Provider costs of professional COVID-19 rapid antigen testing in low-income settings

World Health Organization recommends antigen rapid diagnostic tests (RDT) as point of care tests for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in suspected outbreaks when polymerase-chain-reaction testing is not accessible; to trace the extent of outbreaks; and in areas with widespread community transmission. Annual economic costs were estimated for professional SARS-CoV-2 testing as part of several COVID-19 testing use cases in Malawi, Nigeria and Zimbabwe. Symptom screening and antigen-based RDT was implemented as part of a multi-country, Unitaid/STAR 3ACP (Africa, Asia, America COVID-19 Prevention) funded project (April 2022-June 2023). Testing services were provided through trained health providers in outpatient departments of primary care facilities (Malawi and Nigeria) and two primary non governmental organisation (NGO) use cases separately targeting key population (KP) and the general population in Zimbabwe. Combined financial expenditure analysis and on-site micro-costing took the provider/health system perspective in 2025 US$. Per test average costs were $9.73 (range across sites: $5.49-$29.90) in Malawi, $13.99 ($11.64-US$18) in Nigeria and $10.11 ($4.19-$209.09) and $19.98 ($10.76-$56.40) in Zimbabwe for general population and key population clinics respectively. Average costs per positive case identified were $521 ($61-$800) in Malawi; $1,118 ($202.66-$4,804.45) in Nigeria; and $1,125 ($336-$ 1,762) and $187 ($161-$ 1,272) in Zimbabwe. Major cost contributors were test kits in Malawi, test kits and building (consultation room space costs) and storage in Nigeria and personnel and training in Zimbabwe. Excluding above site level costs, the average cost per SARS-CoV-2 test was $9.73 in Malawi, $13.99 in Nigeria and $10.70 and $9.79 in Zimbabwe. Integrating COVID-19 testing into existing sites can reach people at high risk of severe illness at a reasonable cost. For resource-limited settings where programmes are threatened by low fiscal space, costs might be reduced when scaling up, through greater spreading of startup and capital costs.