Bangladesh's Covid-19 testing criticised

Public health experts in Bangladesh have  expressed  concern  about  the government's decision to charge people for Covid-19 tests amid a sharp decline in the number of tests being done. In late June, the government decided to charge  Tk 200  (£1·80)  for  testing done  at  government  facilities  and Tk 500 for samples collected from  home  to  "avoid  unnecessary tests".  The  private  sector  charges Tk 3500 per test. Almost one in four Bangladeshis  live  below  the national poverty line.

Since  the  decision,  testing  rates have  fallen  to  around  0·8  tests  per 1000 people per day, with a low of just 0·06 tests per 1000 people in August. Bangladesh is administering on average between 12000 and 15,000 tests per day for a population of 168 million, and has recorded almost 275,000 confirmed cases and more than 3600 deaths.

Shamim Talukder, head of Eminence, a Bangladeshi public health research organisation, told The Lancet that the pandemic had exposed the country's "unethical" health-care system. "From the  beginning  of the  pandemic, the government  wanted  to  control  the Covid-19 testing system", he said. "At the beginning it didn't allow the private sector to do the tests and now they've applied a charge for testing in the public sector, which just means that the poor are excluded."

Talukder told The Lancet that he had visited  multiple  graveyards  across Dhaka, where graveyard managers had told him the death rate from Covid-19 was  "four  times  higher"  than  the recorded figure was. Many people, he said, had died of Covid-19 but had not been tested, or had died before they had received their test results.

Former Director of Bangladesh's Institute of Epidemiology, Disease Control and Research, Mahmudur Rahman, condemned the government's decision. "Charging  people  for  tests  is  really creating problems; it is creating barriers, especially for the poor", he said. "During the pandemic,  people  do  not  have work, they do not have money, they're at a huge disadvantage...Governments should not charge anyone for testing."

Other barriers  to  testing,  Rahman said, include the low trust people had in the health-care system. "We've had testing scams here. There is a lack of confidence in the health-care system, so people don't want to get tested because they don't want to get a result they don't trust", he said. "Another problem is the delay in getting the results- sometimes it takes a week, other times it just doesn't come. If someone needs a result immediately, why bother? They just stay at home instead."

In mid-July a Bangladesh  hospital owner  was  arrested  over  allegations he issued thousands of fake negative Covid-19 test results, further shining a light on the country's unregulated private sector. Rahman called for the country  to  urgently  set  up  a  sentinel  surveillance  system,  as  in  2009 in  response  to  the  H1N1  influenza pandemic,  which  would  enable  a better understanding of the  virus  at the  community  level  to  see  where the infection was moving and to plan accordingly. "This sort of surveillance is  crucial.  If  people  are  not  coming for  testing,  then  there  has  to  be  a mechanism in place so we can under- stand the situation of our country."

A  doctor  in  Dhaka,  who  spoke to  The  Lancet  on  the  condition  of anonymity, feared what was coming.

 "In a country of more than 165 million, that  is  performing  a  maximum  of 15,000 tests per day, it is nothing and largely those tests are just being done in Dhaka itself", he said. "This plague will stay for quite a long time. What I'm afraid of is when the Bangladeshi winter arrives. People are afraid."

Talukder said that the pandemic had further exposed the country's failing health-care system, which spends just 0·69 per cent of the country's Gross Domestic Product on health, making Bangladesh one of the lowest spenders on health globally. Moreover, two-thirds of health expenditure is out of pocket and borne by households, many of whom  are propelled into poverty by catastrophic health-care costs.

Talukder   called   for   a   complete restructuring of the health-care system, which would include banning doctors who work  in the  public  sector  from supplementing  their  income  with private practice, which has led to the neglect of patients in public facilities, among  other  interventions.  "Most people do not like to go to the hospital due to the poor quality of services and they do not want to go to the private sector because of the high price", he said.

With Bangladesh in the grip of the monsoon season and the  dengue season approaching, all three experts expressed  concern  about  Covid-19 continuing   to   spread   unchecked throughout the country. They feared that the worst was yet to come. "The government's priority is the economy, [but] Covid-19 will continue to spread into rural areas and more people will die", Talukder said.

The  ministry  of  health  did  not respond  to  The Lancet's  request  for comment.

[Source: www.thelancet.com

(Vol 396, August 29, 2020)]