IFC requires that this document is made available through the World Bank InfoShop and to the locally affected community no less than 30 days prior to project consideration by the IFC Board of Directors. The Summary of Project Information (SPI) also provides details of where the ERS has been made available to the locally affected community. The SPI must be sent to World Bank InfoShop no less than 30 days prior to project consideration by the IFC Board of Directors.

This is a category B project according to IFC’s environmental review procedure because specific impacts may result that can be avoided or mitigated by adhering to generally recognized performance standards, guidelines or design criteria. The review of this project consisted of appraising technical and environmental information submitted by the project sponsor and a field visit to the Bavaro and Hospiten Santo Domingo hospitals. The following potential environmental, social, health and safety issues and potential impacts of the project were analyzed: Environmental conditions of existing facilities including asbestos in existing structures. [Impact 1] sustainability and quality of potable water supply; discharges to the environment (e.g. air, water); handling and disposal of hospital solid waste including management of hazardous health care waste; [Impact 2] hygiene and implementation of good hospital management practices required to prevent nosocomial infections; quality and environmental issues management; occupational health and employee training programs; opportunities for energy conservation and efficiency in building design; purchasing practices to eliminate mercury and other materials of concern in the hospital environment; industrial hygiene, occupational health and safety programs; and, life and fire safety.

The sponsor has presented plans to address these impacts to ensure that the proposed project will upon implementation of the specific agreed measures, comply with the environmental and social requirements - the host country laws and regulations and the World Bank/IFC environment and social policies and the environmental, health and safety guidelines. The following paragraphs provide a discussion of how each of these issues and potential impacts will be mitigated in the Company’s project. Environmental conditions of existing facilities including asbestos in existing structures. Completion of construction and refurbishing for the existing six-floor hospital building in Santo Domingo is scheduled for December 2002. The concrete shell was completed in the early 1990s and asbestos containing materials were not used in construction. Upgrades include retrofitting fire management systems, internal distribution of oxygen and other medical gases, complete finishing and furnishing of three floors, demolition, reconstruction, refurbishing and refurnishing two existing floors completed in the early 1990s; reorganization and reconstruction of emergency medical access and infrastructure; reconstruction and reorganization of medical laboratories, pharmaceutical storage and services; and overall infrastructure redesign and retrofit including air conditioning, lighting, fire detection and alarm, and potable water supply systems. The two Mexican hospitals in the network were designed by international engineering firms and will be all new construction. Sustainability and quality of potable water supply. Potable water supplied by the City of Santo Domingo is of adequate quality when dispatched from the treatment works. However, there are intermittent supply failures. Because of leakage in the system and illegal connections, the volume of water supplied to the City is ~900 liters/capita/day. Western European and North American systems provide roughly 450 liters/capita/day. System pressure failures can lead to inflow into supply lines and water contamination. The implications for the Santo Domingo hospital are the need to reevaluate potable water treatment and storage to determine if the volume is adequate for fire protection and potable water supply needs considering the impact of supply outages, and to install a supplemental water treatment system to ensure that all water supplied for hospital operations at all times is potable. The results of ongoing analysis of City water supply will allow Hospiten to define the nature of supplemental water treatment processes required for the hospital. Potable water supply systems and local water quality for the Mexican hospitals will also be examined carefully to define storage requirements and the need for supplemental treatment. Discharges to the environment (e.g. air, water). The local grid supplies electrical energy for the Hospiten Santo Domingo; a diesel-powered standby generator is used for emergency power as needed. The facility boiler is gas-fired and emissions comply with IFC/WBG guidelines and Dominican regulatory limits. The configuration of the constructed wastewater system is not available and an investigation is underway to confirm that the system was designed, constructed and is operating in accordance with City requirements. Any required modifications to the wastewater treatment system will be constructed in accordance with the attached Corrective Action Plan (CAP). Detailed engineering information related to air emissions and to hospital wastewater discharges for the two Mexican hospitals will be submitted to IFC for evaluation as each project progresses. Shortcomings in systems’ designs will be rectified to ensure compliance with Mexican regulations and IFC/WBG guidelines and policies. Handling and disposal of hospital solid waste including management of hazardous health care waste. Solid waste management in Santo Domingo is a pervasive, serious problem. Waste is not collected from all areas consistently and tends to pile up in some neighborhoods creating public health problems. The solid waste that is collected is shipped to an old City landfill, La Duquesa. There are no environmental controls such as leachate or gas collection and management systems. Hospiten's internal procedures for waste segregation and management are well developed for other facilities and these, along with IFC’s guideline requirements, will be integrated into Hospiten Santo Domingo operations. Hospiten Santo Domingo waste management infrastructure will include a refrigerated storage area for collected, segregated waste awaiting collection. Hospiten will modify the facility design as needed to comply with IFC’s guideline requirements. Hospiten will contract with a permitted local company for management of waste classified as municipal or non-hazardous. Hospiten Santo Domingo will investigate other local hospitals’ hazardous healthcare waste management practices and ensure that its procedures are adjusted to comply with IFC requirements. Hospiten will update its waste management to local best practices and monitor the availability of specialized waste management services and employ these as they become available. The Mexican hospitals will be required to contract with permitted, specialized waste companies to manage collected hazardous health care waste to ensure adequate waste collection and management capacity and compliance with Mexican regulatory and IFC policy and guideline requirements for the management of hazardous health care waste. Hygiene and implementation of good hospital management practices required to prevent nosocomial infections. The Hospiten hospital network has well developed procedures in prevention and control of nosocomial infections. These procedures will be incorporated into hospital infection control programs at Hospiten Santo Domingo and the new hospitals in Mexico. As part of their infection control programs, the hospitals will develop and implement specific disinfection and sterilization policies and procedures, which will be based on internationally accepted guidelines such as Guidelines for Disinfection and Sterilization in Healthcare Facilities (with necessary modifications mandated by location and the availability of specific materials). Quality and environmental issues management. Hospiten will develop the infrastructure and implement training and procedures required for environmental and quality management in Hospiten Santo Domingo hospital and the two new hospitals in Mexico. Hospiten will incorporate environmental and social management requirements into the quality management framework to ensure compliance with host country regulatory and IFC policies and guideline requirements. Quality and environmental management program management is required for the hospitals in the Dominican Republic and in Mexico to ensure compliance with myriad environmental and social compliance requirements including occupational safety and health programs, employee training, management and monitoring of discharges to the environment, prevention of nosocomial illness, management of hazardous health care waste and management of other hospital-specific environmental and social issues. Hospiten has ISO 9000 certification for the Bavaro Dominican Republic operation and is pursuing upgrading the certification to ISO 9000-2000. Utilization of this or other internationally reputable quality certification or accreditation system to achieve the objectives above is acceptable to IFC. Occupational health and employee training programs. Hospiten will expand its existing training programs to ensure that all health care facility and support staff is trained in the specific occupational hazards that confront them in the health care setting. A specialized training program will be provided on a continuing basis for all employees involved in cleaning, disinfection and infection control. Training of employees will include specialized course materials provided by IFC, and supporting information such as Material Safety Data Sheets (MSDS) or International Chemical Safety Cards (ICSCs) to familiarize employees with the hazards and personal protective equipment required for specific tasks and chemical compounds that they use in their work or with which they come into contact (e.g. disinfectants, fumigants). Additionally, Hospiten will monitor in-house occupational safety and health statistics to ensure that training programs are continuously updated to reflect the needs of the hospital community. Hospiten occupational safety and health programs will be upgraded in accordance with the attached CAP. Opportunities for energy conservation and efficiency in building design. Hospiten will review all building designs to ensure a high level of energy efficiency is incorporated into building design taking into account lighting and associated heat load as well as ventilating and air conditioning systems. Purchasing practices to eliminate mercury and other materials of concern in the hospital environment. Hospiten will integrate the following practices into hospital purchasing (equipment and consumables) to promote the reduction of waste generation: prohibition of mercury (Hg) containing apparatuses and equipment; minimization of waste in packaging; selection of supplies that are less wasteful or generate less hazardous health care waste; preference for recyclable products (use of materials and equipment that may be recycled either on- or off-site); and the application of good management practices to purchase of chemicals and pharmaceuticals to minimize inventory quantities and associated management and disposal costs. Life and fire safety. In accordance with IFC’s life and fire safety guideline, Hospiten will develop a life and fire safety master plan for Hospiten Santo Domingo and the Mexican facilities. Hospiten’s architects and professional consulting engineers must demonstrate that affected buildings are designed, constructed, equipped, maintained and operated to ensure the safety of all occupants in case of fire. Life and Fire Safety systems and equipment will be designed and installed using appropriate prescriptive standards and/or performance based design, and sound engineering practices.

Based on its review of available information regarding potential environmental and social impacts and proposed mitigation measures, IFC concludes that the proposed project is being designed to meet Dominican and Mexican government regulatory requirements, as well as WBG policies and environmental, health and safety guidelines.

IFC will monitor compliance with Dominican and Mexican regulatory and IFC/WBG policies and guidelines requirements during the life of the project. Hospiten will submit annual environmental monitoring reports. IFC will evaluate these monitoring reports and elicit the implementation of remedial measures as needed to maintain compliance. Additionally, IFC will conduct periodic site reviews during project supervision.