22 October 2014 - Lesotho, the small, landlocked country completely surrounded by South Africa, has a population of two million people. It has high poverty levels, with a GDP of just per capita and a high unemployment rate of 25%.
In 2007, the Millennium Challenge Corporation (MCC) Lesotho Health Infrastructure programme was conceptualised. In this same year, the average life expectancy in the country was 41 years old, mainly due to the 23% prevalence of HIV/AIDS in the country and the fact that approximately 96% of people living with HIV/AIDS suffer from tuberculosis (TB). These statistics present an almost catastrophic impact on not only the Lesotho economy, but more importantly, the quality of life in Lesotho.
The programme, which involved a health care infrastructure overhaul which encapsulated 154 construction sites across Lesotho, including 138 health centres, 14 outpatient facilities, additional staff housing, a blood transfusion centre, a new laboratory and a 120-roomed dormitory facility for nurses, was funded by the Government of Lesotho (GoL) and the MCC, an American bilateral funding initiative. It kicked off in October 2009 and was completed in March 2014.
Aurecon Lesotho was appointed by the Millennium Challenge Account Lesotho – an entity instituted by GoL in agreement with MCC – as programme manager, construction supervisor and environmental manager on this ambitious health sector improvement project.
“Aimed at mitigating the negative economic impact of HIV/AIDS, tuberculosis and other diseases on the country’s economy, this programme has already literally changed the face of health service delivery in Lesotho,” believes Paul Lombard, Aurecon’s General Manager of Development & Operations for Aurecon Africa, MENA and Americas. The rehabilitation and renovation of Lesotho’s health care infrastructure addressed by the programme will see more than 720 000 Basotho benefit from the project over the next 20 years, he explains.
“The programme means that the majority of Lesotho’s population now have access to primary health care services. Diagnostic services in the country have been improved considerably thanks to the new laboratory; there’s now increased access to tuberculosis and anti-retroviral treatments; and there is also adequate blood supply from the new blood transfusion centre. Additional housing allows nurses to live nearby health care centres and provide immediate service for acute and maternity care and an increasing number of health professionals are attending the National Health Training College thanks to the new 120 bed dormitory,” comments Lombard.
The client wanted the project team to implement a first world contractual framework and standards in a developing world environment. Just some of the challenges the project team faced are described below.
When the client first launched the procurement processes, the majority of South African contractors shied away from bidding, fully realising the extent of the programme, the arduous timelines and severe logistical challenges that were involved.
“Local contractors were appointed through Design and Build FIDIC contracts – a framework that most involved parties were completely unfamiliar with. As programme manager and supervisors, Aurecon faced huge capability gaps that needed to be overcome. Notwithstanding this, the programme’s structure has eventually been lauded by government officials in Lesotho,” says Lombard.
“The project delivered excellent facilities of world class standard according to international best practice,” confirmed Andrew Mayock, MCC Deputy Vice President, on occasion.
Aurecon managed all the design and build teams, each with their own consulting teams. What started out as a project team with four main contractors eventually multiplied to 11 emerging contractors.
“Some of the contractors simply underestimated the requirements of the project. This added a lot of complexity to Aurecon’s role as project managers, including managing 14 construction teams across 154 sites in the country. We found ourselves in the middle of a complex relationship structure, but the end result was solid partnerships and strong collaboration between all involved,” said Lombard.
Integrating various multi-disciplinary teams and collaborating to meet the rigorous demands of multiple client bodies ensured not only contractual compliance but also successful implementation of the programme.
The greater part of Lesotho consists of mountains, so traveling to sites was no simple task. There were 154 construction sites across the country and approximately three quarters of these sites were on mountains. Mountainous terrain, multiple river crossings and sub-standard access roads to the construction sites were among the challenges facing construction managers and contractors.
“We frequently worked at heights of 2800m above sea level. Some health centres were accessible by 4x4 low drive vehicles only, resulting in all building material having to be transported via these vehicles. The majority of contractors completely underestimated the logistical constraints, which caused many delays,” says Lombard.
Besides the tough terrain, the project team also experienced extreme weather conditions such as heavy snowfall in winter and flash floods in summer.
A major client requirement was to deliver fully functional, hygienic and structurally fit for purpose facilities, all according to international standards. Many of the existing facilities, however, were completely run-down, without access to water and electricity.
Some of the specific requirements included applying green, energy-saving technology; the new laboratory needed to meet World Health Organisation standards in terms of Biosafety Level 3 in order to improve the infection control of the TB laboratory; and both HIV/AIDS and TB services needed to be integrated within the health centres.
Remote localities without access to electricity required innovative design to comply to set standards for limiting cross infection in clinics where patients are accommodated in one common area. Through natural light, air movement optimisation and ventilation, the desired standards were achieved.
“I’m pleased to report that integration of all health services was achieved. Disabled access, double volume circulation areas and hygiene control, among other measures, were all included in the designs. The buildings also comply with international ISO criteria and standards and are energy efficient and constructed with durable material in order to reduce intensive maintenance,” says Lombard.
One of the most positive outcomes of the project was the job creation opportunity and the ability to close the gender gap.
In total, the health project created 5 600 local employment opportunities. In a country with an unemployment rate of 25%, this was a significant achievement.
A key legacy of this included the massive skills transfer achieved through the various training programmes Aurecon introduced, which will have a significant impact on future economic growth and livelihoods in Lesotho. Apart from the job opportunities created, a key legacy of this programme is the massive skills transfer achieved through the training programmes Aurecon introduced, which will have a significant impact on future economic growth and livelihoods in Lesotho.
“Some of the skills transfer projects that were initiated and implemented included construction skills training, health and safety awareness campaigns, specialist training to address gaps in design capabilities as well as quality forums to facilitate design improvements,” says Lombard.
“Empowering women to increase their participation in the economy was also a big driver for the MCA, not just on this specific health project but also on other projects delivered,” he adds. Accordingly, gender empowerment initiatives were introduced and women were appointed as site agents, quality managers and general workers.
Aurecon also developed an innovative and unique health and safety system for this project. “What was unique about this system was that it was developed for contractors and site staff who had never done this type of project before – as well as a client who expected advanced health, safety and environmental management,” explains Lombard.
Extensive training was done and material was developed to cater for both literate and illiterate workers as well. Daily statistics from individual contractors were kept; there was strict supervision and management to minimise risks; and there was zero tolerance on health and safety rules.
Through strict adherence to structured health and safety procedures and extensive training, Aurecon achieved remarkable safety performance throughout the project.
“The successful development and implementation of this system was so highly regarded by the MCA that Aurecon was invited to present our unique approach to a meeting of global MCC representatives in Washington DC. We also shared this system with other teams in Aurecon, providing a replicable best practice example that can be applied across the company on similar projects,” says Lombard.
It goes without saying that to work on a health improvement programme in a country with the third highest HIV/AIDS infection rates in the world comes with enormous responsibility. Aurecon responded by encouraging project workers to be tested voluntarily and running awareness campaigns for the project teams. “This resulted in 1700 workers getting tested and 2200 workers attending awareness sessions,” says Lombard.
Because the project covered such a large part of Lesotho, the project campaigns reached even the most remote rural areas in the country.
The Basotho people have shown sincere gratitude for the programme.
“I really appreciate the new facilities for pre and post-natal care. In a country with an infant mortality rate of 65 per 1000 babies, it is a critical improvement,” says Veronica Tumane, a nurse at Mont Marte clinic in Lesotho.
“The new Domiciliary Clinic used to serve 250 patients a day. It now serves 700 a day. This improves not only health outcomes, but assures we are promoting economic growth,” commented the Hon Pakalitha Mosisili, Lesotho Prime Minister in 2010.
Lombard says that the team involved in this programmed successfully implemented a project that has engineered a better future for the entire Basotho nation.
“Despite numerous challenges, this was a team who made things happen and challenged boundaries. This project is making a real difference in our communities and promoting diversity and safety. It was a privilege to be involved in such a significant project.”