A Memorandum of Understanding (MoU) was signed by the Ministry of Health (MoH) in Malawi and Haukeland University Hospital (HUH) to support surgery service delivery and develop a training programme in general and orthopaedic surgery at Kamuzu Central Hospital (KCH).
2008 - 2012:
At least one surgeon from HUH has been at KCH full time since March 2008 to support the surgery training programme. More than 2 million US$ worth of equipment have been donated to KCH through HUH. Four medical engineers at PAM have been trained through a one year diploma course in Zanzibar to maintain the equipment and support has been given continuously through HUH engineers. A support project with the departments of Pathology and Radiology was established to ensure that KCH had the proper facilities for surgical training. HUH has on several occasions assisted KCH engineers in keeping the CT machine and other vital hospital equipment running through guidance and donation of spare parts and tools. Orthopaedic surgery is not possible without a considerable amount of modern equipment.
An idea for LION was developing in the KCH surgery department with support from the KCH hospital director.
The CEO of Haukeland University Hospital (HUH) visited KCH, and met with the Ministry of Health (MoH) together with the Permanent Secretary (PS), the Director of Clinical Services, and representatives from Department of Planning. In this meeting the idea of LION was presented and KCH was encouraged to continue the work.
A preliminary steering committee was established, consisting of the KCH Hospital Director Dr N. Alide (KCH/MoH), Head of Orthopaedic Surgery Dr L. Banza (KCH/CBM), Dr S. Young orthopaedic surgeon (KCH/HUH) and director of Department of International Collaboration at HUH Mr J. W. Dahl.
HUH facilitated expansion of support for surgical training to include Queen Elisabeth Central Hospital (QECH) in Blantyre through a new 3 million US$ “NORHED” grant over 5 years from the Norwegian Development Agency (NORAD) to make the surgery training programme a national programme.
In March a new visit from the CEO at HUH took place and another meeting were held specifically about the LION project. The necessity of keeping the first cohort of trained surgeons from KCH training programme at KCH to sustain the training programme for the benefit of the nation were also discussed at this meeting. A letter of commitment was written as support of the project, the establishment of the LION trust and HUH was encouraged to start fundraising. At this meeting the team was put in contact with Department of Planning for further development of the project. All steps since have been made in collaboration with MoH Department of Planning, including the Director of Planning.
A MoU was developed by the initial partners (MoH, CBM and HUH), and the agreement was vetted by Ministry of Justice (MoJ) who also approved the establishment of LION Trust.
Later this year a workshop was held with AO Alliance Foundation were the partners agreed to apply for 1 million US$ for the LION project.
Support for training of future Malawian Neurosurgeon for LION in Addis Ababa was secured through HUH connections with Addis Ababa University (AAU). Fellowship funded through joint venture of HUH, GIZ and the NORHED programme.
In January a new visit from the CEO at HUH took place with official signing of the LION MoU outlining the key areas such as allocation of land, financial independence, staffing structure, finance of staff and running costs, and retention of staff being trained for the facility. A KCH surgery resident Dr K. Kumwenda started his neurosurgery training at Addis Ababa University (AAU).
A new master plan for KCH needed to be developed before land allocation to LION Trust could be completed. The formal land allocation letter for LION project came in June 2015 and the Government of Malawi Public Sector Investment Plan (PSIP) was included in the project.
The AO Alliance Foundation Fracture Care Initiative was launched by the Minister of Health, Dr Peter Kumpalume, in Blantyre on December 1st 2015. AOAF confirmed 1 million US$ contribution to LION project, with possibility for more funding if the Trust is established. Burden of injuries and LION project was presented and the honourable Minister gave his support to the project.
In November a LION Trust Deed was developed and already in December the Deed was vetted and approved (with some edits) by MoH. The Board members of LION was identified and accepted. Within the first few months of 2016 the Trust Deed was also vetted and approved by the Ministry of Justice (MoJ).
In March 2016 the new CEO of HUH came to visit Lilongwe to be introduced to the project and the progress so far. A meeting with Directorate of Planning and Policy Development (DPPD) and the planning team at MoH took place on March 2016. The DPPD reiterated to the Government of Malawi (GoM) the need for support for staff and running costs for LION when operational.
On November 3rd 2016 the first LION Trust Board meeting was held and the Trust was officially established. Mrs Grace Mkupu was elected Chairman of LION Trust, Dr Sven Young was engaged as CEO and secretary to the LION Trust Board, seconded by HUH.
In parallel with the establishment:
While working towards the realisation of LION a refurbishment of KCH's Main Operating Theatres and construction of Department of Surgery's office block was funded by The Royal Norwegian Embassy in Lilongwe, Malawi through Norwegian Church Aid. This was necessary in order to scale up trauma services to meet the increasing demand in Lilongwe and the districts while waiting for LION.
On April 12th 2017 the Minister of Justice signed the LION Trust Certificate of Incorporation, officially confirming the legal establishment of the Trust and ensuring the legal independence of the LION Trust.
In April a comprehensive workshop were held where the stakeholders could comment on the design of LION. All relevant departments at Ministry of Health and at KCH were represented in addition to the Medical Council of Malawi (MCM), the Nursing Council, Department of Building (DOB) and the architects, MOD Chartered Architects. CBM reiterates support and wish to fund a stand-alone project to fund the rehabilitation building for LION.
A cost estimate from MOD indicated that the phase 1 construction could only incorporate surgery and administration buildings with the funds that had been raised so far by HUH and AOAF. HUH applies to a private donor who contributes 1.5 million US$ more bringing the total phase 1 budget to 5 million US$ and making it possible to include the Ambulance & Emergency building and the Outpatient Department (OPD) building in phase 1.
Throughout the year the LION CEO and a consultant in hospital architecture in Seattle, USA give extensive feedback on the drawings, and the various user groups at KCH are consulted in every step.
In July/August the process for prequalification of contractors is completed and 4 contractors are approved for tender. In December the construction of LION Phase 1, including buildings for Administration, Surgery, A&E and OPD, went to tender.
An application regarding staff establishment review for LION was sent from Directorate of Human Resource and Management Systems (DHRMS) to the National DHRMS in December.
In February there were a workshop with Government of Malawi and the LION Trust to agree on the way forward for construction of LION and financing of staff and running costs. The meeting was facilitated by an experienced health system financial director in Aga Khan Foundation based in Switzerland, Mr Alex Manu, and was attended by the Secretary for Health, Dr Namarika, several MOH department representatives (Planning, Nursing, HR, PAM, KCH), MoJ, DOB, and representatives of LION donors. A fruitful discussion was held on the governance and financial structure of LION.
The day after the workshop a LION Board Meeting were held with a progress report on the tender. Tender opening on 1st February 2018 revealed that all tender bids were more that 140% higher than the consultant architects’ estimates. All the tender bids were rejected and the CEO was tasked to work with the architects (MOD) to moderately downscale and rework parts of the project plans, without threatening the function of the facility.
At the LION Board meeting in May MOD recommended retendering to the prequalified contractors with the downscaled drawings, specs and BoQs, followed by entering into negotiations with the contractors to see if value engineering and redesign could bring the project down to budget. This was approved by the board. The MoH architect team and an independent monitoring company, SGS, was invited to monitor the whole tender process, and were also invited to oversee the final evaluation and selection process led by MOD.
Tender opening after retender was held at SFS offices in Lilongwe on May 25th. The lowest bid was still 35% over budget, but after negotiations and two weeks working on value engineering the project was brought down to the 5 million US$. However, this bid did not include the 10% fees for the architects or a 10% contingency, and there are external works worth about 500 000 us$ that are not covered. MOD generously agreed to not claim their fees until late in the contract period giving the Trust more time to fundraise.
In June 2018 a Round Robin e-mail vote was held by the LION board of Trustees and all the Trustees voted for awarding the contract to Delta Construction Ltd. An award letter was signed on behalf of the Trust by the LION Trust Chair, and an acceptance letter received from Delta shortly after.
The final construction contract between LION Trust and Delta was thoroughly vetted by the necessary official offices (DOB, MoH, MoJ, Contracts Department) and donors (HUH, AOAF/SGS), and was signed by the LION Trust and Contractor on 29th and 30th October.
The contractor mobilised on the construction site on October 1st, and a stone turning ceremony took place on 14th November. Depending on full commitment from all stakeholders, LION can expect to have official opening of services in last half of 2020.