Inequalities and determinants of unmet need for SARS-CoV-2 testing in Ghana, Burkina Faso and Madagascar (2020 – 2021)

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BACKGROUND: Many sub-Saharan African countries faced considerable challenges in containing SARS-COV-2 transmission due to limited capacity to test and treat all those affected. While previous studies have measured testing uptake, no study has examined uptake in relation to WHO testing criteria. We assess unmet need for SARS-CoV-2 testing in Ghana, Burkina Faso, and Madagascar as a measure of health system preparedness, defined as the gap between individuals meeting WHO testing criteria and those actually tested. METHODS: We used urban population-based data from 2434 households in Ghana, Burkina Faso, and Madagascar sampled between February and May 2021. We defined unmet need for testing using three measures (serological, exposure-based, symptom-based) aligned with WHO testing criteria and used logistic regression models to examine associated factors and concentration indices to quantify socioeconomic inequalities. RESULTS: Here we show that unmet need for SARS-CoV-2 testing is high, ranging from 93% to 95% across all three countries, regardless of the measure used. Socioeconomic inequalities exist, with the poorest quintile experiencing the highest unmet need. Wealth, travel history outside the city, and perceived COVID-19 risk are associated with lower unmet need. CONCLUSIONS: Our findings reveal critical weaknesses in health system preparedness that call for urgent measures to strengthen testing capacity and ensure equitable access for both routine care provision and future health crises.

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