This war is not going to be easy to win, but we have won wars before and with the right intent and smart effort we will win this war as well.

The writer is a global health economist who is currently Assistant Professor at the Department of Economics at the University of Georgia, USA