Covid-19: Reflections on the Zikomo Presidential Awards

This past weekend, we had our weekly presidential address on Covid-19. Among the various updates President Lazarus Chakwera provided was the announcement of the Zikomo Presidential Awards, a quarterly ‘token of thanks’ to “five of the most dedicated health workers selected through nomination by their peers around the country in recognition of their service”.

At its core, this is the President committing to supporting and showing his appreciation of the hard work that health workers are undertaking on the front lines of the battle against Covid-19. This is an important step as we have increasingly seen cases of health workers being ostracised, refused access to public transport and kicked out of homes, among others, due to stigma and discrimination and myths around health workers and transmission of Covid-19. So, coming at this time, this is a welcome gesture of support to health workers from the highest office. And indeed in his speech the President denounced violence against health workers and indicated that anyone caught doing so will be prosecuted.

The address, however, came at the end of a week in which Malawi registered its first health worker deaths (a nurse in Blantyre and a medical doctor in Lilongwe) against the background of rising health worker infections, numbers now just under 400 at last count. It was a hard week, as the reality of our mortality on the frontlines became even more apparent. While awards are welcome for motivation and solidarity, they come at a time when we as health workers are more worried about whether we will be alive to see the next day. When you consider the Maslow Hierarchy of Needs— awards are at the highest level of self-actualisation, but as health workers, our current status is on basic survival needs at the bottom of the hierarchy.

If we are thinking of this as the war on Covid-19 led by health workers on the front of the battle lines; if we truly visualise the battle ahead—bullets flying around (translate to mean community transmission of Covid-19 where anyone can be infected and infect others), fellow health workers affected and dying around us, while we try to save our nation’s citizens, there isn’t really time to think of awards. It is almost offensive to even think of winning awards when we are just trying to stay alive and do our jobs and save others while we are at it.

The battle is being fought in every district, by practically every health worker. It is not an individual fight, it is a team effort, both in terms of numbers, cadres and inputs. To put this in perspective, there are teams doing direct Covid-19 work—in isolation centres, treatment units, doing surveillance, contact tracing, testing and so on—all playing various roles across all districts and being dedicated. In these, there is no individual ‘star’ performer–these are working in teams not just doctors, nurses and clinicians, but lab techs testing patients, rapid response teams following up clients, drivers picking up patients, cleaners cleaning the Covid wards, guards protecting the Covid ward doing temperature screening and preventing unnecessary visitors. Who is the most dedicated of them all? Everyone’s role helps and feeds into each other. If we must award somebody, we must award the full team. By selecting only one individual, it undermines the multidisciplinary model we are implementing for Covid-19 management. If we must have awards, we must stop looking for single ‘heroes’ but provide recognition to all involved for whatever successes we want to acknowledge at any one site.

Then there is another battle front: how to continue providing health services when attention is so much on Covid-19 yet babies are still being born, mosquitoes that cause malaria are still biting Malawians, Tuberculosis and HIV have not taken a break, cancers have not paused, accidents are still happening and many more. We are not only fighting one battle here. We have been and continue fighting the other battles mentioned above. We were in battle already even before Covid-19 and all we have added is a new battlefront on the war we were already fighting.

In this context when we start looking to award the five most dedicated health workers, it can be demoralising to the thousands of others whose work is contributing both in small and big ways to each one of these issues–both direct and indirect to Covid-19. We know the battle will be long. Some estimates indicate Covid-19 cases could continue till as late as March 2021 and beyond. So, how then can our President show appreciation to all health workers so that we go past worrying about survival in time of Covid-19 and start looking forward to winning awards.

Here are five ways the highest office can show support and motivate frontline health workers:

1. (The Armour)–Personal Protective Equipment (PPE): When in battle, you need armour to protect yourself. A recent small study in Blantyre showed at least 12 percent of health workers were in infected with Covid-19. What was good to see was that the percentage of health workers infected was not higher than the general population.

However, these figures are still worrying. We must ensure a steady supply of PPE to our health workers so that they can withstand the long battle ahead. One of the challenges has been supplies of PPE being stuck outside the country–sitting in warehouses abroad when our health workers continue to fight the battle daily and stocks of PPE in the country dwindle. The highest office can look to creating special provisions for getting this PPE in the country faster.

Additionally, incentives for local suppliers to produce PPE that meets the standards. We have seen some great initiatives from local universities and manufacturers, what perks can be given to boost these local manufacturers and suppliers.

2. (The Weapons)–Medical Equipment and Supplies: These are the guns and bullets of medical work. One of the most demoralising aspects of medical work is to know what you can do to save a life but not have the resources to do it, the medications and equipment, among others, and watch someone die because these were not available. Top of the current list is availability of oxygen for patients who get admitted.

As we know those with mild symptoms (80 percent of patients) will get better at home, without much intervention. But it is the 20 percent who get admitted who are at risk of death–apart from other medications being given, oxygen is one of the core interventions. But to truly make a difference you need a lot of it and for a long time. Measures must be pushed to get these available faster, especially in the cities and districts where cases of admissions will be highest. With caseloads rapidly rising, the urgency of this need cannot be over-emphasised.

3. (Sustenance)— Remuneration, Risk & Other Allowances for Health Workers: Malawi’s health workers are among the lowest paid in the sub-Saharan Region, and until only a few months ago, risk allowance for health workers for the added risks health workers face in undertaking work in hospital settings where TB, HIV and now Covid-19 was rife was a mere K1 800 per month. That was the added value that was put on health workers lives.

Eventually after many health workers strikes and heavy advocacy this figure has come up to around K40 000. But it is being taxed and front liners are asking that it should not be.

Additionally, we have seen strikes by health workers in various locations who have worked for months on end in Covid-19 treatment sites and not get their allowances. How demotivating can that be? The President must ensure the workforce gets their pay and relevant allowances and that there are provisions made in the new budget for these.

4. (Backup Troops)—Hire more health workers: In 2018 Malawi’s frontline health workforce had a 48 percent vacancy rate. More have been hired since then, but the gap remains huge. When we think back to the battlefield, we were fighting all the other battles (HIV, malaria, TB and so on) with half the soldiers needed to win the war.

And then we have added a new war in the name of Covid-19. Our health workers were overstretched, overworked and in short supply before Covid and now this has made the situation worse. In April, former president Peter Mutharika gave a directive to hire 2 000 more health workers. They were recruited but they are not enough. There are more graduates sitting at home doing nothing, waiting for licensure examinations or final year students who were months away from finishing school, but medical and nursing schools are closed. There are districts like Lilongwe who are meant to manage over 10 000 Covid admissions in the next year.

Apart from the infrastructure, we need the manpower to handle this additional work. The President can direct more hires and explore how these medical and nursing schools can, at the very least, help final years finish their studies and join the available pool of health workers.

5. Time with the Commander: Take time to meet and listen to frontliners. We are aware the new administration is doing many familiarisation meetings for all sectors. We know the new Minister of Health is meeting and visiting many health sites. But what a sense of true lived solidarity if the highest offices of President and Vice-President took the initiative to really spend time with health workers. Not just a familiarisation tour but to hear them out and understand what they are going through.

While they cannot do this for every front liner but for those that they do meet, they will hear what the battle is like from the horse’s mouth. At the very least, giving an audience to the various health worker associations so that they can give these updates themselves will be key. As a member of the doctors body, I know doctors are more than ready to do this, but as mentioned before this battle is not for one individual or cadre.

Our leaders need to listen to every cadre–nurses, midwives, lab staff, health surveillance assistants, among others. When the leaders can sit and listen directly to our needs, then we will truly feel appreciated and know that even if only five individuals get the Zikomo Awards, our leaders are truly saying ‘Zikomo’ to each one of us through their various other actions as outlined above.

The author is a medical doctor and public health specialist. She is currently the country director for Seed Global Health in Malawi and also an executive member of Society of Medical Doctors.