C. Savona-Ventura
The spreading cult of Christ the Healer resulted in sick-nursing being viewed as a Christian duty. As a natural consequence of the doctrine of the Mystical Body of Christ which sees in the sick person Christ himself, the organised and skilled care of the sick and suffering developed within the framework of the Church.
The Council of Aix-la-Chapelle (816 A.D.) required that every bishop should provide a house for the poor and the sick, supporting it out of Church funds. The hospital was to be near the church and under the care of a priest. Hospitals were secularized after the Reformation of the sixteenth century. The first hospital recorded in Malta was already functioning in 1372, while in the sister island Gozo a hospital was founded in 1454.
The arrival of the Hospitallier Order of St. John to the Islands in 1530 resulted in the expansion of hospital services in the Islands as part of a state-organized social services system. At the end of the eighteenth century (1798) the hospitals in use during the time of the Knights of St. John included the renowned Sacra Infermeria for men and the Casetta for females, both at Valletta serving the southeastern harbour region. The rural central region of the Island was served by the medieval Santo Spirito Hospital situated at Rabat and which served poor patients of both sexes. These hospitals were supplemented by several hospices for the elderly and infirm including the 280 bed hospice for both sexes at Floriana, the 80 bed hospice for both sexes at Saura Hospital at Rabat, and the 15 bed hospice for females at Zebbug.
There was also a quarantine hospital on Manoel Island. The Island of Gozo was catered for by two hospitals, one for males and one for females, both situated at Victoria [1]. The ousting of the Order by Napoleon Bonaparte in 1798 required a reorganization of the hospital services with a segregation of civil and military patients. The Sacra Infermeria was taken over by the French to be used as a Military Hospital and named the Grand Hopital. A new Hopital Civil for male civilians was established in Valletta. This segregation was further augmented during the nineteenth century under British dominion when hospital services were organized for civilians, military [2] and naval [3] personnel.
Santo Spirito Hospital (Rabat)
The earliest hospital in Malta was the Hospital of St. Francis at Rabat which in 1372 was already functioning under the rectorship of a Franciscan Niccolo` Papalla appointed by the King of Sicily. There does not appear to be any evidence of a Franciscan Minor community in Malta before 1499, and a likely hypothesis is that the hospital was run not by regular Franciscans but by lay Franciscan tertiaries under the rectorship of a regular member of the order.
The main source of income for the hospital came from its real estate consisting of an appreciable amount of land and other immovable property. Mismanagement resulted in the transfer in 1433 of the hospital’s administration to the Universita`, and the hospital’s name was changed to Santo Spirito Hospital. In spite of this transfer, the accounts of the hospital during the medieval period show that the Church, the Universita`, and the hospital were all active constituent elements in one organic closely-linked establishment. The name Santo Spirito, commonly given to several medieval hospitals in Europe, originated with the religious order of Santo Spirito, founded by Guy de Montpelier (ob. 1208), which specialized in the setting up and keeping of hospitals particularly intended for foundlings and maternity cases.
From the middle of the fifteenth century onwards Santo Spirito Hospital in Malta functioned normally caring for a number of persons, mainly too old or too poor or otherwise incapable of caring for themselves, besides foundlings and patients. Another medieval hospital for women – St. Peter’s Hospital at Mdina was functioning before 1418, when it was closed down and converted into a monastery for nuns of the Order of St. Benedict. In the same year of its closure a bequest for the foundation of a second hospital was left by the wife of the Governor of Mdina [4]. In 1574 the Apostolic Delegate and Visitor-General to Malta Mgr. Pietro Duzina visited Santo Spirito Hospital and left a detailed and informative picture of its state of affairs during the mid-sixteenth century.
The patients were received in the small church of Santo Spirito which contained only four beds, each accommodating two patients. The bedding consisted of a mattress filled with flax and covered with a woolen coverlet. A surgeon was attached to the hospital, while the Mdina apothecary served the hospital needs. Duzina’s description suggests that the hospital management was not very satisfactory, and a set of rules for its management were put forward. Duzina suggested that a dormitory containing eight beds should be set up, each bed having a palisade, mattress, four bed-sheets and two blankets in winter. He also laid down detailed rules regarding the reception and care given to foundlings, and required the hospital administrators to submit an annual report to the bishop [5]. Subsequent pastoral visits to the Hospital suggest that Duzina’s regulations and suggestions were gradually put into force. By 1580 at the latest the Hospital had its own resident apothecary with his own pharmacy at the hospital.
The 1599 pastoral visit by Bishop Gargallo indicates that the patients were no longer housed in the church, but in a dormitory with eight beds. Eight foundlings were being received per year. The institution possessed four plates of pewter, two bowls, two small vessels for the administration of syrups and a cauldron. A wooden cot which revolved on its vertical axis (the ruota) to enable the anonymous deposition of the foundlings was set up by 1615. In 1667 the hospital was described to have been expanded to contain nineteen beds for men and eleven beds for women, though after 1685 no further references to male patients can be found.
In 1708 an attempt was made to separate the patients by the setting aside of fever cases in a separate ward. Very extensive modifications were carried out in 1729 when the number of wards were augmented to three to enable the hospital to receive a greater number of patients. Only destitute countrywomen were admitted, while the professional staff consisted of two physicians, a surgeon, two barberotti and an apothecary. By 1778 accommodation was increased to forty beds, while the administration of the hospital became the responsibility of a board composed of the Jurats, the procurators and the medical staff, who submitted their decisions to the Seneschal for approval. During the nineteenth century, Santo Spirito Hospital remained an important establishment in the medical services of the Islands, and in 1838 was assimilated with the Civil Hospital in Valletta serving as an extension of the main hospital after its bed compliment was expanded to sixty beds. During the smallpox epidemic of 1871, it served as an isolation hospital for the duration. It was changed into a convalescent sanitarium in 1883 [6].
In 1937, it catered for medical and surgical cases which did not require specialized care, the patients coming from the central region of the Island. It also received convalescent cases from the Central Hospital in Floriana. It had 34 beds for men and 35 beds for females. The daily average number of patients during 1937 was 58. A Resident Medical Superintendent was in charge of the hospital, while the Senior Physician attached to the Central Hospital acted as a Visiting Physician. The medical cases treated in the hospital included convalescent cases of Brucellosis, subacute heart disease, diabetes and anemia. The surgical cases were mainly orthopedic ones. After 1946 most of the accommodation of the hospital was allocated to orthopedic cases which required a long stay.
In 1956 it was described as having some 70 beds equally divided between male and female patients, with a number of children in each ward. The beds were arranged in a series of wards opening one off the other around the chapel. The wards were high and airy, but cold and uninviting and devoid of outlook. It was suggested that rather than its use as a chronic sick hospital, the hospital could be put to some other use such as a surgical convalescent ward, or even abandoned. It was closed down in 1967, and was eventually refurbished and restored into an Archives Museum [7].
Sacra Infermeria (Birgu & Valletta)
The arrival of the Hospitaller Knights of St. John of Jerusalem to the Islands in 1530 saw the institution of a number of new hospitals on Malta. The Knights concentrated their forces at Birgu, the maritime center of Malta. There they established their first hospital on the Island which was initially of a temporary character.
In 1532, after expropriating and demolishing a number of buildings on the foreshore of the town, the building of a permanent hospital – the Holy Infirmary – was started. Besides catering for members of the Order, the hospital was also open to male civilians and also cared for orphans and foundlings. A few years after its completion the infirmary it was enlarged by the addition of another storey. While the hospital size was suitable for day-to-day requirements, it was unsuitable in times of emergency. It functioned as a regular hospital until 1575 when the Valletta Holy Infirmary was completed.
At Birgu, apart from the Holy Infirmary, the Italian Knights kept a small hospital in their own auberge. This hospital was maintained until the Knights moved to their new quarters in Valletta [6].
Following the Knights victory of the Great Siege by the Turks in 1565, the Order decided to built a new fortified city guarding the major harbour of the Islands. A new Holy Infirmary was planned, the site chosen being the south-eastern side of Valletta.
The building, started in 1574, consisted originally of one long ward. It was subsequently enlarged in 1583 by the addition of a new block, and remodeled in 1662 and in the eighteenth century.
The number of beds varied throughout the centuries. In the late eighteenth century there were 554 single beds which could be increased to 900 in case of emergency. The majority of the beds (370) were provided with canopies of various colour hues, and woolen mattresses. The hospital wards were open for all whether members of the Order, civilians, or slaves. There was also provisions for the deposition of foundlings.
The Valletta Holy Infirmary was one of the best serviced hospitals in Europe and was favorably described by a number of foreign visitors to the Islands during the seventeenth and early eighteenth centuries. The Rev. Henry Teonge in 1675 described the hospital as being “so Broade that 12 men may with ease walk a breast up the midst of it; and the beds are on each syd, standing on four yron pillars with white curtens and vollands and covering extremely neate, and kept cleane and sweet; the sick served all in sylver plate”. A contemporary detailed description of the wards was made in 1687 by Mr. G. Wood. This description of the wards with canopies on four poster beds confirm the depiction of the wards shown in a 1588 engraving probably by Filippus Thommasinus and the 18th century painting of “Blessed Gerald” painted by Favray and held by the National Museum of Fine Arts. Seventeenth century depictions of the wards of the Sacra Infirmeria, including a 1650 German engraving by Christian von Osterhausen and a probably Mattia Preti painting of the “Blessed Gerald” held in the former Infirmeria, show slightly different arrangements where the beds are not four-posters but retain their canopies [7].
Towards the end of the eighteenth century a decline set in the general affairs of the Order including the Holy Infirmary’s management. In 1786 the hospital was described adversely by John Howard. He wrote that “The ceiling is lofty but being of wood is now turned black; the windows being small, and the walls hung round with dusty pictures, this noble Hall makes but a gloomy appearance…. All wards were dirty and offensive, so much so that it was necessary to use perfuming, and the physician had to keep his handkerchief to his face while doing his rounds… the patients…. were served by the most dirty, ragged and unfeeling and inhuman persons I ever saw. (8)
The decline of the Holy Infirmary continued during the two-year French interlude between 1798 and 1800. The French established their first hospital at Mdina on the first day of their occupation, but four days later an order was issued to reserve the Holy Infirmary, renamed Grand Hopital, for the exclusive use of their troops. The civilian patients were transferred first to the Casa delle Alunne and afterwards to the Monastery and Church of St. Mary Magdalen which became the Hopital Civil.
The Holy Infirmary thus started its phase as a military hospital, a function it served also under British dominion until the 22 December 1919 when it was handed over to the Civil Government. It has subsequently been used for a variety of purposes, until in 1978 it was converted into the Mediterranean Conference Center [9]. 
The Casetta (Valletta)
Since the Sacra Infermeria during the period of the Knights was reserved exclusively for male patients, a need for a number of beds to care for sick women was felt. In 1625, Catherine Scapi had set apart a small house in Valletta, known as Santa Maria delle Scala for the care of poor infirm women, the house eventually being moved to different premises. This small hospital was closed down after the founder died in 1655. A new woman’s Hospital known as the Casetta or Ospidaletto was re-established in Valletta by Grand Master Martin de Redin in April 1659.
The running of the Casetta was left under the direction of the Governess who resided in the institution, while the medical care was left to two physicians and two surgeons. A number of female nurses and a midwife were employed in the hospital serving various functions.
Alterations to the building were carried out in the early decades of the eighteenth century so that by 1727 the bed compliment was increased to two hundred, each having a canopy for privacy. The hospital’s conditions deteriorated in the late eighteenth century.
Under British rule, the management of the hospital was entrusted to the Presidents of the Hospitals. In 1850 the women patients in the Casetta were transferred to the newly established Central Hospital in Floriana, and the Casetta was reserved exclusively for inmates of both sexes suffering from incurable disease.
The Casetta was destroyed during the Second World War, while the adjoining orphanage was demolished to make space for a new government school [Evans Laboratories] [10]. 
The Civil Hospital (Valletta)
Before the arrival of the French, hospital services in Valletta consisted of the Sacra Infermeria for males and the Casetta for females. These services were supplemented by Santo Spirito at Rabat. Under French rule, the civilian hospital services for males were transferred to the Hopital Civil. On the 18th June 1798, Napoleon issued Article 12 wherein it was declared that the hospitals were to be reorganized on a new system and the property accruing from closed convents was to be used for that purpose. On the 29th July 1798, the French Commissioner ordered some of the nuns and women inmates of the Mary Magdalen Asylum situated in the vicinity of the Casetta to vacate the premises. On the 21st August, the Commission of Government appointed a sub-committee of three members to report on the suitability of transferring the male civil patients to the Casetta. The committee reported that the Casetta and adjoining Casa delle Alunne – a home for illegitimate children – could accommodate 210 beds. They proposed, however, that alterations to the edifice structure should be made to separate the two sexes so that the hospital would accommodate 108 beds for males and 170 beds for females.
On the 21 December 1798, 70 civilian male patients were transferred from the Sacra Infermeria to the new wards. This arrangement was short-lived, and alternative accommodation was arranged in the nearby Mary Magdalen Convent and Asylum. On the 4th May 1799, the Bishop was ordered by the French to desecrate the church of the former monastery so that this would serve as a casualty ward.
The upper floor of the monastery was used as fever wards, while the lower floor housed the surgical wards and the stores. The basement housed the mental patients. The professional staff consisted of five physicians, five surgeons and two barber-surgeons [8].
With the capitulation of the French, the Hopital Civil was taken over for use by the sick Neapolitan troops, but in November 1800 reverted to civilian use. The management of the renamed Civil Hospital became the responsibility of the Presidents of the Hospitals and a set of regulations for its management were drawn up in 1802. The professional staff consisted of four Physicians, seven Surgeons, a Maestro di Fisica and four apprentices responsible for bloodletting and applying vesicants, a chirurgo d’apparecchio and a braghista responsible for applying splints, bandages and trusses, besides a number of surgical students. The pharmacy was under the direction of a Principal Apothecary and four assistants. By 1837 the wards had become overcrowded. All forms of disease were treated in the hospital with separate wards being provided for cases of scabies, cancer and ophthalmic disorders.
In May 1850 the sick inmates were transferred to the newly established Central Hospital at Floriana. The former convent was in 1851 reorganized as an orphan asylum accommodating 50 boys and 60 girls aged 5-10 years. The building was destroyed during the Second World War and only the church, now used as a store, survives [9]. 
The Central Hospital (Floriana)
The Central Hospital at Floriana was adapted from a building built by Grand Master De Vilhena in 1734 known as the Conservatorio, set up to house pauper girls and teach them various useful crafts. It was transformed into a general hospital for both sexes in 1850 and patients from the Valletta Civil Hospital and Casetta were transferred there.
In 1850 the medical staff consisted of four physicians, four surgeons, a pharmacist and two assistants. The administrative work was performed by the storekeeper and the professional staff. By 1872 it was realized that the Central Hospital had become inadequate to cater for the reception and treatment of the sick since it had become difficult to accommodate the increasing number of patients brought to it. By June 1878, the hospital population had increased to 170. A decision to admit all infectious cases of measles, scarlet fever, diphtheria and whooping cough to the Central Hospital, rather than continue utilizing the inadequate Santo Spirito Hospital, increased the problem of isolating the infectious cases. In 1885, the male surgical division was over-populated and some of the patients required to be accommodated in the corridors [11].
On the 11th November 1885, recommendations were made to replace the Central Hospital by a larger building. The plan envisaged extensive grounds for the recreation of the convalescent patients, to prevent hemming in of the hospital by private houses and enable later extension. The hospital was projected to house 354 beds, with a division for men and one for women. Operating theaters, laboratories and an out-patients block were also provided for. Communication between the various hospital blocks was to be facilitated by a tramway. These plans were shelved and the Central Hospital continued to provide a national service in spite of its shortcomings. In 1898, hospital accommodation accounted for one bed per 900 inhabitants.
Various reports from the Comptroller of Charitable Institutions highlighted the inadequacies of the Central Hospital and proposing the building of a new general hospital. These recommendation were only definitely acted upon in 1927 when financial provisions were made for the establishment of a new general hospital.
In 1937, the Central Hospital remained the principal general hospital in Malta, cases from Gozo being also received in special circumstances. The Resident Medical Staff consisted of the Medical Superintendent and eight Assistant Medical officers, besides a Chief Pharmacist assisted by three pharmacists. The Visiting Medical Staff consisted of two physicians, five surgeons, two accoucher-gynaecologists, two pathologists, an ophthalmic surgeon, an anesthetist, two radiologists, dental surgeon, and three medical officers responsible for venereal disease, dermatology and ENT. The hospital accommodated 253 beds – 125 for men and 128 for women with children under five years being kept in the female wards. The average daily number of patients in 1937 was 310. Other wards were available in the Poor House for incurable disease and for convalescent medical and surgical cases and cases of tracoma [12].
The site chosen for the planed new 510 bed hospital was the promontory of Gwardamangia and the foundation stone was laid on the 5 April 1930. The construction of this hospital progressed slowly for a variety of reasons including technical difficulties and Italy’s declaration of war against Abyssinia in 1935.
The Second World War similarly slowed down the construction of the new hospital and it was only in 1954 that the Central Hospital at Floriana could be changed into the Headquarters of the Malta Police Force.
In 1956 the Central Hospital with a bed complement of 56 beds was serving as the dermatology/venerology and ophthalmology departments. It was also used as a center for the distribution of medicines to needy patients [13].
The hostilities of the Second World War required a reorganization of the medical services of the Islands. This reorganization included the establishment of several emergency hospitals to cater for the expected casualties and increase in infectious disease. By September 1939, the Department of Health was ready to provide 1,200 to 1,500 beds for casualties, as well as a 100-bed maternity hospital and special wards for cases of war neurosis. The mobilization of the Emergency Service was initiated but only put into full operation after the outbreak of hostilities with Italy. The Male and Female Surgical Departments and the Maternity and Gynaecology Departments were transferred to the Bugeja Hospital (previously the Bugeja Technical Institute) at Hamrun on the 28th May 1940. The Male Medical cases were transferred to the Birkirkara Hospital (previously St. Aloysius College, a Jesuit school) on the 26th June, while the Female Medical cases and Ear-Nose-Throat Department were transferred to the Blue Sisters Hospital (previously a private hospital run by a religious order) in July 1940. A Children War Memorial Hospital was also inaugurated in the latter hospital. Infectious disease cases were after September 1940 transferred to St. Luke’s Hospital. The Maternity Services were on the 19th June 1940 transferred to a newly constructed wing of the Adelaide Cini Orphanage at Hamurn, thus increasing the maternity beds from 16 beds at the Central Hospital to 100 in Cini Hospital. Cini Hospital continued to function as an Emergency Maternity Hospital until 1949 when St. Luke’s Hospital was completed and the maternity services could be transferred to the new wards [14].
St. Luke’s Hospital (Gwardamangia)
St. Luke’s Hospital was in 1927 initially commissioned to provide 350 to 450 hospital beds. The initial progress in the construction of the hospital was however slow. It was expected that the hospital would be completed by the end of 1941, but its completion was further delayed by the outbreak of the Second World War.
By 1937, the projected bed compliment was increased to 510. During the war, St. Luke’s Hospital sustained war damage, one block was badly bombed and one employee lost his life and several others were injured. The lower storeys, the basement and ground-floor hospital were speedily conditioned and prepared for 200 beds to accommodate contagious cases and fevers. The post-war period saw the gradual transfer of other departments to the hospital, with the medical section being first transferred in 1946. In 1957, St. Luke’s Hospital was described as having a total of 546 beds made up of the following departments: Surgery (4 wards, 120 beds), Medicine (4 wards, 120 beds), Gynaecology (1 ward, 30 beds), Obstetrics 92 wards, 42 beds), Orthopedics(2 wards, 60 beds), Pediatrics (2 wards, 40 beds), Ear-Nose-Throat (2 wards, 62 beds), and a further 2 unassigned wards (60 beds). The wards had a floor space per bed of approximately 230 square feet. It was suggested however that the number of beds in the hospital should be increased to 750 beds in line with the increasing demands being made by the sick population on hospital services [15].
The post-Second World War period saw a changing attitude towards hospital care. Thus in 1953, the Chief Government Medical Officer commented that “in these islands, like in other countries, we have our own hospital problem which is becoming increasingly pressing year by year. It is due to the fact that the increased hospital-mindedness of the public has not been followed by a corresponding or relative expansion in the hospital service”. This changing attitude resulted in a palpable shortage of hospital beds in the mid-1950s.
The Government at the time proposed a new 500-bed hospital at Naxxar planned to incorporate a children’s wing of 200 beds, 150 beds for general cases, and 150 beds for tuberculosis patients which were eventually to be re-allocated to other specialties. The Government initiated a number of discussions with various commissions, including the Economic Commission, and invited a British Medical Commission to study the proposals. The Medical Commission concluded that despite the evidence presented, the proposed new hospital was not an urgent necessity. Before embarking on a new expensive general hospital for which it will be difficult to recruit the necessary staff, the Commission proposed that it would be better to reorganize the facilities at St. Luke’s Hospital and the other domiciliary medical services, and undertake a limited building program. It was considered doubtful whether the population could really sustain two acute hospitals, since there were considerable difficulties in providing the necessary trained nursing and medical staff. Also the two hospitals would have required the division of resources of the island. The proposal to build the new hospital geographically separated from the main general hospital was shelved on the basis of these recommendations [16].
The subsequent decades saw a number of extensions being made to the main hospital to accommodate the various developing specialties and the progressively increasing demands on the hospital services.
Other hospitals on the Island were reorganized to serve specific functions and supplement hospital beds. King George V Hospital for merchant seamen, rebuilt after its demolition during the Second World War, had closed down in January 1967.
In 1970 this hospital, renamed Sir Paul Boffa Hospital, was refurbished and opened for the management of infectious cases, dermatology-venerology and cancer cases. It also served as a short stay convalescent hospital.
The main extension to St. Luke’s Hospital during this period was the building in 1979 of Karin Grech Hospital dedicated to Obstetric and Gynaecological, Pediatric, Ophthalmology and Ear-Nose-Throat specialties. This new hospital, situated in the grounds of St. Luke’s Hospital and thus can make full use of the main hospital’s investigative and other facilities, allowed for the reorganization and refurbishment of the wards increasing the number of both medical and surgical beds. This augmentation increased the number of beds in the St. Luke’s Hospital Complex to 1100, so that in the 1986 the optimal ratio of 3.3 acute beds per 1000 population was reached.
At this point it was considered uneconomic to plan for additional beds at St. Luke’s Hospital and further development of the facilities at the Hospital were focused on better management and improving back-up services [17].
In the early 1990s, a policy aimed at refurbishing and reducing the number of beds at St. Luke’s Hospital by building a 500 bed “extension” close to the University of Malta at a distance from the Hospital was initiated. The new hospital was scheduled for completion in 1997 and it planned that all departments would be transferred from St. Luke’s Hospital to the new hospital, leaving St. Luke’s as a surgical center only. Karin Grech Hospital would have housed acute psychiatric cases while cancer patients would have stayed on at Sir Paul Boffa.
The proposed new hospital brought on a vociferous opposition from the medical profession and other sectors of the public. In 1997, the general hospital policy was reviewed in the light of the previous decisions and the state of the ongoing building program. After studying several options, a new policy was initiated whereby the new hospital at Tal-Qroqq, situated close to the University grounds, would increase its hospital occupancy to about 800 beds catering for all specialities, while St. Luke’s Hospital will be refurbished to serve as a convalescent and elderly care hospital [18].
On 29 June 2009 this hospital was replaced by Mater Dei Hospital.
Gozo Civil General Hospitals
The first hospital in Gozo owed its origin to a bequest made by Francesco Bonnici on 22 February 1454. The establishment, used as a hospital for destitute sick women, was dedicated to St. Julian (but also known as the Hospital of St. John the Evangelist, of St. Cosmos and St. Damian, and Santo Spirito Hospital) and consisted in 1575 of a few dwellings near the gates of the citadel of Rabat/Victoria. On 3 May 1783 the foundation stone for a new hospital was laid at Rabat/Victoria. This new hospital named St. Julian Hospital accommodated fifty patients and received also unmarried pregnant mothers who sought refuge under its roof at the approach of labour. It was also provided with a ruota to receive foundlings. It ceased to function becoming the Gozo Seminary in 1838 when the Hospital of St. John the Baptist was extended for both sexes. 
The Hospital of St. John the Baptist was founded on 16 June 1719 and opened ten years later on 14 October 1729. The Hospital of St. John initially admitted only male patients and was staffed by two alternating physicians and a resident surgeon. In 1838, the old and infirm inmates were transferred to the Malta Ospizio at Floriana to make room for female patients. It afforded accommodation to sixty males and fifteen females. A home for the disabled poor aged over sixty years, with a bed capacity of 172, was annexed in 1849. The hospital changed its name to Victoria Hospital on the occasion of Her Majesty’s Queen Victoria Jubilee in 1887. Structural expansion was undertaken in the last century to enable the hospital to deal with a greater number of patients.
In 1937 the bed compliment of the hospital amounted to 84, 34 for men and 50 for women. The adjoining Asylum for the aged and invalid poor, established in 1851, accommodated 172 beds. A monthly consultant service for Victoria Hospital was instituted in 1946, though the resident medical staff in 1957 was described as consisting only of a medical superintendent, one resident medical officer, and a recently qualified house officer.
The hospital in 1957 was described as not unattractive with several courtyards pleasantly laid out with trees and flowers. The wards were lofty, cool, old-fashioned but adequate. The bed compliment included 26 medical, 40 surgical, 12 maternity, 6 gynaecological, and 10 pediatric beds. 
A new hospital named Craig Hospital, subsequently renamed Gozo General Hospital in 1989, was inaugurated in Rabat/Victoria on 31 May 1975, and the old hospital was re-utilized as the Government Health polyclinic and other offices [19] including the Gozo Ministry. 
Relgious-run Hospitals
The changing attitudes of the sick population towards seeking hospitalization which occurred in the 1950s [20], initiated a trend towards the development of religious-run private-care hospital services.
The first private hospital to be opened in Malta was run by the Sisters of the Little Company of Mary (Blue Sisters) and named Zammit Clapp Hospital or Blue Sisters Hospital. The hospital situated at Sliema was opened after a deed of donation in favor of the government was made by Emilia Zammit Clapp and her sister Mary Zammit on 23 June 1911. This hospital initially served as a Seamen’s Hospital. The nursing, food, attendance, washing and other services necessary for the patients were to be provided by the Sisters against payment of 2s6d a day per patient by the Board of Trade or other parties. The medical attendant, drugs, surgical instruments/appliances, clothing and bedding were to be provided by the government. This arrangement resulted in a saving in government expenditure during the first year. The government expenditure in the early years of the arrangement (financial year 1913-14) included
(1) medical attendance £40,
(2) drugs and appliances £4.11s3d,
(3) clothing and bedding £6.7s9d,
(4) divine service and spiritual assistance £20, and
(5) telephone £4.
In 1915, the hospital was described as a handsome building with spacious wards and corridors, private rooms, and operating and sterilizing rooms. All classes of patients without distinction of creed or country were treated in the wards. Infectious disease cases were not admitted. In November 1918, a War Memorial Ward for Children, comprising Medical and Surgical Divisions, was set up on the upper floor. Zammit Clapp Hospital ceased to function as a Seamen’s Hospital in December 1922 when the King George V Merchant Seamen’s Memorial Hospital was opened [21].
After being vacated, the hospital with only 20 beds started being used as a children’s hospital. The building was expanded in 1933 and during the Second World War was taken over for use as a Casualty Hospital for the north-western region of Malta. It also housed the Female Medical and ENT Divisions. The Children War Memorial Hospital was also incorporated in the establishment and the hospital was further expanded by utilizing the ground-floor of the adjoining Sacred Heart Convent. After the end of hostilities, the hospital was returned to the management of the Sisters of the Little Company of Mary.
The services offered by the Sisters continued to expand and in 1947 started offering maternity services with a Maternity “Mary Potter” Wing being inaugurated in 1950. In 1957, it was the only privately-managed hospital of any size in the Maltese Islands with 64 adult beds and 15 maternity beds and accommodated 34 infants. It continued to expand its services and in the 1970s could accommodate 110 patients besides 16-20 maternity cases.
It continued to function in this capacity until December 1980 when it was closed down. It was refurbished in 1991 to serve as a rehabilitation hospital for the elderly [22]. 
On 12 April 1959, the Dominican Sisters officially inaugurated another privately-managed hospital named St. Catherine of Sienna Hospital at Attard with accommodation for over 200 patients. The hospital expanded its services to maternity patients in 1961. The hospital was converted into a nursing home in 1980. 
A small 28 bed clinic St. Dominic Clinic in Rabat/Victoria, Gozo was also run by the Dominican Sisters. This hospital, which catered also for maternity cases, opened in September 1974 and closed down its services in November 1976 [23].
Private-run Hospitals
In 1984 a number of small day clinics in Malta were opened to cater for deliveries, notably St. James Clinic at Zabbar and Klinika Vella at Zebbug. Both clinics were established in 1984 following the closure of the religious-run hospitals in 1980.
St. James Clinic started as a small maternity clinic which expanded its services to eventually offer multi-disciplinary treatment. It was upgraded to a hospital in 1996. 
Klinika Vella started off a two-bed affair in line with the regulations in force at the time. During the years it expanded its services and provided single room facilities for overnight patients. It also refurbished a dedicated unit specifically for obstetric patients away from the main surgical facilities.
Clinic facilities offering consulting rooms for several specialists and operating theatre were made available in 1996 at St. Mark’s Clinic at Msida. The first trully purpose-built private-owned hospital in Malta was built in 1995.
St. Philip Hospital must be considered the first private hospital built according to a state-of-the-art design specifications. The letter of intent approving the project was issued by the government authorities in 1992 and a year later the Maltese company owning the hospital – Golden Shepard Group Ltd. – was formed and registered. This company brought together a group of leading Maltese enterprises together with the foreign Independent British Healthcare PLC (IBH). The “hotellier” services offered are comparable to a five-star hotel. All 75 single rooms with en-suite bathroom are air-conditioned. The maternity unit has access to 25 of the beds and is located adjacent to a state-of-the-art delivery suite and close to the operating theaters. A comprehensive antenatal, intrapartum and postnatal maternity scheme was launched in 1996. 
A second private-owned hospital offering a comprehensive service was opened in 1996 in the restored 19thcentury Capua Palace at Sliema. Work on Capua Palace Hospital was approved by the government authorities in 1994 [24]. 
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ENDNOTES
1. Based on a Report dated 13th July 1798 prepared by Dr. Vincenzo Caruana on the request of the Commission of Government under French rule. AOM 6523 B: Registers des Deliberations de la Commission du Government, fol.109-119.
2. C. Savona-Ventura: Hospitals in Malta throughout the Ages: Part III – Military Hospitals. Plexus: the Online Maltese Journal of Health and Medicine. Issue 3, Sept. 1997
3. C. Savona-Ventura: Malta and the British Navy: the medical connection during the nineteenth century. J Roy. Nav. Med. Serv., 1992-93; 78:p.171-176, 79:p.33-36,100-105
4. S. Fiorini: Santo Spirito Hospital at Rabat, Malta. The early years to 1575. Dept of Information, Malta, 1989, +199p.; P. Cassar: Medical History of Malta. Wellcome Hist Med Libr, London, 1964, p13.
5. P. Cassar, 1964: op. cit., p.23-36; S. Fiorini: A prescription list of 1546. Maltese Medical Journal, 1988/89, 1(1):p.19-31
6. P. Cassar, 1964: op. cit., p.23-36; P. Cassar: Inventory of a sixteenth century pharmacy in Malta. St. Luke’s Hospital Gazette, 1976, 11(1):p.26-34
7. Annual Report on the Health Conditions of the Maltese Islands and on the work of the Medical and Health Department for the year 1937. Government Printing Office, Malta, 1938, p.34-35; Report on the Health Conditions of the Maltese Islands and on the work of the Medical and Health Department for the year 1951. Government Printing Office, Malta, 1953, p.97-98; L. Farrer-Brown, H. Boldero, J.B. Oldham: Report of the Medical Services Commission. Central Office of Information, Malta, 1957, p.22-23,33; S. Fiorini, 1989: op. cit. note 1, p.ix-x
8. The Magdalen Asylum for penitent women was established in 1609 by the Ursoline Nuns Hospitalliers who arrived in Malta in 1583. Annual Report….for the year 1937, 1938: op. cit., p.48; C. Testa: The French in Malta 1798-1800. Midsea Publ., Malta, 1997, p.183-187; C. Savona-Ventura: Human suffering during the Maltese insurrection of 1798. Storja ’98, 1998, p.54
9. P. Cassar, 1964: op. cit., p.77-82; Piano per il regolamento dell’ospedale di Malta. Malta, 1802; Annual Report….for the year 1937, 1938: op. cit., p.49-50. The Orphan Asylum was meant to replace the Floriana Conservatorio after this was taken over for use as a general hospital in 1850. Preference was given to orphans of both parents or to children who had lost their father. The institution was under the charge of a Resident Superintendent assisted by a Resident Chaplain, while the girls were taken care of by the Sisters of Charity. Children were discharged when they reached the age of 18 years. They all received elementary instruction, while the boys were also given technical instruction. The girls received training in domestic occupations.
10. P. Cassar, 1964: op. cit., p.69-76; P. Cassar: Female employees in the Medical Services of the Order of St. John in Malta. Melita Historica, 1978, 7(3):p.225-233; J. Howard: An account of the Principal Lazzarettos in Europe. London, 1789, p.58-60
11. P. Cassar, 1964: op. cit., p.83-89
12. P. Cassar, 1964: op. cit., p.83-89; Annual Report….for the year 1937, 1938: op. cit., p.30-34
13. E.P. Vassallo: Strickland. Progress Press, Malta, 1932, p.307-309; L. Farrer-Brown et al, 1957: op. cit., p.18-19
14. Annual report on the Health conditions of the Maltese Islands and on the work of the Medical and Health Department including the Emergency Medical Services for the year 1940. Government Printing Office, Malta, 1941, p.28-31; C. Savona-Ventura: Reproductive performance on the Maltese Islands during the Second World War. Medical History, 1990, 34:p.164-177
15. Annual Report….for the year 1937, 1938: op. cit., p.31; Annual report on the Health conditions of the Maltese Islands and on the work of the Medical and Health Department including the Emergency Medical Services for the year 1943. Government Printing Office, Malta, 1942, p.11; L. Farrer-Brown et al, 1957: op. cit., p.1-2,17
16. J. Galea: Report on the Health conditions of the Maltese Islands and on the work of the Medical and Health Department for the year 1953. Government Printing Office, Malta, 1954, p.10; J.O.F. Davies: Report on a hospital building progamme for Malta. Central Office of Information, Malta, 1957, p.11
17. L. Farrer-Brown et al, 1957: op. cit. note 4, p.96; Health Services Development Plan. Malta 1986-1990. Department of Health, Malta, (1987), p.39-42
18. D. Carruana-Galizia: A new hospital for Malta. Hospital Reform. The Sunday Times, 10/17 October 1993; D. Caruana Galizia: New hospital and the MAM. The Sunday Times, 12 March 1995, p.9; K. Causon: Milan’s San Raffaele and Malta. The Sunday Times, 9 April 1995, p.15
19. P. Cassar, 1964: op. cit., p.90-92; S. Fiorini, 1989: op. cit., p.11; J. Bezzina: Religion and politics in a crown colony. The Gozo-Malta story 1798-1864. Bugelli Publ, Malta, 1985, p.79; Annual Report….for the year 1937, 1938: op. cit., p.50-53; L. Farrer-Brown et al, 1957: op. cit., p. 25-26; H.A. Clews: Malta Year book, De La Salle Brothers Publ, Malta, 1976, p.74
20. J. Galea, 1954: op. cit.
21. A. MacMillan (ed.) Malta and Gibraltar Illustrated. Collingridge, London, 1915, p.310; Malta Government Gazette Supplement, 22 November 1912; Reports on the Working of Government Departments during the financial year 1911-12. Government Printing Office, Malta, 1912, M:2; Reports on the Working of Government Departments during the financial year 1913-14. Government Printing Office, Malta, 1914, L:2; Reports on the Working of Government Departments during the financial year 1922-23. Government Printing Office, Malta, 1925, Q:1
22. P. Cassar, 1964: op. cit., p.408-409; A. Bonnici: History of the Church in Malta. Vol.III Period IV – 1880-1975. Veritas Press: Malta, 1975, p.119,136-137; L-Isptar Zammit Clapp Ghall-kura ta’ l-Anzjani, San Giljan 1991. Secretariat for Care of the Elderly, Malta, 1991, +8p; J.O.F. Davies, 1957: op. cit., p.4
23. P. Cassar, 1964: op. cit., p.409; A. Bonnici, 1975: op. cit., p.136-137; C. Savona-Ventura, Caesarean section in the Maltese Islands, Medical History, 1993, 37:37-55
24. Anon.: A special kind of caring. The Malta Independent, 28 July 1996, p.4; Anon.: A ramble through St. James Hospital. Galleria – The Malta Independent, 17 November 1996, p.4; R. Bugeja: A purely private affair. The Malta Independent, 30 October 1994, p.12; St. Philip Maternity Scheme: op. cit., M.J. Naudi: Pioneering building techniques used in Capua Palace Hospital. The Sunday Times [of Malta], 16 June 1996, p.44-45; Maternity Department. Capua Palace Hospital, Malta, [1996], +6p.
MATER DEI HOSPITAL
Mater Dei Hospital is an acute general teaching hospital offering hospital services and specialist services. It is a public hospital located in Msida, Malta.
The hospital opened on 29 June 2007 replacing St. Luke’s Hospital as the main public general hospital. The 250,000 square metre complex includes 825 beds and 25 operating theaters. It was designed and built by the Swedish construction firm Skanska Malta JV. The project was planned to cost 50m MTL (around 116m EUR) but rose to more than 250m MTL (around 582m EUR).
The hospital houses or caters for the faculties of Health Sciences, Medicine and Surgery, and Dental Surgery of the University of Malta. The hospital is located adjacent to the University of Malta. The hospital houses the Health Sciences Library which is a branch library of the University of Malta Library.
Oncology Centre – The Sir Anthony Mamo Oncology Hospital
The new centre, costing €52 million, replaced the oncology department at Sir Paul Boffa Hospital in Floriana. The center is located adjacent to the Mater Dei hospital and houses bunkers that hosts three linear accelerators for radiotherapy use.
The Sir Anthony Mamo Oncology Hospital welcomed its first 50 outpatients on Monday 22 December 2014 in the first step towards migration from Boffa Hospital by May 2015.
The hospital started being excavated in 2010 and building started in 2012. It cost €52 million and an estimated €8 million a year are required to run it. The hospital offers more advanced radiotherapy with two machines commissioned from the Leeds Spencer Centre, where they were introduced in 2013. The machines enable more precise radiotherapy and stronger doses reducing the length and frequency of sessions. Beds at this hospital were increased from the 78 at Boffa Hospital to 113 and the outpatient clinics from two to 12. The type of chemotherapy given Is also more advanced. Palliative care beds were also increased from the 10 at Boffa Hospital to 16.
Malta recorded 2,000 new cases of cancer per year and 700 to 800 deaths.
Brief History of the Mater Dei Hospital Project
1990: The idea of building a new hospital to serve as a centre of excellence complementing St Luke’s took root.
8 December 1990: The Foundation for Medical Sciences and Services (FMSS) was established by the Government of Malta by a deed of foundation as “an autonomous body corporate of a non-commercial nature” with the following aims: · The furtherance and promotion of medical and related studies and scholarship, through research, publications and teaching; · The provision of health care services through hospital, day care and other facilities; and · Collaboration with other similar entities, especially on a regional and international basis. The following sat on the first FMSS board: Dr Louis Galea (president), Prof. John Rizzo Naudi (appointed vice-president on 27 June 1992), Dr Antoine Mifsud Bonnici (appointed 27 June 1992), Dr George Hyzler (appointed vice-president 3 October 1991, retired 27 June 1992), Sig. Mario Cal, Prof. Frederick Fenech, Rev. Peter Serracino Inglott, Rev Charles Vella (appointed vice-president on 3 October 1991), Edwin Vella, Maurice Zarb Adami. Following the 1996 October general election Prof. John Rizzo Naudi, Prof. Frederick Fenech, Edwin Vella and Maurice Zarb Adami offered their resignations. On this date too, the Government of Malta signed a Collaboration Agreement with the Fondazione San Raffaele del Monte Tabor – Istituto Scientifico Ospedale San Raffaele. This agreement sought collaboration in the “sectors of health care and medical sciences.” On this date too, an agreement was signed between FMSS and the Government of Malta for the management of the Zammit Clapp Hospital.
27 February 1991: FMSS (represented by its president Dr Louis Galea) and the Fondazione Centro San Romanello del Monte Tabor (represented by Rev. Prof. Luigi M Verze) together with the Centro Assistenxa Ospedaliera S Romanello (represented by Mario Cal and Dott. Raffaella Voltolini) and the Associazione Italiana per la solidarieta tra i popoli (represented by Ing. Enrico Pianetta) set up the Monte Tabor Foundation – Malta (MTFM), an Italo-Maltese Centre for the promotion of scientific research and health, educational and training services. The deed of foundation set up MTFM as an autonomous, charitable non-profit making organisation. MTFM was established as an autonomous body corporate of a non commercial nature with its seat in Malta and the following aims: · The furtherance and promotion of a philosophy and practice of medicine and health care inspired by the evangelical message ‘heal the sick’ and by humanitarian and sound ethical standards… · Setting itself up as a centre of reference in the Mediterranean region for the study and treatment of ailments especially those relating to metabolism and degenerative diseases… · Setting itself up as an educational and training centre for health care personnel. On the signing of the deed MTFM was endowed with the sum of Lm120,000 borne equally between the two parties.
February 1992: The Nationalist Party wins a second term of office. Dr Fenech Adami is re-appointed Prime Minister and Dr Louis Galea is re-appointed Minister for Social Policy and Dr J. Rizzo Naudi as Parliamentary Secretary for Health. In 1995, following a cabinet reshuffle, Dr Louis Deguara replaced Dr Rizzo Naudi as Parliamentary Secretary for Health.
June 1992: The day to day running of the Foundation was originally entrusted to the Director General, Philip Rizzo who was officially appointed by the board in June 1992. Mr Rizzo remained in office until 6 December, 1994. During his term of office Mr Rizzo occupied other posts namely that of chairman of the St Luke’s Refurbishment Committee and Director of Planning at university. In August 1994, the president of the board of FMSS intimated that the fact that Mr Rizzo occupied the above mentioned posts was complicating matters and rendering control difficult. Subsequent to Mr Rizzo’s resignation some of his decisions, of which the FMSS board was not aware of, came to light. These related mainly to acceptance and/or authorisation of expenditure on the San Raffaele Hospital and St Luke’s refurbishment projects. Rizzo denied the claims that featured in Deo Scerri’s report in The Times of 31 December 1996.
15 July 1992: A Letter of Intent was signed between FMSS and MTFM specifying the building of a hospital to complement St Luke’s as per business plan dated August 1991 presented by FMSS. Investment on FMSS part: Provision of land, construction of structure, construction of building, provision of all equipment including medical and sanitary equipment. MTFM’s part: To obtain the ‘know how’ of the Scientific Institute San Raffaele and the other Italian founding entities so as to be responsible for the design and construction supervision as well as the operation of the hospital. The Government of Malta was to pay MTFM (via FMSS) a charge calculated on the basis of 1. Rent of hospital; all operating expenditure including costs, administration expenses. 2. Government guaranteed payment on the basis of an occupational level of not less than 80 per cent of total beds available.
August 1992: In view of the entity of San Raffaele project, FMSS engaged the services of Eng. E Farrugia to act as project director. Mr Farrugia occupied the post until February 1994.
9 July 1993: FMSS and MTFM signed a Frame Agreement confirming the letter of intent of 15 July 1992. This covers the Government of Malta’s desire to “construct a scientific institute to undertake research and … provide specialist medical treatment to complement public health care facilities … available in Malta. Such an institute shall be known as the San Raffaele Hospital and MTFM desires to “participate in the project and to operate the hospital.” The agreement signified the Maltese Government’s desire that the hospital be operated according to the orientation and culture inspired by the philosophy of the Parco Scientfico Biomedico San Raffaele, an “association of hospitals and scientific institutions sharing the same evangelical philosophy: Ite, docete, senate”. The letter of intent as confirmed by the agreement covered the “total design of the hospital, the statutory supervision of the construction of the hospital, the operation of the same hospital and the allocation of beds to the Government of Malta.” The agreement sets out the framework of the contractual relationship between FMSS and the Government of Malta on one part and the MTFM and the Italian co-founders on the other part. The agreement however does not only set out the framework but also provides the basis upon which the contractual relationship was to be built. According to the Frame Agreement, FMSS shall be responsible: To define health care requirements which the hospital should meet; to procure land on which hospital will be built; to assist the government in organising the international construction tender; to manage the administration and accounting relating to the construction agreement. The MTFM on its part was engaged by FMSS to be responsible for: Design, planning, application for permits, preparation of tender documents; technical and economic evaluation of tenders. The San Raffaele Hospital (Malta) project was entrusted to MTFM who sub-contracted part of their rights and obligations (design and construction supervision) under the “frame agreement” to ORTESA Spa, a related company of the Italian co-founders of MTFM. Work on the designs started during 1993. The Frame Agreement lists four contracts to be entered into, which are considered to be an integral and substantive part of the agreement and consequently the guarantor’s obligations apply to all these agreements, unless other arrangements are made.
1. Design contract: An original annex to the Frame Agreement and is clearly binding on FMSS, MTFM and the Guarantors.
2. Construction supervision agreement: Eventually called Construction Supervision Contract. This had to be negotiated and agreed to by 31 December 1993, but the date was later extended to 28 February 1994. No criteria were set out in the frame agreement in connection with the contents of this agreement which was eventually signed on 2 June 1994.
3. Operation Agreement which was to be agreed by 31 December 1995 on the basis of principles set out in the letter of intent annexed to the Frame Agreement. This agreement had not been signed but the latest information indicates that Rev. Prof. Verze had agreed in writing to extend the date for negotiations to 31 December 1996.
4. Allocation of beds agreement was to be negotiated and agreed by 31 December 1996 on the basis of the principles set out in the letter of intent.
18 August 1993: Project Management Agreement between FMSS and Project Management Office Malta University Services Ltd for the latter to carry out detailed supervision of the construction of the hospital. Although MUS Ltd appeared on the contract with FMSS, PMO is made up of a joint venture between MUS Ltd, University of Malta and the Director of Works. The remuneration of PMO which comprises fees and expenses is calculated at five per cent of the total cost of the project. For the purposes of this agreement, the estimated project management fee was considered at Lm1.75 million which was to be paid in 48 equal monthly installments. On completion of the project, PMO’s definite remuneration was to be calculated at five per cent on actual total cost in terms of the final project certificate. Payments paid to PMO will then be subtracted to arrive at the net balance payable. As per Deo Xerri’s report, FMSS considered that PMO was understaffed and did not have enough manpower to ensure a proper detailed supervision of the project.
2 June 1994: Construction Supervision Contract signed. It forms an integral part of the Frame Agreement and is therefore binding between the parties to the agreement but is binding also on the other signatories thereto. MTFM’s obligations under this contract is to carry out general supervision of the construction of the hospital, it being understood that the detailed supervision will be carried out by the Project Management Office, Malta University Services Ltd, who were appointed project managers for the hospital project. In effect, MTFM’s duties consist of the provision of the following qualified specialists: Hospital construction manager; Hospital services manager (civil works); Hospital services manager (mechanical, electrical, medical equipment); Hospital medical manager. MTFM cannot assign benefits, obligations or subcontracts without the written consent of FMSS. It was, however, agreed in this contract that MTFM shall make use of Maltese architects and civil engineers (England &England were appointed) for certain services.
15 July 1994: Roads Contract between FMSS and IRB signed. The contract for the excavations, geotechnical survey and external roads for San Raffaele Hospital is between, on the one part, FMSS as client and on the other part a joint venture made up of Impresem Spa, Rainbow Mix Concrete Ltd and G & P Borg (IRB).
15 March 1995: FMSS leased and occupied one floor of office space at Gattard House in Blata l-Bajda. FMS left Gattard House offices on 15 April 2000. FMSS has also leased another floor at Gattard House to be used by its agency SWDP.
12 September 1995: Construction Agreement between FMSS and SKANSKA International Building Ltd, Blokrete Ltd, Devlands Ltd and Cassar, Grech, Ebejer & Partners. Skanska was selected following a decision of the Adjudicating Committee set up by the Prime Minister in the later part of 1994. The committee was composed of nine members, including four Italians appointed on the committee to represent MTFM. FMSS did not have its own representatives on this committee. It should be noted that one of the Monte Tabor representatives, Dott Vincenzo Mariscotti, was involved in corruption allegations in Italy. Dott. Mariscotti informed the committee that due to the allegations he would not be attending the committee meetings. It is not clear, however, whether Dot. Mariscotti actually resigned from this committee. The conditions of the construction contract are based on the (standard) conditions of contract for work of civil engineering construction, published by the Fondation Internationale des Ingenieurs (FIDIC). The contract for the construction (civil works) of the San Raffaele Hospital for the price, which includes VAT, of Lm31.75 million. This price which is based on Bills of Quantity appended to the contract, includes a negotiated discount of 7.5 per cent and comprises deductions from and additions to the original Bills of Quantity. The total costs of the hospital excluding the drainage system would cost Lm51 million. The idea was to build a centre of excellence to complement the 50-year old St Luke’s general acute hospital which was to undergo an extensive programme of refurbishment. The 480-bed, state-of-the-art specialised hospital was to operate in the fields of diabetology, cardiology and degenerative diseases and other chronic illnesses prevalent in Malta and other Mediterranean countries. The new hospital was also to have a strong research and teaching aspect. CMC (Coiperaiva Muratori e Cementisti) appealed the government’s decision that awarded the tender to Skanska.
10 October 1995: Skanska started construction work on the San Raffaele Hospital Project.
6 January 1996: FMSS approved the assignment of another design contract of MTFM referred to as ‘On site design contract’ (OSDC) for a fee of Lm50,000. This agreement was for the service of on-site CAD operator, secretarial service and a link with Milan.
February 1996: Emmanuel Attard is employed as Chief Executive of FMSS.
March 1996 Skanska maintained that 50 per cent of Ortesa’s mechanical drawings required adjustment; clerical specifications submitted were totally different from tender specifications; whereas the electrical drawings of the stairwell had to be produced by Skanska. PMO on its part, maintained that although discrepancies in Ortesa design were more than normally expected in a project this size, Skanska’s delay was not totally attributable to design problems. PMO, however, pointed out that unless the design problems were sorted out in the near future, Skanska’s claims in this respect could become stronger. Skanska had in fact made a 12-week delay claim up to January 1996 because of design problems. PMO instead awarded a two-week delay to Skanska in this respect. In October 1996, however, Skanska submitted another claim of Lm2 million in relation to an envisaged 42 week delay (which also includes the 12 weeks mentioned above).
27 June 1996: The surrounding roads contract was completed by IRB on the date when the completion certificate was issued, nearly two years after the completion date stipulated in the contract. IRB instituted court proceedings against FMSS stating that the work undertaken could not be carried out properly due to lack of proper design and radical changes in original plans. Contractor claimed damages estimated at Lm500,000. On its part FMSS wrote to IRB on 18 November 1996 requesting payment of penalties for late completion estimated at Lm636,000. A further sum of Lm128,024 was also claimed due to lack of progress in terms of Clause 25 of the General Conditions of Contract for the Execution of Work in Malta which conditions form an integral part of the contract. As a result of the above claim, FMSS offset the balance of Lm96,978 due in respect of interim certificate no. 16 against the total values of damages claimed, leaving a net balance in favour of FMSS of Lm667,047. FMSS was also requesting payment under the Performance Bond.
July 1996: The board of FMSS received an offer from Skanska to finalise the Ortesa drawings for a fee of Lm250,000. The responsibility of the design was to remain with Ortesa, however the delay responsibility (originating from design shortcomings) would be transferred to Skanska. Subsequent to a meeting with the PMO, the above offer was turned down by FMSS.
23 August 1996: In view of the serious problems with Ortesa, the board of FMSS decided to suspend all payments to MTFM.
September 1996: FMSS received a letter from Prof. R. England wherein he threatened to withdraw his legal representation because his company was not being paid the fees agreed to in the contract with MTFM. In order not to disrupt this project further, FMSS considered paying these fees directly to England & England out of its own funds. The monthly progress reports contemplated on the construction supervision contract were never presented to FMSS. The significant design problems were highlighted to Rev. Prof. Verze in a meeting with the Prime Minister and FMSS and PMO representatives. Don Verze visited the site for the last time.
10 October 1996: The drainage consultancy agreement was signed between FMSS and England & England according to which the latter were appointed as consultants on the drainage extension from the hospital to the Gzira pumping station.
26 October 1996: The Labour Party wins the general elections. October 1996: The new Labour government immediately commissions reports in order to be in a position to take decisions about the hospital. From the reports the following was concluded:
a. A new medical brief had to be prepared.
b. The concept of the hospital had to change from that of a specialised hospital of 450 beds to an acute general hospital of 800 to 1,000 beds. This hospital had to replace St Luke’s Hospital.
c. The contract of Ortesa Spa had to be terminated and a new tender was to be issued. d. Skanska Malta JV had to continue the works on the existing footprint of the hospital from the designs of the original plans (those of the San Raffaele Hospital). Minister Michael Farrugia, in reply to PQ 11438 says that this was a cabinet decision and the additional cost is estimated at Lm2 million.
6 December 1996: A new (provisional) FMSS board is appointed. Mario Cacciottolo was appointed president, Joe Barbara and Alfred Vella were appointed as board members. This board was dissolved on 15 July 1997.
March 1997: FMSS commissions MSD Consultancy to quantify claims against MTF. According to this report the value of potential claims against MTF as at March 1997 was Lm9,120,046.
11 April 1997: The FMSS was instructed to request the Monte Tabor Foundation’s local representatives not to report on site and the locks of the FMS offices used by the MTF were changed.
23 April 1997: Dr Giovanni Bonello, on behalf of the MTF, alleged the unilateral termination of various agreements by FMSS and wrote that termination must be properly grounded and clearly expressed. He also alleged that the eviction of MTF from their offices was tantamount to an act of spoliation.
30 April 1997: Dr Richard Camilleri, on behalf of the FMSS, alleged that the accusation of spoliation was unfounded and that it was the MTF which unilaterally terminated the contracts in question, and which had already been practically abandoned. The FMSS had sufficient grounds to proceed with termination of all relevant contracts in accordance with their terms and therefore, in the existing circumstances, the government accepted termination by MTF. The FMSS reserved the right in respect of any damages suffered or which may be suffered as a result of MTF’s actions or omissions.
21 July 1997: A new FMSS board was appointed with Alfred Sladden as president (resigned 19 February 1999), Joe Bugeja as vice-president, Joseph Buttigieg; Joseph Portelli, John Cachia (resigned 19 February 1999), John Bonnici, Vince Cassar (resigned 19 February 1999), Saviour Gauci, Joseph Saliba (resigned 19 February 1999) and David Spiteri Gingell.
8 January 1998: The MTF president, Rev. Luigi Verze informed the FMS that a meeting of the MTF was held in Milan on 14 November 1997. He also requested the FMS to nominate their member on the MTF. Moreover the president of MTF reminded FMSS that a sum of Lm365,764 was still pending.
16 February 1998: In reply to PQ 12301 made by Jesmond Mugliett, Minister Michael Farrugia said that the total construction cost of the New Hospital Project is Lm100 million.
March 1998: The constitution of the Foundation for Medical Sciences and Services was amended and the foundation split into two separate organisations. The Foundation for Medical Services (FMS) which retained responsibility for the health sector services and the Foundation for Social Welfare Services (FSWS) which took over Social Welfare Services.
July 1998: Norman & Dawbarn were chosen as the new designers for the new hospital. Minister Michael Farrugia would later confirm, in a reply to PQ 14624 that the tender offer of Norman & Dawbarn was not the cheapest bid.
5 September 1998: The Nationalist Party is returned to power.
September 1998: The new hospital project is re-evaluated. According to a reply to PQ 749 by Minister Deguara, the new administration found a situation where: The structure was built on the Ortesa designs for a 480-bed hospital – with an additional floor and an additional wing to Block D. The mechanical and electrical services were suspended as from 7 February 1997 to 31 December 1998. The new wing of Block D and car park were to be completed by February 1999. A medical brief for a 980-bed hospital. The hospital concept had been changed from one of research and training to a general acute hospital. The new administration decided to re-dimension the new hospital to a 650-bed hospital with a possible extension to 825 beds. The new hospital was to cater for Malta’s acute medical needs into the next century whilst incorporating secondary and tertiary services including all major specialities. All the clinical functions were to have a strong research and teaching component. The completion of the first section of Mater Dei Hospital was due in 2003 and to be fully completed in 2005. It is decided to terminate the contract of designers Norman & Dawbarn.
11 November 1998: FMS terminates the Design Consultancy Contract with Norman & Dawbarn. Due to previous experience on the project, the government concludes that it is far more advantageous to have one contracted entity to design and build the project. One has to note that this option was also considered during the Labour administration although it was not taken on board. The contract with Norman & Dawbarn places no onus on the client to give a reason for the termination of the contract.
19 February 1999: A new FMS board is appointed for two years: Dr Joseph L Pace (president), Rene H Formosa (vice president – resigned 2 June 2000), Dr Ray Busuttil, Dr Ray Xerri, Albert Attard, Dr Natasha Muscat Azzopardi, David Spiteri Gingell (resigned 1 October 2000), Emmanuel Micallef (appointed 10 May 2000), Saviour Sciberras (appointed 10 May 2000), Paul Camilleri (appointed 25 October 2000).
6 December 1999: FMS starts negotiations with Skanska on the Design and Build Contract, with a draft proposal prepared by FMSA.
29 February 2000: Skanska Malta JV and the Foundation for Medical Services enter into an agreement for the building, finishing and commissioning of the new hospital in Tal-Qroqq. The contract is a Design and Build Contract. Apart from FMS representatives, the FMS negotiating team also includes a prominent worker, a prominent lawyer from a local law firm and a foreign consultant belonging to an international firm specialising on contract advisory services. The advantages of a Design and Build contract include the following: Speed: It allows for a fast method of construction as construction time is reduced because design and building proceed in parallel. Early start on site is possible, long before tenders have been invited, for some of the work packages.
Complexity: An efficient single contractual arrangement integrating design and construction expertise within one accountable organisation. Design and construction skills are integrated at an early stage which will allow a better coordination of the design, procurement and construction works.
Quality: The client requires certain standards to be shown or described. Skanska is responsible for quality of work and materials on site and its expertise is fully utilised throughout all stages of the project including the design stage.
Flexibility: the client can modify or develop design requirements during construction, Management contractor can adjust programme and cost to meet the client’s requirements.
Competition: The management contractor has been appointed because of management expertise. However, competition can be retained for the works packages which will be subject to competitive tendering.
Responsibility: The client has access to all of the management contractor’s records due to “open book” system of working. Controls applied to contractor: All of the Management Contractor’s systems of working are subject to discussions and approval, by the client’s control ones its employment of expatriate staff.
Sectional completion: The hospital will be completed in parts, which will allow the client the possibility of early possession and a flexible method of migration from St Luke’s Hospital. Failure by the management contractor to complete on time will be closely monitored and penalties will be applied where necessary. Comparisons between Design & Build Contract and the pre-1998 administration negotiations:
Cost: the costs reported by Norman & Dawbarn were subject to confirmation only after considerable design development which was still to be carried out while the Lm10 million figure mentioned by Anshen Dyer Consultants can only be a very rough estimate as no professionally prepared estimate has been presented. In comparison with this, the estimated target cost of Lm83 million of the project was calculated on pre-construction documents giving scheme design details of all medical and engineering systems within this project.
Design: The Skanska and Norman & Dawbarn contracts cannot be compared on a “like for like” basis. Skanska’s Lm4.8 million incorporates a larger scope of work than N&D’s Lm3.9 million design.
Management fee: Skanska’s management fee as per 2000 per Design & Build contract = 7.5 per cent of Lm75 million = Lm5.6 million capped at Lm5 million. Skanska’s management fee as per 1998 negotiations: nine per cent of Lm10 million = Lm9 million.
Accountability: The Design & Build contract gives the advantage of contractor responsibility. When FMS had Ortesa as designers and Skanska as building contractors, significant designer-contractor problems emerged. With the 1998 Norman & Dawbarn appointment as designers, the problems would have persisted and this would have encouraged further delays. Maltese control: The FMS team has been enhanced with professional staff as from 1990s. Before that it had a weak organisational structure.
Expropriation: The surrounding land areas of the MDH project are held from being built on in case of any future expansion. This would solve the problem of cramming buildings into each other if expansion is necessary.
Saving on penalties: Due to awarding the Design & Build contract to Skanska, the Maltese government saved circa Lm7 million that was due because of changes in designs.
Approval of expenses: All MDH project expenses have to be approved by the client (FMS). An open book system allows FMS access to all related documents including wages and allowances of contractor’s employees.
18 February 2001: New FMS board is appointed: Dr Joseph L Pace president (resigned 28 May 2003), Albert Attard vice president (resigned 11 April 2003), Dr Natasha Muscat Azzopardi (resigned 28 May 2003), Paul Camilleri, Dr Ray Busuttil (resigned 28 May 203), Dr Ray Xerri (resigned 28 May 2003), Emanuel Micallef (resigned 31 December 2002), Saviour Sciberras, Prof Joseph Bannister (appointed 21 January 2002 and resigned 28 May 2003).
12 April 2003: The Nationalist Party is returned to power, Dr Eddie Fenech Adami is sworn in as Prime Minister and Dr Louis Deguara is appointed as Health Minister.
28 May 2003: New FMS board is appointed: Rene Formosa president, Paul Camilleri vice president, Prof. Albert Fenech, Alfred Rizzo, Saviour Sciberras, Jesmond Sharples (board members).
April 2004: Lawrence Gonzi is sworn in as Prime Minister. Following a Cabinet reshuffle, Dr Louis Deguara is appointed Health, the Elderly and Community Care Minister. Helen d’Amato is appointed Parliamentary Secretary.
April 2004: FMS Finance consultant Jackie Camilleri completes the Mater Dei Hospital Gap Analysis Target Value vs Projected Final Cost.
3 May 2004: FMS presents the same report to the Health Ministry.
12 August 2004: Rene Formosa resigns as FMS President. The Health Minister appoints Perit Paul Camilleri as acting president.
30 September 2004: The government decides to stop, with immediate effect, all negotiations regarding the Target Cost and the completion date of the project with Skanska after it received the company’s latest counter-proposals. The government remains open to further offers by Skanska. Following the Prime Minister’s announcement that Target Cost and Completion of project were suspended, it is announced that Skanska submitted further proposals which were yet again rejected by government, describing them as a sign of good will but not yet good enough.
3 October 2004: Lawyer Dr Richard Camilleri, a government appointed member of the MDH Negotiation Team vs Skanska “sets the record straight” in The Times to allegations that his firm was chosen because he is the Prime Minister’s cousin. Camilleri argued that “Like everyone else in Malta, I have countless close relatives, one of them being former minister Evarist Bartolo, who is my brother-in-law. This has never caused any problems and I have acted for government entities even under the 1996-1998 Labour administration.”
By the end of 2004 the government agreed to new plans with Skanska which agreed to finish the project by 1 July 2007. Plans the government had agreed with Skanska in 2004 for the completion of Mater Dei Hospital had evolved during the passage of the three years up to 2007, when the hospital had been delivered.
A major difference was the fact that the space then earmarked for an oncology centre in the new hospital had been given up for other services, and the oncology centre would now be outside the physical contours of Mater Dei. The cost of completion of Mater Dei was projected to reach Lm139 million, but the final figure had risen to Lm149 million.
The construction of Mater Dei had been a long saga.
The new Mater Dei Hospital was officially opened on 29 June 2007. This meant that the new hospital opened two days before the original target date.
After Mater Dei was opened by Prime Minister Dr Lawrence Gonzi, an open weekend was held on June 30 and July 1 for the public, who was able to visit the hospital and take part in a number of organised events. Over 9,000 people had visited the hospital site between 2001 and 2007. They included representatives of trade unions, councils, professional associations, political parties, voluntary organisations and other non-governmental organisations. After contractor Skanska delivered the hospital, which cost around Lm200 million, a carefully phased migration started immediately and the hospital was expected to be fully operational within three to four months of opening.
To mark the completion of the migration process from St. Luke’s Hospital to Mater Dei Hospital, the Minister of Health, the Elderly and Community Care, the Hon. Louis Deguara addressed the press at Mater Dei on 20 November 2007. The Minister said that he and the hospital authorities were very satisfied with the smooth and safe process without any major problems. This is a result of the thorough planning process carried out with all internal and external stakeholders prior to migration. The Minister added that the in-patient migration took 9 days to complete instead of the anticipated 10, without placing patient safety at risk. The Minister said he wanted to emphasise that there was no point when patient safety was jeopardised or compromised. Presently there are almost 400 patients recovering or receiving treatment at Mater Dei Hospital. This number will continue to rise as elective surgeries resume with a full load in the coming days.
All acute services are now being offered from Mater Dei Hospital (Outpatients and Inpatients). The process has been made possible through the hard work, commitment and dedication of all hospital staff who rose to the occasion and managed to run two hospitals simultaneously, while stocking the new hospital wards and closing down St. Luke’s Hospital. At the same time, all essential hospital services were kept running on a 24 hour basis. Considering that no extra hospital staff were made available to cater for this special process, the achievement is even more remarkable. The Minister thanked all staff and all those who contributed to this success, including all volunteers and the general public. The migration process was also made possible after government successfully concluded very important agreements with the Malta Medical Association and the Malta Union of Midwives and Nurses. The Minister made it clear that there was still room for fine tuning. The Migration process is now over, however a period of time is needed to settle down in the new hospital. The Mater Dei authorities are working hard to iron out some teething problems. These are normal problems that crop up when using a brand new facility for the first time. Three particular issues are: · Parking rates and efficiency in traffic management · Distribution of staff meals · Patient entertainment system “We have already achieved a lot by moving to Mater Dei. Now we need to strive for excellence, even in research infrastructures, and to improve waiting times. There is a lot of work still to be done in this regard and we are committed to reduce these waiting times,” the Minister said. Mater Dei cannot be seen in isolation. This hospital is a link in the chain of important measures undertaken to improve our hospital and care services. The fight against cancer is a top priority for this government. Zammit Clapp will be transformed into a specialised Oncology Centre which can accommodate twice the number of beds (26 to 60) currently at Boffa Hospital. This requires a substantial investment in new medical equipment. 27 March 2014 – The planning authority unanimously approved the development of an additional two storeys on Mater Dei’s Emergency Department block. It was noted during the hearing that the block was lower than the rest of the hospital so the general height of the hospital would not be affected. The two wards would form the Medical Assessment Unit and take 62 to 68 beds. They are intended to reduce crowding at the Emergency Department. No additional parking spaces were requested.
In 2012 there were 18,000 admissions to emergency department.
Present State Medical Facilities
Malta State Hospitals 
MATER DEI HOSPITAL
Mater Dei is Malta’s main public hospital located in Msida. It is an acute general teaching hospital offering hospital and specialist services. The hospital is relatively new; it opened in 2007, replacing the old public hospital St Luke’s. Mater Dei has a total of 7156 rooms, 825 beds and 25 operating theatres. 
SIR PAUL BOFFA HOSPITAL
Sir Paul Boffa Hospital in Floriana was a specialised hospital for Oncology and Palliative Care and Dermatology. This hospital provided both in- and out-patient services. The hospital had a Genitourinary (GU) Clinic, and the following departments: Pharmacy, Psychology, Physiotherapy, Occupational Therapy, Social Worker and Chaplaincy services. The Oncology Centre migrated to the Sir Anthony Mamo Oncology Centre adjacent to the Mater Dei Hospital in 2015.
SIR ANTHONY MAMO HOSPITAL
This hospital, situated adjacent to the Mater Dei Hospital, offers more advanced radiotherapy with two machines commissioned from the Leeds Spencer Centre, where they were introduced in 2013. The machines enable more precise radiotherapy and stronger doses reducing the length and frequency of sessions. Beds at this hospital were increased from the 78 at Boffa Hospital to 113 and the outpatient clinics from two to 12. The type of chemotherapy given Is also more advanced. Palliative care beds were also increased from the 10 at Boffa Hospital to 16.
The Sir Anthony Mamo oncology centre adjacent to Mater Dei Hospital was inaugurated on Sunday 20 September 2015 by Health and Energy Minister Konrad Mizzi, Parliamentary Secretary for Health Chris Fearne and the Parliamentary Secretary for EU Funds, Ian Borg. Prime minister Joseph Muscat could not attend due to family mourning.
In their speeches the three acknowledged the work of the former Nationalist government, which kicked off the project.
Dr Mizzi said the government was planning to upgrade other facilities to the high standards of this facility, including the Gozo Hospital, St Luke’s and Mt Carmel Hospital.
The guests included former Health Minister Joe Cassar and the shadow minister for health, Claudette Buttigieg.
Archbishop Charles Scicluna blessed the facility.
The new 113-bed centre received its first outpatients in December 2014. The migration of services from Boffa Hospital started in August 2015 and was completed by 18 September 2015. New state-of-the art linear accelerators have now been commissioned. The site of the new oncology centre started being excavated in 2010 and building started in 2012.
MOUNT CARMEL HOSPITAL
Mount Carmel Hospital in Attard is a mental health hospital that offers both in- and out-patient services. This hospital prides itself on the professionalism and capabilities of human resources and takes a multi-disciplinary approach in all its psychiatric services offering its patients holistic and customised psychiatric, psychological and social care. 
ST VINCENT DE PAUL RESIDENCE
St Vincent de Paul Residence is Malta’s largest state-owned long-term residence home for the elderly. With its varied staff members, the hospital does its utmost to ensure the quality of life of its residents. 
GOZO GENERAL HOSPITAL
Gozo’s General Hospital in Victoria is a 291 bed hospital. The main activity is that of a general hospital with a mix of acute care wards. However, within its grounds there are also dedicated geriatric and long term psychiatric wards delivering long term care and mental health care respectively. The hospital offers diagnostic treatment to both in and out-patients. Its medical care facilities include a hyperbaric unit which is mainly used to manage diving related conditions. 
KARIN GRECH HOSPITAL
Karin Grech Hospital in G’Mangia is a rehabilitation hospital. Patients who have undergone, for example, an amputation, stroke or trauma are treated on both an in- and out-patient basis. 
Health Care System Malta:
List of All Health Centres
There are nine Government health centres in Malta and Gozo. These centres provide general practitioner and nursing services, as well as specialised health services such as immunisation, speech therapy, antenatal and postnatal clinics, and wound clinics. The clinics are strategically located to cater for residents in all regions of the islands.
Birkirkara Health Centre (can be used by those living in Birkirkara, Lija, Balzan and Iklin) Tel: ++356 21485376
Floriana Health Centre (can be used by those living in Valletta, Floriana, Hamrun, Sta. Venera, Mriehel, Marsa, Zurrieq, Safi, Luqa, Mgabba, Qrendi and Kirkop) Tel: ++356 21243314
Gzira Health Centre (can be used those living in Pieta’, G’Mangia, Msida, Ta’ Xbiex, Gzira, Sliema, Kappara, San Gwann, Taz-Zwejt, Saint Julians, Swieqi, L-Ibrag, St. Andrew’s, Pembroke, High Ridge and Victoria Gardens) Tel: ++356 21337245
Qormi Health Centre (can be used by those living in Qormi, Zebbug and Siggiewi) Tel: ++356 21484450
Paola Health Centre (can be used by those living in Paola, Tarxien, Sta. Lucia, Birzebbugia, Zejtun, Marsaxlokk, Zabbar, Marsascala, Xghajra, Fgura, Gudja, Ghaxaq, Hal Far or Benghajsa) Tel: ++356 21691314
Cospicua Health Centre (can be used by those living in Cospicua, Vittoriosa, Senglea and Kalkara) Tel: ++356 21675492
Mosta Health Centre (can be used by those living in Mosta, Naxxar, Gharghur, St. Paul’s Bay, Burmarrad, Mellieha, Mgarr, Bugibba, Qawra, Bahar ic-Caghaq, Madliena, Mriehel and Fleur-de-Lys) Tel: ++356 21433256
Rabat Health Centre (can be used by those living in Rabat, Mdina, Mtarfa, Dingli, Attard, Bidnija and Kuncizzjoni) Tel: ++356 21459082
Gozo Health Centre (can be used by those living in Gozo) Tel: ++356 21561600
Private Hospitals and Clinics
There are also a number of Malta hospitals which are privately owned and various private health clinics scattered all around the Maltese islands. They’re all licensed by the Public Health Authorities.
Vassallo History 
Dear Profs. Savona Ventura,
I enjoyed reading your interesting article as I enjoy entering or passing by old buildings in Malta and know their story and how many lives they must have touchd..
Of interest to me is the Central Hospital of Floriana. If I understood correctly the hospital was used as an orphanage during the 1850 ‘s? It will be greatly appreciated if you can tell me if in 1871 babies born out of wedlock and up for adoption were born at same hospital pls?
Thank you
Usually women gave birth at home not in a hospital. This was the norm in Malta till the mid 1960s
Dear Sir,
Can you send some history of hospital zammit clapp
Regards Frederick Zammit Gera
Check here https://vassallohistory.wordpress.com/midwifery-hospitals/