Life Healthcare

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

29199

Country

South Africa

(IDA)

Region

Sub-Saharan Africa

Sector

Hospitals and Clinics

Department

Reg Manufact, Agri & Services, CAF/CLA

Company name

Life Healthcare Group Pty Ltd

Environmental category

Status

Active

Date ESRS disclosed	May 12, 2010
Last Updated Date	February 8, 2012
Previous Events	Invested: June 9, 2010 Signed: June 4, 2010 Approved: June 3, 2010

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

IFC staff visited the company’s HQ in Illovo, Johannesburg, South Africa in order to conduct a desk review of existing environmental, occupational health and safety (OH&S), social and community operational procedures. Meetings were held with senior management representatives (National Quality Manager, National Infection Prevention Risk Manager, Regional Engineering Manager - Inland and General Manager - National Healthcare Function). Operational performance at existing facilities were discussed, including an overview of the existing quality management system (QMS), audit review and strategic objectives and guidelines for the company’s expansion plan with regard to environmental, OH&S, life and fire safety (LF&S), social and community issues.
Considering the time constraints due to the proposed imminent listing of the company’s shares, the scope of the due diligence did not encompass a site visit to existing hospital facilities. In addition, limited information was made available on the targeted hospital facilities to be part of the expansion plan. As such, this appraisal was restricted to a desk-top information review. The approach adopted was to make an assessment of the Environmental and Social Management Framework adopted by the company that could be extrapolated to its future hospital facilities. As such, the findings from the appraisal are based on limited information on the company’s expansion plan in Africa, Turkey and India.

Project description

Life Healthcare (“Life” or the “Company”) was established in 1983 and is currently the second largest private hospital group in South Africa. Aside from the company’s own facilities located in South Africa and Botswana, Life also has public-private partnerships (PPP) with the government of South Africa.
The company is in the process of:
restructuring its shareholder base through an IPO so that: (a) some existing shareholders can exit; and (b) the investment objectives of its shareholders are better aligned with the company; and
(ii) considering expanding its services, capacity and geographic footprint both locally as well as in a number of African countries, Turkey and India (the “Project”). IFC is considering an investment of both debt and equity in the company to support the project.

Identified applicable performance standards

While all Performance Standards 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:

- PS 1: Social and Environmental Assessment and Management Systems- PS 2: Labor and Working Conditions- PS 3: Pollution Prevention and Abatement- PS 4: Community Health, Safety and Security- PS 5: Land Acquisition and Involuntary Resettlement

Other Performance Standards, i.e., PS 6: Biodiversity Conservation and Sustainable Natural Resource Management, PS 7: Indigenous Peoples and PS 8: Cultural Heritage, were not identified as being applicable to the project.

Environmental and social categorization and rationale

The key environmental, health and safety and social issues associated with this project include:
- Adequacy of environmental and social assessment and management systems;
- Construction related environmental, health and safety and social impacts;
- Labor relations, human resources policy and practices;
- Worker’s health and safety, including training and housekeeping; disinfection, sterilization, hygiene, LF&S risks, adequacy of emergency preparedness and response programs;
- Pollution prevention in terms of indoor and outdoor air emissions control, wastes and effluents treatment and disposal;
- Hazardous materials management;
- Implementation of good hospital management practices;
- Opportunities for energy conservation and efficiency as well as waste minimization; and
- Community health, safety and security.

Potential adverse impacts arising from the issues mentioned above are limited, site-specific and can be avoided or mitigated by adhering to generally recognized performance standards, guidelines or design criteria. The company has a robust and rigorous management system and audit process in place. The company stated that it intends replicating this for all new acquisitions to ensure that consistency in best practices, as was highlighted regarding its current operations, is achieved for facilities added to the company’s portfolio. Therefore, this is a Category B project according to IFC’s Environment and Social Review Procedures.

Key environmental and social issues and mitigation

PS1: Social and Environmental Assessment and Management Systems

Social and Environmental Management System:

The company is certified ISO 9001:2008 (quality management system) which is the first and only multi-site certification for a healthcare company in South Africa. Certification was obtained in 2007 and is annually reviewed by a recognized, qualified agent. The quality management system (QMS) was selected by the company as the management system that most appropriately focused their efforts and attention on the company’s customers, i.e., their patients, and their operations. The QMS contains relevant elements of environmental as well as OH&S management requirements and practices; for example, within pharmacy legal processes, storage of pharmaceuticals, procurement and management of clinical and operational equipment and building design and renovations. Legal requirements are included in the QMS, alongside internally-derived and developed performance indicators, as well as quality and business outcomes. PPP operations have a separate QMS outside of the ISO certification that comprises a separate quality scorecard and a Safety, Health, Environment and Quality (SHEQ) checklist. The company is considering applying for certification for their PPP’s, however this, along with the accreditation standard to be selected, has not been confirmed.

Social and Environmental Assessment and Management Program:
The QMS is integrated throughout the company. It is organized and managed from the HQ level, but in many cases, hospitals and then wards themselves are responsible for identifying risks to be prioritized and subsequently managing them to meet corporate standards of performance. For example, the Risk Management Procedure applies to all business processes at the hospital level, such as hazardous chemical substances risks. The use of such procedures is relied upon to ensure compliance with legal and quality requirements and to ensure a systematic approach to the assessment process for objective evaluation and risk prioritization. The combination of consistency of approach (based upon corporate priority and commitment) and implementation at the operational level is judged to be a valid methodology that can create and promote sound managerial performance on all matters, not least of which is environmental, health and safety (EHS), at all levels within the organization. Where required, outside qualified experts are used to conduct additional assessments and audits, e.g., occupational hygiene survey (that reviewed exposure to noise, matters of air quality non-ionizing radiation, legionella, and air ground and water pollution, etc.). Such assessments reference South African regulation and/or international standards and include specific recommendations when results indicate the need for improvements in order to meet these standards. Action plans are then created internally and implemented to address assessment findings and outcomes assessed as part of the audit program.

Life Healthcare Group Holding (Proprietary) Limited will maintain a management system which meets IFC's Performance Standards and report any breaches of the IFC Performance Standards together with a corrective action plan. The specific actions in the attached environmental and social action plan (ESAP) refer to the company's international expansion operations.

Organizational Capacity:
For their current operations, safety, health, environmental and quality (SHEQ) responsibility is coordinated from HQ, but is operationally translated to SHEQ Coordinators, employee safety representatives and SHEQ committees at each hospital. Responsibilities of all individuals with SHEQ-related duties are outlined in relevant QMS documentation. Additional management, nursing, administration and support staff that has a role to play in management of SHEQ-related issues is also described in such procedures. Each hospital also has an infection prevention coordinator. Hospital staffs participate as safety representatives that focus on OH&S issues; issues reviewed are reported in monthly health and safety meetings at hospital and corporate levels. As noted above, PPP operations have recently become more integrated with respect to QMS and EHS management and now also have SHEQ coordinators on site. To date, newly acquired operations within South Africa receive assessment/audits of current operational practices in conjunction with corrective actions, including extensive training and engagement with staff to integrate Life’s quality systems into hospital operations, including that of the SHEQ representative.

Training:
New staff receives a quality induction and safety awareness training. In-service training plans are used to drive development. Competence of individuals in conducting their jobs is assessed through the use of internal audits by reviewing outcomes. As is required in South Africa, 1% of payroll is paid to government training authorities. Developmental training plans for employees are created; company performance against the content generates rebates from the training fund. Existing staff, working for operations that are acquired by the company receive training on company systems and practices. A certification-based train-the-trainer methodology is used to ensure consistency of message; certified trainers then train others within the new acquisition. IFC will require that the implementation of the QMS, the strengthening of its organizational capacity and the reporting structures be applied to all future operations. Compliance with all relevant national laws and regulations, as well as IFC’s Performance Standards and General and Health Care Facilities’ EHS Guidelines will be integral to company operations, regardless of geographic location.

Community Engagement:
The company interacts with the communities where their hospitals are located in many areas. For example, regular outreach activities on general healthcare issues (e.g., blood pressure monitoring), provision of emergency care (stabilization of patients arriving at emergency facilities is required under South African law regardless of ability to pay), and operation of retail pharmacies are a few such examples. EHS issues, such as construction or alteration of buildings were stated as being managed in a way that avoids or minimizes impacts to communities resulting from noise, dust, traffic, materials management, etc. With regard to a community grievance mechanism, national/local regulations require that large scale projects or new facilities complete an environmental impact assessment; this process requires community engagement to address any concerns the community may have regarding the project. Smaller projects, that may include the need for re-zoning, also require comment from and consultation with communities. In both cases, building cannot commence until the engagement process is deemed to be completed, an environmental license delivered and a construction permit provided. For small internal projects, any concerns raised or complaints received are dealt with by the Hospital Manager or Project Manager.

The company has established a Foundation that works to support projects that have a public health focus, such as provision of working toilets in an area previously subject to a cholera outbreak and promotion of pumps to provide clean water to underserved schools.

Monitoring and Reporting:
The internal audit process, as presented by HQ-based senior management, is deemed to be extremely robust. Each hospital is audited internally on an annual basis; external, or surveillance audits are conducted at least every three years for each hospital. Internal audits are staffed by individuals from HQ and those drawn from other hospital operations that are used to audit the same departments that they work in, albeit in the different hospitals targeted for the audit. In this manner, relevant expertise is brought to bear in an objective way to ensure rigor in the process. All departments within a hospital are audited (e.g., engineering and human resources). A comprehensive list of parameters is tracked as part of the audit process and other oversight activities. Prior findings are targeted during follow up audits (including environmental incidents, if they have occurred); this process is used to determine the effectiveness of actions taken as a result of initial findings. Frequent “quality walkabouts” are conducted at the hospital level to provide comment and continual feedback on performance. Reporting is conducted extensively; for example, internally to the Executive and to the Board, monthly in a National Quality Review Meeting, amongst all 60 hospitals in the group and externally through the Quality Review publication. The company also performs due diligence of contractors. Further examples of ongoing oversight were discussed; e.g., staff participates in monthly meetings on health and safety issues and trained incident investigators work to determine the root cause of incidents and results are shared among all operating units.

PS2: Labor and Working Conditions

Human Resources Policy and Procedures:
The company’s current operations in South Africa were stated as being in compliance with South African Labor Law; this labor law is well developed and comprehensive in nature such that compliance with its requirements is adjudged to meet the requirements of PS 2. For example, the company has a Human Resources policy, standard working procedures, rights and responsibilities are required to be posted for employees to review and policies regarding recruitment stipulate non-discrimination. A human resources meeting is held monthly to review staffing levels. One operation has a union; other facilities have consultative forums through which employees can express concerns, make suggestions, etc., with respect to work and their employment. Employee questionnaires are used to garner employee opinion and feedback on a variety of issues; these events are undertaken every two years. Approximately 96% of the total workforce at Life is made up of Historically Disadvantaged South Africans (HDSA). Minimum age of employment and wage/salary requirements are in compliance with South African labor law.

If the company does acquire operations in countries that do not have such well developed labor law, IFC will require compliance with the requirements inherent of the national laws. IFC duly recognizes that the company will as far as possible replicate systems already proven in SA operations, thereby realizing business efficiencies while promoting good international practice. If national law precludes certain aspects of local law, then the company will put in place alternatives that meet, at a minimum, requirements under PS 2. This is addressed in the Environmental and Social Action Plan (ESAP).

Retrenchment:
There are no current plans for significant retrenchment of staff. If changes in the organization do occur, they will be managed according to South African law. Similarly it is intended that, retrenchment in operations acquired or constructed as part of any expansion will be managed according to the more stringent of either applicable national law, or IFC’s PS 2.

Grievance Mechanism:
Life utilizes an employee questionnaire on a periodic basis. On an interim basis, individuals have access to a variety of means of expressing views, making complaints etc., that are provided for under SA labor law. In addition, committees at the hospital level facilitate the receipt of issues raised by staff. For any sensitive issues related to terms of employment, harassment or any other similar issues, each employee has right to contact the Human Resources Department (direct approach or by other means such as a letter) whose job is to receive complaints, listen to all concerned parties and suggest the corrective action for resolving the issues. A formal grievance procedure, which is part of the HR procedures governs this process.

Occupational Health and Safety:
The company has implemented OH&S procedures at all its operations. Workplace hazards are addressed in accordance with South African legislation and many internal procedures have been developed and implemented (e.g., permits required for “hot work,” confined space entry, lock-out-tag-out, etc.). Procedures are seen to be mature in their development, i.e., those issuing permits have to have been trained and certified in the process before they can issue such permits for jobs that contain hazards. It was stated that availability and suitability of signage is audited against, as are other issues such as flammable liquid storage, inspection of fire extinguishers, exposure to noise areas and bio-hazardous materials at healthcare risk waste areas, and use of protective clothing when conducting jobs with inherent hazards. This was confirmed by reviewing the scope of internal audits of such areas and examples of audit reports.

Protocols for nosocomial or hospital-acquired infection have been developed to prevent healthcare-associated infection for the staff, patients and visitors. This protocol includes sterilization, single use devices, disinfection, washing hands before and after contact with each patient. Other protocols regarding incidental exposure to biological hazards have been developed and are in use. Periodic internal audits to check up the compliance with such procedures and practices are performed (as part of the overall audit process described above). All accidents and incidents are documented, reported and analyzed according to South African health and safety legislation and internal procedures and relevant corrective and preventive actions are suggested, implemented and subsequently re-audited.

PS3: Pollution Prevention and Abatement

In discussions with the company’s senior management, it was demonstrated that they are very aware of EHS issues associated with the construction and operation of hospitals (including waste management). A senior representative of the engineering department, whose responsibilities includes many EHS issues, participated in the discussion at HQ. Confirmation was provided to IFC that any proposed project will be brought into compliance with applicable national EHS laws, applicable IFC Performance Standards and applicable sections of IFC’s Healthcare Facilities’ EHS Guidelines, if not already in compliance. No current operations were visited as part of the appraisal to verify whether standards and requirements were currently being met; however, audit scope and records did adequately demonstrate that EHS matters are prioritized and managed and are seen to be integral to the overall QMS. Regardless, evidence to verify actions related to these requirements and standards will be required by IFC at the appropriate stage of a proposal to acquire new operations (acquired as a going concern, or to-be-constructed). This is addressed in the ESAP.

Pollution Prevention, Energy Conservation and Energy Efficiency:
Data on water use, energy consumption, etc., is maintained; benchmarking on key indicators, including those of oversees operations is undertaken. Life is undertaking a comprehensive electrical energy use review program. This is in lieu of possible future penalties being levied against major consumers by the national electricity utility (ESKOM), and recognition of the contribution that such consumption has on Greenhouse Gas (GHG) generation. A baseline of electricity use across all hospitals will be developed and, based upon results, implementation of behavioral, operational, technology and/or process changes to reduce energy use will be considered. Once this process has been completed, IFC will request the summary data for use in estimating the GHG emissions associated with the project; this is addressed in the ESAP. The process is progressive with some of the large capex-intensive processes that may be required being phased in over a longer period.

Wastes, Hazardous Waste and Material Management:
Anatomical waste is sent off-site for incineration. Recent alleged incidents concerning improper disposal of medical wastes by a contractor within South Africa resulted in the company focusing on generating less waste and better sorting waste that is generated so as to minimize risks from such third party operations. Improvement in processes, such as weighing and recording the amounts of waste taken by contractors are also now being followed. For any new operations, a Health Care Waste Management Plan (HCWMP), or its equivalent in the QMS, will be developed to manage both hazardous and non-hazardous waste streams that will meet the more stringent of national laws and regulations and IFC’s PS requirements including those of the WBG’s EHS Guidelines. This is addressed in the ESAP.

Emergency Preparedness and Response:
Comprehensive Emergency/Disaster Plans are prepared for each hospital. Events such as fire, bomb scare, flood, loss of water, robbery/hostage situations, power failure, gas leaks, spills of hazardous substance, etc. are included, as are the roles and responsibilities of staff, responders (internal and external) in the event of such emergencies occur. Drills are conducted to practice response and to ensure procedures are understood by those responsible for their implementation. Pathways of evacuation for patients and personnel are described in the Emergency/Disaster Plans.

PS4: Community Health, Safety and Security

Community Health and Safety:
The company QMS Department is responsible for a process to manage complaints reported to HQ while complaints at the hospital level are ultimately the responsibility of the Hospital Managers. Life follows internationally accepted principles and best practices of infection control. This includes appropriate hand-washing facilities, single-use materials and instruments, disposable gloves and other protective attire, disinfection and sterilization program, and handling and disposal of instruments and materials contaminated with blood and other body substances. Protocols have been developed to address cases of suspected AH1N1 flu. This includes patients with respiratory symptoms that are admitted to the hospital and procedures for confinement and prevention of disease transmission. Life staff is obliged to wear masks, wash hands before and after the examinations, use disinfectant substances in dispensers (medical offices, clinic toilettes), etc.

IFC learned that all Life operations conform to local fire codes and that each of them has an emergency response program, which includes evacuation procedures for fire and other types of emergencies, staff training, regular inspections, drills and coordination with local safety authorities. Such procedures conform to applicable legal frameworks. For each location, a specially designed team is trained in case of fire and general rules are described to each employee as a part of the emergency awareness.

Senior management at HQ stated that overall fire detection and building separation system are well implemented, with appropriate infrastructure such as smoke alarms, manual alarms, fire extinguishers and fire water hoses distributed in all areas, and automatic shut down and separation of building compartments including ventilation systems in case of a fire or fire alarm. Where gaps exists e.g. in older hospitals, a phased, risk-based approach is applied to closing the gaps. For any new hospitals, Life will commit to complete a formal LF&S Master Plan, or its equivalent under the QMS, prior to construction. This will be prepared by a qualified professional acceptable to IFC, certifying that design of the facilities meets WBG's EHS Guidelines. Following construction, an audit will be undertaken by an independent third party to confirm that the facility was constructed in accordance with the original Master Plan. WBG’s EHS Guidelines (as included in the General EHS Guidelines) are that fire safety must be of an equivalent or similar level to fire code of US (i.e. NFPA), EU member states, such as the UK or France, or other codes recognized to be of a required standard, such as South Africa. This is addressed in the ESAP.

Security:
Security personnel are employed through approved private security contractors. Once appointed, the security company undertakes a risk assessment to determine the number and category of guards required. These companies are affiliated with a national security association which regulates the different categories of guards and the training they will require. Security personnel are therefore trained in the appropriate use of force for defensive purposes and in an appropriate conduct toward patients and local community. Guards appointed for Life duties often attend the Life Healthcare quality and customer service training. Buildings are generally equipped with audio and video surveillance system (CCTV) in areas such as the main entrance, reception, emergency units, maternity and pediatrics.

PS5: Land Acquisition and Involuntary Resettlement

Site Selection and Site Environmental and Social Conditions:
Any land acquisition that is required to construct and operate new facilities will be assessed against the requirements of PS 5. It is intended that all utilities such as power supply, water supply and waste water systems, and other services required to construct and operate a hospital will meet the standards of existing operations in South Africa.

IFC PROJECTS

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