At a time when the country is grappling with the coronavirus pandemic, two of the biggest stakeholders – the government and health workers – are increasingly at odds with each other.

On February 26, a student travelled back to Karachi from Iran, becoming the first coronavirus patient in the country. This was Pakistan’s first brush with a novel disease which had already overwhelmed healthcare structures in the most developed of countries.

Experts had been issuing warnings months in advance about the deadly disease.

Now that the Covid-19 was right at our doorstep, it was clear that something needed to be done. Although, the government should have been prepared for dealing with the virus, subsequent events showed that it was not.

Before the arrival of the pandemic, the Punjab government had been engaged in a pitched battle against its own healthcare professionals.

Healthcare workers, under the banner of the Grand Health Alliance (GHA), were protesting the Medical Teaching Institutes Act 2019 (MTI), a legislation meant to revamp the province’s healthcare infrastructure.

The health professionals claimed that the bill would strip them of their “civil servant” status and pave the way for the eventual privatisation of all the medical teaching institutes in the province.

This tussle had been going on for a year. During this time, the frenzied healthcare workers vacillated between negotiations, OPD closures, hunger strikes and street protests.

The government had responded with terminations and issuance of show-cause notices.

The most recent protest had taken place in the first week of March when several cases of Covid-19 had already been reported.

The sorry saga finally came to an unceremonious end when the MTI Act sailed through the Punjab Assembly on March 12, much to the chagrin of healthcare workers. The same day a Covid-19 health emergency was declared in the province.

The dynamic shifted overnight. Healthcare workers who were being harassed and intimidated by the police only days ago were declared “frontline heroes”. Government ministers showered praises and the police force presented elaborate tributes. However, this too proved to an eyewash.

As the disease spread the number of infected healthcare workers rose rapidly. Young Doctors’ Association (YDA) president Salman Haseeb says in some cases, hospitals had more infected healthcare staff than other patients.

According to a situation report issued by the World Health Organisation (WHO) issued on May 4, Pakistani doctors have emerged as the most-affected ones by coronavirus among their healthcare peers, including paramedics and nurses.

Of the 509 healthcare workers affected by the novel coronavirus, 263 are doctors (52 per cent), 171 paramedics (33 per cent), and 75 nurses (15 percent). Together, they form almost 2.5 per cent of Pakistan’s almost 21,000 Covid-19 cases.

Some 2,663 contacts of the healthcare workers were identified, according to the WHO, and 2,499 of them tested for the virus. Of those who were tested, 194 were diagnosed as positive and the results for 234 are awaited.

As the situation worsened and healthcare workers began to die, demands for proper personal protection equipment (PPE) and well-established quarantine facilities gained traction among the medical community.

On April 10, Sadaf Jamil, a staff nurse at the Gujrat tehsil headquarters hospital, succumbed to Covid-19. Her request for a Covid-19 test had been repeatedly ignored by the administration.

Her death was the main agenda when a delegation of healthcare staff met with Punjab Health Secretary Nabeel Awan on April 16.

The negotiations fell apart and Punjab Grand Health Alliance (GHA) announced a hunger strike at the health secretariat in Lahore.

The two-week sit-in culminated in an agreement on April 30. A government notification promising a “martyrs package” for health workers was issued. The YDA declared victory and its leadership passionately celebrated the agreement - but the reality is far more complicated.

Of the 509 healthcare workers affected by the novel coronavirus, 263 are doctors (52 per cent), 171 paramedics (33 per cent), and 75 nurses (15 per cent).

The agreement and the subsequent notification is largely vague and silent on issues pertaining to implementation. “The language of the notification excludes a majority of healthcare workers from the ambit of the martyrs package,” says Dr Shahid, a senior member of the YDA.

“While the notification focused only healthcare professionals performing corona-related duties a majority of the healthcare workers who had the disease were, in fact, working outside the corona wards,” he says.

Dr Jamal, a house officer serving at the Mayo Hospital, agrees.

“It’s not uncommon for corona patients, especially those with co-morbidities, to slip through the triage process and end up in the emergency room” he says. Such a slip can mean disaster for healthcare workers.

“Since the hospital administration prioritises the provision of PPEs to personnel performing corona-related duties, those in the ERs are often left without PPEs,” he says.

Dr Jamal says he himself had come into contact with suspected coronavirus patients in the ER several times.

The agreement also excludes a large segment of the junior hospital staff.

“Hospitals typically outsource cleaning operations to outside contractors who bring in their own janitorial staff. Even in normal times, this staff is not eligible for any government benefits. It is outright excluded from the meagre protections offered by this agreement” says Shahid Butt, the Punjab Paramedics’ Associations president.

Such is the situation of people who are charged with disinfecting our hospitals amidst a pandemic.

“It’s not just the janitors, paramedics and security guards too are hired through such third-party contracts.” Shahid says.

There are reports of several such employees working even after showing symptoms of Covid-19 because they have not been provided with sick leave.

Young Nurses’ Association (YNA) president Sobia highlights another important fact. The government and hospital administrations have been negligent in testing healthcare professionals.

“In the absence of a timely and accurate testing regime, notifications like the ‘martyrs package’ are pointless,” she says.

According to the agreement, after a health professional succumbs to the infection, a committee will be formulated to “investigate” the reason of their demise. The committee will “scrutinize” the duty rosters, attendance registers and the clinical record of the health worker to assess their eligibility for the package.

Such an exercise will be not be needed if health professionals are periodically tested, or at least tested when they overtly show symptoms of the disease like in the case of Sadaf Jamil.

A cursory glance at the signatories to this agreement reveals an even bigger loophole. The agreement and the notification were signed by the Specialized Health Care and Medical Education Department (SHC&MED) and apply only to those employed directly by the department or those working in facilities being run by the department.

More than half of Punjab’s population lives in rural areas. The basic healthcare units (BHUs) and rural health centres (RHCs) serving these people are the backbone of our healthcare system.

These BHUs and RHCs are run by the Punjab Health Facilities Management Company (PHFC) and not by the SHC&MED.

This means that the healthcare professionals manning our rural health infrastructure are not even a party to this agreement.

“I don’t know of any agreement; it does not apply to me,” says Dr Salman, a doctor working at a BHU in Pakpattan.

The situation at BHUs is dire. “While performing duties at a quarantine centre in Pakpattan with several confirmed Covid-19 patients, eight of us were issued only one N-95 mask and a 100 ml bottle of hand sanitizer every three days,” Dr Salman says. These professionals were posted on screening duties at hotspots like the Baba Farid shrine without thermal guns or PPEs.

“My colleagues and I worked eight-hour shifts for 40 days non-stop without PPEs. Finally, when many of us, including me, came down with symptoms, we were sent home on a 14-day leave,” says Dr Salman, still in self-isolation at his house.

The recent agreement is a temporary fix. As the number of infected healthcare staff is increasing by the day, the agreement looks extremely fragile. Widespread grievances persist.

At a press conference held by the medical fraternity of the Lahore General Hospital, the government was called out on a lack of provision of PPEs after at least 20 professionals tested positive in 24 hours.

The government was given a 12-hour ultimatum; no doctor will work in any setting (emergency or OPD) without proper PPEs.

The government must seriously address the needs of healthcare workers.