Andalusia Hospitals

Environmental & Social Review Summary

This Environmental and Social Review Summary is prepared and distributed in advance of the IFC Board of Directors’ consideration of the proposed transaction. Its purpose is to enhance the transparency of IFC’s activities, and this document should not be construed as presuming the outcome of the Board of Director’s decision. Board dates are estimates only.
Any documentation which is attached to this Environmental and Social Review Summary has been prepared by the project sponsor and authorization has been given for public release. IFC has reviewed this documentation and considers that it is of adequate quality to be released to the public but does not endorse the content.

Project number	25918
Country	Egypt
Sector	Health Care
Department	Health and Education
Company name	Arabian Andalusia Holding Company
Environmental category	B
Status	Active

Date ESRS disclosed	June 19, 2007

Previous Events	Invested: January 10, 2008 Signed: October 23, 2007 Approved: August 16, 2007

View Summary of Proposed Investment (SPI), click here

Overview

Category & Applicable Standards

Key Issues & Mitigation

Community Engagements

Client's Documentation

Overview of IFC's scope of review

The review of this project consisted of a site visit to Al Salama Hospital, Alexandria, Egypt; detailed discussions with corporate and Al Salama medical, infection control and environmental management personnel and appraisal of voluminous technical and environmental/social information for the existing Al Salama and Hai Jamea Hospitals submitted by the project sponsor. The site visit included a detailed inspection of Al Salama’s physical facilities assisted by hospital engineering and infection control staff and the consultant responsible for hospital structural design.

Project description

Andalusia Group (Andalusia or the Group), a hospital and healthcare company established in 1984, is operating under the brand name of “Al-Salama” in Alexandria, Egypt and “Hai-Al-Jamea” in Jeddah, Saudi Arabia. Andalusia’s network operates 200 beds in total (88 in Jeddah; 112 in Alexandria) and provides services to 420,000 patients a year.

The Group has developed an $68 million 3-year expansion program which consists of:

An investment program in Egypt of $33 million which entails:

- expansion of Al-Salama hospital in Alexandria from 83 to 115 beds, and
- construction of a new 100 bed Al-Salama hospital in Cairo.

An on going investment program in Saudi Arabia of $35 million which will result in:

- construction of a new 120 bed hospital in the new Jeddah Gate down town,
- expansion of existing Hai Al-Jamea Hospital in Jeddah, and
- expansion of dental and dermatology center in Jeddah.

The proposed IFC investment is an A loan for IFC’s own account of up to $15 million and an equity investment of up to $10 million.

Identified applicable performance standards

While all Performance Standards (PS) are applicable to this investment, IFC’s environmental and social due diligence indicates that the investment will have impacts which must be managed in a manner consistent with the following Performance Standards:

- PS1: Social and Environmental Assessment and Management Systems with respect to the company’s management of its environmental, health and safety performance in the construction and operation of its facilities; compliance with national and local environmental permitting and hospital medical certification requirements; and its engagement with local communities regarding environmental, health and safety performance, as well as any corporate social responsibility efforts.

- PS2: Labor and Working Conditions with regard to fair, safe and healthy working conditions in construction and operation of facilities.

- PS3: Pollution Prevention and Abatement with regard to efforts to optimize resource inputs, including energy efficiency and waste minimization practices as well as the storage, handling, application and disposal of hazardous materials used in the construction and operations of facilities and medical waste generated in the facilities.

- PS4: Community Health, Safety and Security with regard to the impacts of the construction and operations of facilities, including: movement of vehicles to and from construction sites, operation of construction equipment, containment of dust, noise and other nuisance factors; and control of public access to construction sites.

- PS5: Land Acquisition and Involuntary Resettlement: Development of the new hospital in Cairo will involve site acquisition in an urban environment. Involuntary resettlement is not anticipated at this time; however, since no decisions have yet been taken with regard to site acquisition and development, the possibility can not, a priori, be eliminated

There was no indication that any of the proposed expansions or new developments in Alexandria, Cairo or Jeddah would have any impact on biodiversity, cultural heritage or indigenous peoples, hence PS6: Biodiversity Conservation and Sustainable Natural Resource Management; PS7: Indigenous Peoples and PS8: Cultural Heritage do not apply.

Environmental and social categorization and rationale

This is a Category B project according to IFC’s Procedure for Environmental and Social Review of Projects because a limited number of specific environmental and social impacts may result that can be avoided or mitigated by adhering to generally recognized performance standards, guidelines or design criteria.

Key environmental and social issues and mitigation

The following potential environment, health and safety and social impacts of the projects (and the corresponding applicable Performance Standards) were analyzed:

- Systematic management of quality, environmental issues, and occupational health and safety (PS1);
- Occupational health and safety and implementation of good hospital management practices and
employee training programs to prevent nosocomial diseases (PS2);
- Quality and sustainability of potable water supply (PS3);
- Handling and disposal of hazardous and non-hazardous health care waste (PS3);
- Liquid effluent management (PS3);
- Air emissions (PS3);
- Adequacy of disinfection and sterilization programs (PS3);
- Life and fire safety in the design, construction and outfitting of new and existing facilities (PS 3);
- Community health, safety and security (PS4); and
- Site selection, acquisition, development and permitting (PS5);

The client has presented plans to address any impacts to ensure that the proposed project will upon implementation of the specific agreed measures, comply with the environmental and social requirements of Egypt and Saudi Arabia as well as IFC environment and social policies and the environmental, health and safety guidelines. The information about how these potential impacts will be addressed by the projects is summarized in the paragraphs that follow.

PS1: Social and Environmental Assessment and Management Systems.

Organization for Environmental and Social Assessment: Andalusia has a clearly defined corporate vision and mission statement as well as policies and operational procedures in all key areas. The Group has developed a strong effective management team. The President/CEO of the Group reports to the Board and has a corporate office that provides a staff function to the hospitals. Each hospital has a Chief Operating Officer (COO) with a Chief for Medical Operations and a Chief for Administration. Each hospital has a Steering Committee (SC) chaired by the COO and with each medical service (e.g. X ray, lab services) and each administration department (e.g. marketing, maintenance, catering, and finance) head as a member. In addition to the committees detailed above, each hospital has a Quality Assurance and Safety Committee that also meets on a regular basis. The Quality Dept. is responsible for infection control and for environmental compliance at each hospital. This has resulted in excellent EHS performance in the two existing hospitals. Hai-Al- Jamea is certified by the Mecca Region Quality Program, a Saudi certifying agency. Al Salama has applied for Egyptian Healthcare Accreditation, issued by the General Directorate of Quality, Ministry of Health and Population, which is expected in 2008.

Quality Management Program: For the next few years at least, Andalusia prefers to maintain it its current management and quality model, based on the system already in place at Hai-Al-Jamea and Al Salama, that of the Mecca Region Quality Program, rather than seeking international certification. Andalusia has demonstrated that it is capable of designing and implementing a systematic approach to management of internal affairs, environmental and occupational health and safety. Given the demonstrated positive results, this is acceptable to the IFC.

Monitoring and Reporting: IFC will evaluate the project’s compliance with the applicable environmental and social requirements during the lifetime of the project by reviewing the annual monitoring reports (AMRs) prepared for the project covering: a) the status of implementation of all measures contained in the Corrective Action Plan and b) ongoing performance of project-specific environmental, health and safety activities as reflected in the results of periodic and quantitative sampling and measuring programs. Periodic site supervision visits will also be conducted.

PS2: Labor and Working Conditions.

Human Resource Policy & Management: Current employment in the Group is 508 in Jeddah and 675 in Alexandria. Staffing for the hospitals is therefore in the range of 4 to 5 employees per bed (i.e. 0.75 doctors, 1.3 nurses, 0.5 technicians and 1.5 administrative/support staff) – thus for the new Cairo hospital the full staff compliment will be about 500-550 with approximately 90 doctors, 155 nurses, 60 technicians, and 180 administrative/support staff. One of the major issues facing Andalusia relates to the hiring, training and retaining of high quality staff from the medical sector (e.g. doctors, nurses, laboratory technicians). This is the motivation for the establishment of the planned 350 student nursing school in Cairo.

Andalusia’s Corporate Human Resource policies and procedures are very detailed. All Andalusia facilities are required to comply with these policies and procedures and their performance in this regard is monitored very carefully. Andalusia complies with the labor laws of Egypt and Saudi Arabia as the case may be.

Workers Organizations: There is currently no collective bargaining arrangement with any level of staff in either Jeddah or Cairo. There is no formal worker grievance mechanism beyond that required by national labor law.

Retrenchment: Retrenchment, forced labor and child labor are not issues with this project.

Protecting the Workforce: Andalusia devotes considerable resources to workforce safety including very complete safety management and infection control programs and employee health and safety programs comprising screening, preventive health services, non-occupational illness treatment, health education and counseling and medical insurance.

Occupational Health & Safety: Andalusia has a corporate occupational health and safety (OHS) policy as well as detailed procedures in place in both hospitals. Each Group facility has a trained OHS officer responsible for these issues as well as staff training. Each department in each facility has a nominated OHS representative who supports the OHS Officer. All relevant staff undergo training in topics such as infection control, sharp safety and disposal, isolation procedures and precautions, disease transmission precautions, etc.(internal and external training). An annual schedule of staff OHS training is prepared and implemented. All accidents must be reported in writing and initially investigations completed within 24 hours by the OHS Officer.

Life and Fire Safety: All Andalusia existing buildings have the required smoke and fire detection equipment with either fire extinguishers or, in the larger facilities, sprinklers and hose and reel fire fighting systems. Building designs also allow for proper egress in emergency situations. These requirements are consistent with IFC’s Life and Fire Safety Guidelines.

Planned expansions in Jeddah and Alexandria and the new hospital and nursing school in Cairo will be required to comply with IFC’s Life and Fire Safety Guidelines, including independent verification of fire proof design.

PS3: Pollution Prevention and Abatement.

Pollution Prevention, Resource Conservation and Energy Efficiency.
Potable water for Al Salama and Hai Jamea for general hospital use is sourced from the municipal water systems. Hai Jamea uses bottled water for drinking purposes. Both use additional purification for water supply to hemodialysis unit. Analyzed water sample results are of acceptable quality. Where required, such as laboratories, Al Salama uses additional local solids filtration systems.

Liquid effluent: Both hospitals are approved by their respective municipalities to discharge sanitary effluent untreated to municipal collectors for treatment at municipal WWTP’s.

Disinfection and sterilization programs. Andalusia has disinfection and sterilization programs consistent with local regulatory requirements and international best practice. General use and invasive procedures equipment is sterilized in accordance with these guidelines and with the nature of the material. Andalusia uses ethylene oxide, steam, formaldehyde, and solutions of acetic acid and glutaraldehyde among other techniques for equipment sterilization. Precleaning, sterilization and disinfection procedures are overseen by graduate nursing staff.

Electric energy is supplied to both hospitals from their respective national grids. Al Salama has a 500 kVA diesel back up generator and Hai Jamea a 1000 kVA diesel back up. Inspection of Al Salama indicated acceptable soundproof enclosure and noise control. Medical equipment has battery back up as required. The diesel generators are sized to support fire fighting water pumps as well as complete hospital operation.

HVAC (Heating, Ventilation & Air Conditioning): Al Salama has a modern hospital ventilation system (positive pressure in OR, negative in ICU, neo natal, central roof level exhaust fans, etc). For AC, it has a Carrier central system and 150 split units, all of which use permitted R-22 or non-ODS refrigerants. The central system does not have any condenser cooling water cooling water towers/water recycle design, ostensibly due to space limitations in the roof top utilities area. This is a water utilization efficiency problem which should be addressed in the design of the expansion wing. Both hospitals have detailed Utility System Management and Emergency Response Programs.

General Solid Waste Disposal: Both hospitals use contractors to dispose of solid waste in government approved landfills.

Medical Waste: Andalusia has very detailed procedures for handling all types of medical wastes. Medical waste is collected by Andalusia staff, segregated and stored onsite. In both Jeddah and Alexandria, licensed contractors collect this waste for transport to a Government licensed incinerator for disposal. In addition laboratory and radiological wastes are also collected regularly by Government licensed contractors for proper treatment and disposal. In Al Salama, there is no on premises cold room to store medical waste, as recommended by IFC Health Care Facilities Guidelines. Management is aware of this requirement and cold room construction is already planned. The situation at Hai Jamea requires clarification.

Hazardous Materials: The hazardous materials present at both hospitals consist of relatively small volume of laboratory reagents, other chemicals, solvents and cleaners, and high pressure hospital gas containers. They are handled in accordance with acceptable practices.

Emergency Preparedness & Response: Both hospitals already have very complete Emergency Preparedness & Response Plans and carry out fire and emergency evacuation drills as required by local regulation.

PS3: Supplementary Actions: Please refer to Corrective Action Plan (CAP) attachment.

PS4: Community Health, Safety and Security.

Community Health, Safety and Security: There are few if any negative community impacts associated with the existing hospital or the planned facilities expansions – only community benefits from the availability of private high quality medical facilities.

Emergency Preparedness and Response: In the case of emergencies the Andalusia hospitals will be expected to respond – hospital staff have been/will be trained and Andalusia has detailed operational procedures in place for emergency preparedness and response and these will be implemented both the expanded and new facilities. Emergency drills will be coordinated with the local civil defense, fire and police authorities as dictated by local regulation.

PS5: Land Acquisition and Involuntary Resettlement.

Development of the new hospital and nursing school in Cairo will involve site acquisition in an urban environment. Involuntary resettlement is not anticipated at this time; however, since no decisions have yet been taken with regard to site acquisition and development, the possibility can not, a priori, be eliminated. At the appropriate time, Andalusia should inform the IFC of site acquisition details so that a determination can be made through mutual consultation concerning the applicability or not of PS .

Supplementary Actions: Please refer to Corrective Action Plan (CAP) attachment.

IFC PROJECTS