The NeoTest working group aims to accelerate the development and uptake of neonatal sepsis diagnostics in low- and middle-income countries (LMICs). A joint initiative of the Center for Global Development (CGD) and the Market Shaping Accelerator (MSA), we are designing a pull incentive mechanism centered on an advance market commitment (AMC). In February 2026, the working group convened for its second meeting, to move from broad exploration toward concrete design choices across four areas:
- Target product profile (TPP)
- Pull incentive design
- Country partnership
- Implementation architecture
Across all four domains, the second working group clarified where there is convergence, where decisions are yet to be finalized, and what it will take to design a credible, implementable pull incentive. Below, we summarize the core insights from the second working group.
1. Target product profile
Key takeaway: Our priority is a rapid, accurate, and easy-to-use triage diagnostic to rule sepsis in or out, building on the World Health Organization (WHO) TPP. Some parameters, particularly cost and allowable sample types, are still to be finalized.
At our first working group in August 2025, WHO—building on prior work from ICMR and other partners—introduced their target product profile for a rapid neonatal sepsis triage test. The second working group meeting focused on grounding this TPP more firmly in evidence and resolving areas of prior contention, particularly the central question: is there a credible, scalable use case?
Following our first meeting, the NeoTest secretariat developed additional epidemiological modeling, early health economic analysis, and technical feasibility assessments. Based on this evidence, the working group endorsed the WHO TPP and agreed to focus on:
- A rapid triage test to rule serious infection in or out i.e., guide initial management decision on whether to start antibiotics. The group thought such a test was a necessary upstream building block for more specific testing and targeted treatment later.
- An accurate and easy-to-use test. There is a significant and clear use case for testing newborns in a “gray zone” with non-specific signs and risk factors. To inform decision-making for this use case, a test should be accurate, easy to use and give results within 30 minutes.
- A test for primary healthcare and hospitals. Neonatal sepsis is not confined to secondary and tertiary hospitals. Neonates are born and managed across primary-level facilities and hospitals, and clinical decisions that affect outcomes are made at both levels. The group agreed this matters for design: if the test is only usable in higher-level facilities, it risks missing a large share of the addressable clinical pathway.
There were two design parameters which received focused discussion and which remain to be resolved:
- Sample type and format. The WHO TPP focuses on diagnostics using capillary blood sampling. During the meeting, the working group supported allowing less invasive samples than capillary blood, and were excited by the opportunity that artificial intelligence and machine learning based diagnostics present. However, some members flagged risk in integrating such tests into clinical workflows, and ensuring regulatory acceptability.
- Price of tests. Price was discussed as being a binding constraint, especially in resource-constrained and out-of-pocket settings. Participants encouraged us to sharpen the TPP’s cost framing and consider thinking about “cost per test delivered,” rather than relying on a cost of goods.
2. Pull incentive design
Key takeaway: A hybrid milestone and AMC model is well-supported, but will not succeed without explicit implementation support.
We entered the meeting with a working proposal: a hybrid pull incentive combining (1) a milestone award that rewards the first innovators who meet a defined TPP and regulatory threshold, and (2) an AMC that rewards commercialization and use in LMIC settings over time. The group broadly agreed with the logic of a hybrid, with a milestone accelerating successful innovation, and an AMC encouraging scale-up whilst maintaining competition between firms and allowing for a test of market fit.
The group was concerned that this structure alone may not be sufficient; in LMIC diagnostics markets, demand does not automatically materialize once a product exists. Fragmented procurement, unclear clinical guidelines, constrained diagnostic budgets, and limited implementation capacity can all suppress uptake.
This led to a strong emphasis on pairing the pull incentive with deliberate implementation support to encourage market formation. While there was no consensus on a specific instrument design during the working group meeting, the economists of the working group convened afterward to work through how to operationalize this principle This resulted in a new, third component to the pull facility: an implementation support fund, which would bridge the milestone and AMC. The fund would be dedicated towards demand-side work, including guideline development, adoption support, and evidence generation that decision-makers actually use, as well as credible early signals to manufacturers that reduce commercial risk during initial uptake.
| Stage 1: Milestone | -Post-working group addition-
Stage 2: Implementation support |
Stage 3: AMC |
|---|---|---|
| A shared, lump-sum prize awarded to the first innovator(s) that produce a test meeting a TPP | Flexible funding to several countries to address context-specific barriers to adopting diagnostics | A per-unit “top-up” payment for every qualifying test sold, complemented by a co-payment from the procurer |
3. Country partnership
Key takeaway: Country ownership must shape the design, but engagement must be carefully staged given that products do not yet exist.
On country engagement, the group converged on both a principle and a practical challenge.
The principle is that country ownership must be central. Countries will ultimately determine what “fit-for-purpose” means—shaping product requirements, evidence standards, and adoption pathways. Participants emphasized the importance of engaging not only ministries of health, but also procurement agencies, regulators, professional associations, and relevant private sector actors.
The challenge is one of sequencing. NeoTest is operating upstream of product availability, which makes traditional engagement models difficult. Countries cannot reasonably be expected to commit resources or make decisions about products that do not yet exist.
This points to a staged approach: early engagement to understand decision processes and reduce uncertainty, while avoiding premature asks. Designing this engagement carefully will be critical to ensuring both relevance and feasibility.
4. Implementation architecture
Key takeaway: There is no obvious delivery model for a pull fund for diagnostics, and getting the administrative architecture right will be central to credibility and feasibility.
Finally, we discussed what it would take to implement a pull facility in a diagnostics market where there is no centralized procurer, such as there is for vaccines or for conditions such as tuberculosis or HIV/AIDS.
Because there is no single global buyer that can aggregate demand and manage long-term contracting, neonatal diagnostics typically face fragmented procurement channels. That complicates both verification and disbursement for an AMC-like instrument, and it increases transaction costs for firms trying to serve multiple markets. The group discussed plausible implementation models and the roles different institutions could play, ranging from global health market-shaping organizations to development finance institutions that may be better positioned to structure funds, manage risk, and coordinate across donors and countries. The secretariat is currently exploring partners who have the ability and credibility with countries, funders, and innovators to help host and administer the funding facility.
Moving toward implementation
The second working group moved NeoTest decisively toward implementation. It confirmed that the TPP is grounded in a real, cross-setting use case while clarifying remaining design choices. It sharpened the pull incentive approach, reinforcing that a milestone + AMC structure must be paired with explicit market formation efforts. It provided a clearer framework for country engagement that balances ownership with practical sequencing constraints. And it elevated implementation architecture as a central design challenge in fragmented diagnostics markets.
Over the coming months, as NeoTest transitions from deliberation to implementation, we are also launching the NeoTest Playbook (outlined here). In this playbook, we will publish our final decisions across each of these four pillars, as well as the analyses that underpinned those decisions.
Figure 1. The NeoTest working group in London
We are grateful to the members of the working group, including representatives from Boston University, CARB-X, CHAI, CGD, Dartmouth College, Duke University, FIND, Harvard Kennedy School, ICMR, KEMRI, London School of Hygiene and Tropical Medicine, MedAccess, NEST360, ReAct Africa, University of Lagos, University of Southern California, and the WHO.
We are deeply grateful for the generous support of our primary donors, Coefficient Giving and Bukhman Philanthropies, whose partnership has made this work possible. Their support has enabled us to convene leading experts, undertake the analyses that underpin this work, and advance an initiative that could save hundreds of thousands of newborn lives.