A Comparative Policy for the COVID-19 Emergency Management of Frontline Health Workers in Selected African Countries

Health workers are often exposed to health risks and danger in the discharge of their duties. This is especially distressing during the COVID-19 pandemic. This study employs a multiple case study design to investigate the COVID-19 emergency management of frontline workers in South Africa, Kenya, Ghana, and Nigeria. The findings from the study reveal that governments in the selected countries prioritize the response phase of the emergency management theory over the mitigation and preparedness phases. The response phase was meted with inevitable consequences. Health workers feared risking their lives, and the majority threatened to abandon their jobs due to insufficient personal protective equipment (PPE) and welfare support. The study concludes that the government should prioritize all the phases of emergency management instead of focusing on the response phase, which involves the use of both human and financial resources on an overwhelming pandemic. They should have prepared the frontline workers adequately and equipped their health systems in preparation for any impending epidemic.

Tyanai Masiya is a senior lecturer at the University of Pretoria's School of Public Management and Administration (SPMA). He holds a PhD (Public Administration) from the University of the Western Cape. His research focus is on Public Administration and public policy, with specific emphasis on public service delivery, citizenship and democracy as well as local government management. He has also written extensively on constitutionalism, democratisation as well as transparency and accountability of the state.

Introduction
As both the developed and  (Mangai et al., 2018, p. 146; World Health the pandemic are those who contracted the disease and the frontline workers whose profession is to save lives. They are in the frontline to fight the COVID-19 pandemic. According to WHO (2020a), the hazards which place the frontline workers at risk of infection are "pathogen exposure, long working hours, psychological distress, fatigue, occupational burnout, stigma, and physical and psychological violence" (p. 1). The present study focused on the emergency management (EM) of frontline workers during the COVID-19 pandemic and how the government adopts ways to reduce the vulnerability of frontline workers to the pandemic.
Prior to the COVID-19 pandemic, a number of frontline workers in Africa died, risking their lives due to the lack of equipment, environmental health hazards and their lives directly targeted by individuals and communities (WHO, 2015). During the COVID-19 pandemic, the death toll among frontline workers across the globe rose significantly (WHO, 2020a). Further, the WHO spokesperson reported that in April 2020 alone, there were more than 35 serious incidents in over 11 countries that involved attacks on either individual health workers or groups (WHO, 2020c).
The occupational risk frontline workers undergo during the COVID-19 pandemic has worsened because of the nature of the outbreak and partially due to the overreaction by individuals or communities who are uninformed, scared and do not fully understand the severity of the pandemic themselves (WHO, 2020b). Frontline workers endure assaults because they are perceived as bringing the health hazard of COVID-19 back to their communities. However, they simultaneously face the traumatic pressure of exposing their families to the pandemic while worrying about contracting the virus themselves (Schwikowski, 2020;WHO, 2020b).
At the time of writing this paper, Africa had recorded more than 3400 COVID-19 infected frontline workers (WHO, 2020b). This has raised the question of the significance of EM and whether the policy response to inhibit and control the infection among frontline workers is adequate.
The pandemic experience further demonstrates that government policies matter and have a key role to play in leading and coordinating preparedness, response, and recovery among infected frontline workers. Capacity development must be activated swiftly and adjusted to the demanding and fast-evolving epidemiological and health challenges faced globally (Kauzya, 2020;Uroko, 2020;WHO, 2020c).
To combat the outbreak and reduce the risk of the pandemic on frontline workers, proactive, effective, accountable, and inclusive policies along with innovation in healthcare service delivery is critical. Fortunately, many African countries moved fleetingly toward readiness in policy response as more COVID-19 cases were confirmed on the continent (Kauzya, 2020).
This study sets out to answer the following research questions: (i) How is the COVID-19 EM of frontline workers expedited in South Africa, Kenya, Ghana, and Nigeria? (ii) How did the respective governments reduce the vulnerability of frontline workers to the COVID-19 pandemic in South Africa, Kenya, Ghana, and Nigeria?
The study employed the four phases of EM theory to explain the handling of frontline workers during the COVID-19 pandemic and specific policy responses implemented to reduce the risk of the pandemic on frontline workers. Our contribution to scientific knowledge is an investigation of the vulnerability of frontline workers to  and how the government responded to reduce the risk of the pandemic on frontline workers. To achieve this aim, a multiple case study design and a qualitative approach was used.
The selected countries are considered regional powers in sub-Saharan Africa. Hence, lessons learned from the selected countries could be utilized to strengthen frontline workers management in the rest of the sub-Saharan region.
Moreover, these countries recorded the earliest COVID-19 cases on the continent. The various experiences related to effective policy actions to control and manage COVID-19 risk among frontline workers in the selected countries are also considered. Subsequent sections of the paper will discuss the theoretical underpinnings of disaster management and the role of street-level bureaucrats during a disaster, followed by a section on the adopted research methodology. The next section expounds on the results and detailed discussion, followed by a conclusion.

Disaster and Emergency Management
Disaster and EM literature explains how society responds to: (i) a sudden circumstance threatening core values; (ii) unpredictability of the circumstance; (iii) urgency of the action to be taken; and (iv) immediate action to be taken (McEntire, 2005;Rosenthal et al., 1989).
The following constitute the characteristics of a disaster: the virus can reproduce quickly and spread through human-to-human contact (this occurs when infected persons incubate the virus unknowingly and spread it to others), the mutation of the virus happens rapidly, and the virus causes 'multiple waves' of victims.
Resolving the circumstances would include specific management challenges associated with sense-making, policy-making, reforms, public information, learning, and accountability (Weible et al., 2020).
According to Weible et al. (2020, p. 235), "disasters/emergencies such as COVID-19 pandemic demand swift and coordinated action that adapts fluidly to condition". Coordination requires various agencies, levels of government and policy cycles to participate. The interplay between the policymakers who formulate the policy, public administrators who interpret it, and street-level bureaucrats who will operationalize and implement the policy on the ground is necessary to manage and eventually combat the disaster/emergency. Certain schools of thought assume the role of the street-level bureaucrats encapsulates an entire policy cycle (Lipsky, 2010).
This suggests that adequate policy response is required to manage their welfare, considering the crucial role they play in disaster and EM (Erasmus, 2010;Weible et al., 2020). Resistance could come in the form of, inter alia, strikes, protests, and absenteeism (Erasmus, 2010).
In a disaster/emergency like the novel COVID-19 pandemic, the role of street-level bureaucrats who are considered government implementers or frontline workers is critical as it was in similar crises, for example, Ebola, AIDS, Lassa fever, etc. (WHO, 2015). They are left to develop creative strategies, standards, and procedures to manage the difficult tasks assigned to them in unprecedented times (Hupe, 2013;Weible et al., 2020). Frontline workers, in particular, undergo hospital rounds and heuristics as essential services in their response to contain the COVID-19 pandemic. This is aside from their schedule to manage staggering COVID-19 positive cases while coping with the short supplies of medical equipment (Erasmus, 2010;Schwikowski, 2020;Weible et al., 2020;WHO, 2015). Weible et al. (2020) gave credence to the fragmentation that can complicate the implementation of a pandemic response such as COVID-19. This strengthens the argument that the COVID-19 pandemic places frontline workers in a self-regulatory and discretionary position and in a position to resist government expectations through industrial action, protest and even absenteeism (Erasmus, 2010). In order to avoid frontline workers resistance during the fight against a novel pandemic such as COVID-19 disaster, appropriate frameworks should be implemented to support and protect them from the risk of the pandemic.
A theoretical framework from the EM theory is developed in Figure 1 below to analyze the 'before', 'during' and 'after' of COVID-19 EM of frontline workers. EM is an "organized analysis, planning, decision-making and assignment of available resources to mitigate, prepare for, respond to and recover from the effects of all hazards" (McEntire, 2005, p. 45). The four phases (mitigation, preparedness, response, and recovery) of EM theory are employed to save lives, prevent injuries, and protect properties and the environment before, during and after the disaster.
The first phase, which is mitigation, occurs before the disaster. In this phase, efforts are made to reduce the risk and impact of the disaster, and the loss of lives and properties to the lowest minimum should a disaster occur. At this stage, hard choices are made to understand local risks, and investment in the long-term well-being of the people is the norm.
Preparedness is the second phase and also occurs before the disaster. During this phase, a coordinated approach and operational readiness in the form of adequate planning, training, organizing, evaluating and corrective actions are put in place to combat any upcoming disaster.
The level of readiness in Phases 1 and 2 would determine the degree of risk and impact of a foreseeable disaster. When the disaster eventually occurs in the third phase -an integrated response is required. The deployment of necessary capabilities to save lives and properties, stabilize the situation and restore the people and community to a stable and functional state becomes a priority.
The third phase of EM occurs during the disaster and transition to the fourth phase, which is the recovery phase. In the recovery phase, efforts are made to return society to a "normal" state. This is the process of ensuring everything is restored after the disaster hits.
The public sector is predominantly responsible for EM, and research in the field is focused on the public officials in this arena to deal with or prevent the disaster. During the COVID-19 pandemic, frontline public officials were involved in dealing with infected patients, maintaining lockdown rules and a host of related professional assignments. However, the four phases of EM could be utilized to study the interplay of the government and other stakeholders and sectors in the mitigation, preparedness, response, and recovery of the COVID-19 pandemic in general.
This study only focused on the COVID-19 EM of frontliners using the four phases.
As earlier reiterated, the crucial role of frontline workers in a disaster such as COVID-19 cannot be ignored. A proactive and comprehensive EM is required to prepare the frontline workers before, during and after the COVID-19 pandemic. The results were presented using networks and Code-Document Table. The networks were used to visualize the results (see Figures 2, 3 and 4), while the Code-Document Table illustrates the outcomes of the comparison analysis from the document groups and the themes that emerged from the theoretical framework (see Table 2 below). The findings are presented in the results and discussion section. Certain studies revealed the benefit of multiple case studies to include representativeness and robustness (Anderson et al., 2014). However, the limitation of this study is the inability to collect and analyze primary data from policymakers about why there is no preparedness against disaster and emergencies on the continent and what they would do differently to mitigate pandemics, such as COVID-19, in the future. It is also acknowledged that this study does not fully represent the COVID-19 narrative in Africa. Nevertheless, it is hoped that other African countries will learn, replicate, and adapt the study findings.

Results and Discussion
The results and discussion section presents the EM variables and how government policy reaction led to the marginal or substantial impact of COVID-19 on the frontline workers in South Africa, Kenya, Ghana, and Nigeria. The thematic variables in the theoretical framework in Figure   1 was inductively coded in the data that was analyzed using Atlas.ti 8. These themes form part of the focal discussion in this section. One of the recurring codes from all the selected countries is "inadequate PPEs" (see Figure 3). The result of our analysis revealed that in the wake of the COVID-19 pandemic, many  Governments in the selected countries did not hesitate to avail the PPE; however, it was adjudged by the frontline workers to be limited in supply (Schwikowski, 2020;Tshangela, 2020).

Workers against the COVID-19 Pandemic
It is unfortunate that these governments only became responsive to providing PPE during the COVID-19 pandemic. A Nigerian doctor said: "Coronavirus is a blessing in disguise". He was, on the one hand, happy that the health equipment they had been requesting for extended periods had Policymakers did not hesitate to meet this demand (Adejoro, 2020;Hasnain, 2020). There was a swift policy response to increase the COVID-19 risk allowance, which in the end, minimized the rate of frontline workers absconding from their duties for fear of contracting the COVID-19 virus (Engelbrect, 2020). The COVID-19 pandemic exposed the poor remuneration that frontline workers in Africa receive in the health sector. The health sector is one where both health and nonhealth workers receive risk or hazard allowance as part of their wages (Drager et al., 2006;Hasnain, 2020). The reason for the risk allowance is obvious because this set of workers interface with patients who might visit their health facilities with highly contagious diseases. As a result, they are vulnerable and exposed to the disease themselves.

For many decades health workers in
Africa had expressed dissatisfaction with their remuneration and especially hazard allowances (Drager et al., 2006;Adejoro, 2020;Schwikowski, 2020). In a study conducted by Drager et al. (2006) on the "health workers wages in more than 150 countries" (p. 2). They revealed that health workers' monthly wages in high-income countries are five times higher than most of the low and middle-income countries. The average monthly wage rate in high-income countries is between US$6000 to US$10000, while in low and middleincome countries it is US$150 to US$2000. The huge wage difference is regardless of the control for contextual factors in the model.
There was a hike in the frontline workers risk allowance due to COVID-19 in the selected countries of this study. In Nigeria, before the COVID-19 pandemic outbreak, the frontline workers received N5,000 monthly equivalent of US$12.81 as a risk allowance. In the wake of the pandemic, the government responded to the numerous and backlog of complaints from health workers and increased their risk allowance by N620,000 (US$1,588) per month (Olufemi, 2020;Uroko, 2020). At the federal level, the minister of health said: "A special COVID-19 hazard and inducement allowance of 50 per cent of Consolidated Basic Salary will also be paid to all health workers in Nigerian Teaching Hospitals, Federal Medical Centres, and designated COVID-19 centres for the first three months in the first instance" (Adebowale, 2020, p. 1). Moreover, 5,000 frontline workers are also granted life insurance.
Similarly, in South Africa, the government perceived the frontline workers' allowance as a form of compensation and recognition for their direct exposure to the danger of the COVID-19 pandemic. The allowance was tagged "special danger allowances related to COVID-19" (Tshangela, 2020). The pre-COVID-19 standard risk/danger allowance was R474 (US$27) per month, which is now increased to R709 (US$40) as a special risk/danger allowance (Hasnain, 2020).
Although the incremental risk allowances were disproportionate across these countries, there are, however, similarities in the way their governments responded to increase the frontline workers risk allowance. Frontline workers would receive a special COVID-19 risk allowance for a period of 3 months (April to June). While COVID-19 may outlast three months, it is unclear whether these governments would continue to pay the new risk allowance in a post-COVID-19 era.
In the past, governments in Africa have not responded appropriately to the healthcare workers welfare package (Drager et al., 2006). It is expected that the COVID-19 pandemic would be a caveat for better policy responses to the health, safety, protection, and welfare of frontline workers. Ghana had presented a sound example of a prepared response to the pandemic (Adejoro, 2020). It would appear that the Ghanaian frontline workers' risk allowance was equal to their expectations. Hence, no protest was recorded at the time they were most needed to fight COVID-19.
This illustrates the Ghanaian government as proactive and responsive to the value it places on the welfare of its frontline workers. However, it took the other selected governments the COVID-19 pandemic to value the contribution of frontline workers. It can be inferred that much can be learned from the Ghanaian approach toward its health policy.
A positive spin-off from the COVID-19 pandemic is that the selected African countries have implemented swift policies and strategies to solve their problems. E.g. Even though the production of local health equipment may not be a direct benefit for the frontline workers, it does impact on their psycho-social stress, which is part of the determinants of health workers epidemic infections identified in the literature (Erasmus, 2010;WHO, 2015). The discussion above shows that it is possible to make swift policies when needed. These can be lessons for governments, post the pandemic, in response to other urgent issues such as the deep poverty and inequalities in many African countries. It is worth noting that the South Africa government also introduced an array of measures to also support both the business sector and its citizens (in particular, marginalized groups such as the poor) with economic recovery packages and social relief or protection measures.
In conclusion, the pandemic revealed that the COVID-19 EM does not have to be an extended process and quick-fix solution to frontline workers' support or occupational health and safety.
Governments must be ready to invest in their health workers and their facilities to ensure it is always work-ready. The face of a pandemic revealed that policymakers could take swift decisions.

Theme 3 -Recovery of Frontline Workers after the COVID-19 Pandemic
From the theoretical framework in Figure   1, the last phase of the COVID-19 EM of frontline workers is the recovery phase. Since this study was conducted during phase 3 of the EM of  (Catton, 2020, p. 2).
The director called on national governments and the WHO to ensure there is a systematic collection of infection and deaths among frontline workers, which is centrally held by the latter. It is hoped that this suggestion would go a long way, respecting frontline workers who have sacrificed their lives but also inform preventive strategies such as addressing pertinent issues, such as the lack of PPE and frontline workers' welfare.  From the number of codes utilized in the data for each country, there is a considerable difference between Theme 2 and the remaining themes.
Governments in the selected countries focused more on the EM of frontline workers during the COVID-19 phase than the 'before' and 'after' phases. Theme 2 has 70% code usage in Nigeria and more than 50% in Ghana and South Africa; however, less than 50% in Kenya. This reveals that these governments prioritize phase 2 over phase 1 and 3 of the EM theory. Instead of focusing on the response phase, which involved

Conclusion
This article endeavored to analyze the management of frontline workers using the four phases of the EM theory. Inadequate funding, low medical supplies and understaffing have characterized the health systems in Africa (Mangai et al., 2018). Moreover, a sudden and vile pandemic like the novel COVID-19 has further exposed the unpreparedness of the health sector in Africa (WHO, 2015;Schwikowski, 2020