Open this photo in gallery A Canada Goose is the only visitor outside at a Covid-19 testing centre in Toronto on Monday April 13, 2020. Ontario has increased its testing since the middle of April, with the province now processing more than 12,000 samples a day. Frank Gunn/The Canadian Press

More than two weeks after Ontario Premier Doug Ford demanded a ramp-up in testing with “no more excuses,” the province still ranks near the bottom in Canada for the proportion of its population that has been screened for COVID-19.

It’s a worrying metric, some experts say, as Ontario will need much more testing if the Premier hopes to safely reopen even a fraction of the province’s shuttered economy as early as the May long weekend, as he has suggested. Meanwhile Alberta, which is already testing at twice the rate of Ontario, says it is expanding its testing beyond health care workers and high-risk groups to all Albertans with possible COVID-19 symptoms.

“I don’t know what it looks like when we try to slowly let people start to go out again,” said Janine McCready, an infectious diseases doctor at Toronto’s Michael Garron Hospital. “The only way to do that is if you can really aggressively test.”

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Ontario has increased its testing since the middle of April, with the province now processing more than 12,000 samples a day. Ontario health officials also issued a new directive last week calling for more testing of residents and staff in hard-hit long-term care homes, where hundreds have already died from COVID-19.

But the province failed to hit its original goal of 19,000 tests a day by mid-April. It has since pledged to test 16,000 a day by May 4. According to federal data, Ontario has tested less of its population, measured per capita, than all but B.C., Newfoundland and Labrador, and Nunavut.

In the face of the pandemic, governments around the world have been scrambling to secure supplies of the special swabs needed to gather samples through patients’ nostrils and the chemicals, known as reagents, required to perform lab tests to verify the presence of the illness.

But all provinces faced these challenges, bringing in criteria to ration tests and ensure health care workers and other high-priority cases are first in line So why has Canada’s most populous province failed to test more of its people, more quickly?

Senior Ontario health officials say the problem was a lack of lab capacity at the provincial government’s public-health agency, Public Health Ontario, and the decentralized nature of Ontario’s health system. Other provinces, such as Alberta, already had lab capacity to turn to under more centralized health systems, Ontario officials say.

Even after ramping up its efforts, Public Health Ontario’s own lab could only handle 3,000 tests a day, up from just 900 when testing began. As March dragged on, the province was struggling to keep up: A backlog of samples swelled to more than 10,000. Some people waited days for results.

Behind the scenes, officials were setting up a new system on the fly to co-ordinate a broader network of hospital and commercial labs. The government’s new overarching health care agency, Ontario Health, set up to centralize much of the rest of the province’s health care system, stepped in, along with consultants from accounting firm KPMG. Officials needed to sort out how to transport, track samples and collate thousands more results while helping to ensure a steady supply of swabs and reagents.

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Public Health Ontario had begun informal discussions with external labs in February, but the escalating volume of the work meant new formal systems needed to be put in place. On March 12, Toronto’s Mount Sinai Hospital, was brought onstream. Others soon followed, with 25 labs involved as of last week, and more to come. While per capita, Ontario fares poorly, as the most populous province it had still tested more people than any other, with nearly 230,000 tests in total completed as of Saturday.

“We had to do a number of things to function more like a single provincial lab system,” said Matthew Anderson, the former hospital CEO who now heads Ontario Health. “In some of the other provinces, that was designed and built 10 years ago – and we had to do it in a couple of weeks.”

After the 2003 Severe Acute Respiratory Syndrome (SARS) epidemic, as well as the more recent H1N1 influenza in 2009, Ontario was awash in warnings about future pandemics. But Vanessa Allen, the chief of medical microbiology for Public Health Ontario’s lab, said testing on the scale required by the current crisis is unprecedented.

“It’s just that the testing needs for this are, above and beyond anything we’ve ever seen before,” Dr. Allen said.

Both Dr. Allen and Mr. Anderson say they hope the new system will be enhanced and made permanent.

“How I have described it is as a silver lining to a very challenging situation,” Dr. Allen said.

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Public Health Ontario’s former chief scientist Natasha Crowcroft, now a professor at the University of Toronto’s school of public health, said the Ministry of Health should have had plans in place in advance to ramp up for a pandemic that could outstrip the capacity of Public Health Ontario’s own lab.

“It seems to me that they were late in getting that organized,” said Dr. Crowcroft. “That’s all stuff that should be in place before an emergency, not during one.”

Opposition NDP Leader Andrea Horwath also said Ontario should have been better prepared.

“It’s not good enough for the Premier to come up with these statements, saying, ‘We have prepared for every scenario.’ Well, that was just not true,” Ms. Horwath said. “There’s going to be enough blame to go around when all of this is done, for sure.”

Long before the pandemic, Public Health Ontario complained of strained resources. Its annual budget, about $160-million, had been flatlined for years under the previous Liberal government. Mr. Ford’s PC government initially planned to reduce it to $135-million last year, according to government documents, before pausing its plans. However, with the cut looming, several senior staff departed. (Its current CEO, Peter Donnelly, stepped aside from his post earlier this month, on a medical leave unrelated to COVID-19.)

In the agency’s 2017-2020 business plan, it said the demands on its lab had grown by 20 per cent over the previous five years, creating “significant pressures” that “cannot continue to be absorbed.”

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Just a year ago, Mr. Ford was locked in a battle with municipalities over his plans to force municipalities to cover the cost of millions of provincial dollars he wanted to slash from the budgets of local public-health units – now on the front line of tracking positive COVID-19 cases. After an outcry from Toronto Mayor John Tory and others across the province, Mr. Ford softened his plans last year.

Meanwhile, experts say even more testing, paired with better tracking of positive cases and their contacts, is now needed as governments look to reopen parts of the economy while still containing the virus.

Lauren Lapointe-Shaw, a clinical epidemiologist, assistant professor at University of Toronto and scientist at the Toronto General Hospital Research Institute, said Ontario needs to do much more testing if it hopes to relax its physical-distancing rules – possibly as many as 10 times more tests.

“The situation where we all have to just stay indoors and not see anyone ... is sort of putting the lid on the oven fire – the quickest way to put everything out," Dr. Lapointe-Shaw said. “If we remain in this situation where we are behind the eight ball with testing and contact tracing, it’s going to be hard to come out of physical distancing.”

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