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: PS1: 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; and PS 5: Land Acquisition and Involuntary Resettlement.

Based on the discussions with the client and visits to the Sponsor’s existing facilities in Tunis as well as the site for the new clinic in Beja, this project will have limited adverse environmental and social impacts. In addition, impacts will be few in number, site-specific, reversible, and easily addressed through agreed mitigation measures. For these reasons, this is a Category B project according to IFC’s Environmental and Social Review Procedure.

Key issues associated with the project include corporate environmental, social, and health and safety management systems policies and procedures and their implementation across its existing and proposed operations, including national and local government permitting requirements; including occupational hygiene, health, safety and training programs and protocols for all employees, and specific measures for housekeeping, radiation, kitchen and other at-risk employees and contractors; including environmental and social issues typical of health care projects such as air emissions and noise; water and wastewater; power (including fuel storage); hazardous materials management, storage, handling and disposal; minimization, recycling and disposal of solid and hazardous wastes; and opportunities to improve energy and water efficiency; life and fire safety and emergency response, community consultation and disclosure, and corporate social responsibility efforts including HIV/AIDS awareness; and as applicable if land acquisition results in compensation payments and physical and/or economic resettlement. The information about how these potential impacts will be addressed by the project is summarized in the paragraphs that follow and in the E&S Action Plan attached to this document. Social and Environmental Assessment and Management System COMAR has a well defined corporate mission statement as well as policies and operational procedures in key areas of environmental, health and safety, and labor management. Given its plans for growth and expansion in Tunisia and across the region, COMAR is in the process of expanding its environmental, health and safety programs into a comprehensive set or systems that can be rolled out at each of its facilities. The Sponsor has engaged an independent consultant in Tunis to establish a quality management system that is consistent with, and will be certified against ISO 9001 (2008), ISO 9004, ISO 19011, ISO 13485 (medical equipment), Hazard Analysis and Critical Control Points (HACCP, a system to manage food safety and pharmaceutical safety that addresses physical, chemical, and biological hazards), and Haute Autorité de Santé (HAS), the independent French body that certifies quality systems for health care providers. At the time of the appraisal, the consultant had completed several steps in the development of the system, including preliminary diagnosis, designation of the quality management coordinator, identification and training of the quality steering team, drafting and implementation of administrative and management procedures, conduct of an internal audit and two /mock/ certification audits, and initiation of the first review of the COMAR board. The consultant estimates that the first certification audit will take place in mid-2010. COMAR will provide IFC with a copy of the EHS/Quality policy, plans and procedures when these are completed, as well as confirmation that certification has been obtained (Action Plan items 1a and 1b). As part of this effort, COMAR has developed a strong management team with the responsibility for rolling out the quality and EHS systems across its facilities. This includes a corporate quality manager, human resources (HR) officer, and training team. As each new hospital or clinic is opened, a quality/EHS manager will be designated, responsible to the Group head of Quality/EHS. Currently, EHS issues for COMAR’s clinics are overseen by the respective Medical Director’s for each facility; as the Group’s holdings expand, these responsibilities will be transferred to a corporate EHS/quality team. COMAR also has established multi-department quality and safety committees for each facility, chaired by the medical director with participation of other key units (e.g. x ray, lab services, maintenance, training, HR). The goal of these committees is to facilitate the sharing of best practice, review performance and learn within the Group. When COMAR opens a new clinic, its corporate risk management team inspects the new facility and trains key staff in policies and procedures consistent with COMAR’s policies. Land for the proposed new hospital in Tunis belonged previously to the US Embassy, from whom the COMAR group purchased it several years ago. For the clinic in Gafsa, COMAR is considering acquiring an existing clinic. Greenfield sites are generally small land parcels (4-5 acres) in urban/suburban areas that are zoned for this type of use. Tunisian law does not require preparation of an Environmental impact assessment (EIA) for projects of this type or size. In Tunis and Beja, the land has already been acquired for the clinic, on a willing buyer-willing seller basis, and COMAR is in the process of obtaining all of the permits necessary to commence construction. As is the case for the operational facilities in Tunis, COMAR will obtain requisite permits to construct and operate the new facilities from the respective municipal authorities in Tunis, Gafsa and Beja for such issues as zoning, fire protection, water supply, wastewater treatment, solid waste disposal, supply of electricity, and transportation. Authority to operate a medical facility also must be obtained from the Ministry of Health. Once operational, the Ministry of Health inspects the facilities before giving the final approval to commence operations. In addition, the Ministry of Health inspects facilities on an ad hoc basis; the result of the most recent such visit to one of COMAR’s Tunis clinics indicated satisfactory results. Nonconformities, if any, are communicated to the facility; COMAR will communicate any nonconformities it receives to IFC (Action Plan item 2). COMAR has established a written code of patient’s rights and responsibilities. The Sponsor has a strong commitment to patient satisfaction, and requests feedback on a regular basis from patients utilizing any of its facilities. Consistent with this, the Sponsor has established a visible feedback/grievance procedure at each of its facilities, with an open door policy that allows patients to direct inquiries to the management teams at the respective facility. Labor and Working Conditions COMAR has a staff complement of approximately 500, including clinical staff (doctors, laboratory and nurses) plus support staff. Tunisia has strong and well enforced labor policies, and has endorsed the four core ILO labor standards conventions (Tunisia is one of 59 countries that has ratified all seven ILO conventions). COMAR complies fully with Tunisian labor laws. Its HR policies and procedures are open and transparent and COMAR advertises itself as an equally opportunity employer. Employment contracts for management, nurses, and all support staff are on a full time basis; consulting doctors, are generally employed on a part-time basis. All newly-hired employees undergo a mandatory training and probation period. Employee benefits include free medical treatment for the employee plus a discount on treatment for family members. COMAR has a written Human Resource policy and comprehensive procedures that all COMAR facilities are required to comply with. Although none of COMAR’s employees are unionized, there is no prohibition on organized labor. COMAR’s salaries and benefits are excellent by the standards of the region. In addition, COMAR has a well developed and operational performance evaluation and grievance procedure. COMAR’s management team has an ‘open door’ policy and employees are encouraged to talk to management about any problems or concerns. These HR processes (e.g. discipline, grievances, performance evaluation) are well documented and communicated to all staff at the time of hiring. The same HR systems, policies and procedures will be adopted across all new COMAR facilities in Tunisia and throughout the region. COMAR has a corporate occupational health and safety (OHS) policy as well as detailed procedures that cover both operational staff as well as construction contractors. COMAR monitors the OHS performance of its construction contractors, and all of the contracts have termination clauses for non-compliance with corporate OHS requirements. COMAR’s projects team monitors construction progress and working conditions on a daily basis. Each of COMAR’s operational facilities has a trained OHS officer responsible for these issues, who provides training (both at induction and refresher courses) for all staff and contractors. All accidents must be reported in writing and initially investigations completed within 24 hours by the OHS Officer. All staff receive training in life and fire safety and emergency response procedures. COMAR’s laboratory is equipped with a separate ventilation system. A monthly training program targeting paramedical staff has recently been implemented. Six training sessions were held on technical topics and on how to deal with patients. Another training session was held targeting the chambermaids (housekeeping staff). Pollution Prevention and Abatement Water and power for all of COMAR’s facilities are sourced from municipal sources and the national grid respectively. Incoming water is pretreated (reverse osmosis) to ensure potability and quality for medical uses; such systems will also be adopted at all of COMAR’s new facilities. Waste water from all sources is pretreated in an onsite treatment facility prior to being discharged to the municipal sewerage system. The same approach to wastewater treatment will be used at all new facilities. COMAR has detailed procedures for handling all types of wastes. Biohazard (‘red bag’) waste is collected in secure containers, stored onsite, and collected by licensed contractors for transport to a Government licensed incinerator for disposal. Laboratory and radiological wastes are also collected regularly by Government licensed contractors for proper treatment and disposal. Non hazardous solid wastes are collected by a licensed contractor and taken to a licensed landfill for disposal. In addition to local regulatory compliance, COMAR will provide documentation demonstrating compliance to an internationally acceptable (for example, French or European) life and fire safety standards as required by IFC. Also subsequent to construction, COMAR will provide confirmation that construction was carried out according to the accepted design (see section 4 below). Community Health, Safety and Security In the case of national emergencies COMAR hospital staff take part in emergency response provision, along with local fire brigades and other emergency response personnel. COMAR has detailed operational procedures in place for emergency preparedness and response and these will be implemented as each new hospital/clinic opens. Emergency drills are carried out at least twice a year, in conjunction with local civil defense, fire and police authorities. Security at each of its facilities is contracted to a local experienced security company; all security guards receive training and are not armed. In 2008, COMAR established an infections council, chaired by the medical director of the El Amen clinic. Each facility also has a hygiene committee, charged with implementing the hygiene protocol, monitoring performance and reporting results to COMAR management on a monthly basis. A key aspect of the council’s activities is to ensure that COMAR’s OHS policies and procedures ensure the health and safety of the communities living near all of its facilities. COMAR’s existing facilities comply with all national life and fire safety laws and regulations. All of its facilities are audited twice a year by Bureau Veritas to ensure that they are fully compliant with these requirements. With respect to the new facilities to be developed under the Project, COMAR has agreed to submit a life and fire safety Master Plan to IFC that identifies major fire risks, applicable codes, standards and regulations, and mitigation measures (Action Plan item 3a). The Master Plan will be prepared by a suitably qualified professional acceptable to IFC who will certify that the design meets the requirements of IFC’s Life and Fire Safety guidelines. The qualified professional who prepares the L&FS Master Plan also will undertake a review at the time of L&FS systems testing and commissioning and certify that construction of these systems has been carried out in accordance with the accepted design (Action Plan item 3b). COMAR will adopt a disaster response plan that covers all possible large scale emergency situations (Action Plan item 4). The plan will include scenarios in which disease; pathogens and other bio hazards might be released under during normal and emergency scenarios, based on a risk assessment and analysis. Land Acquisition and Involuntary Resettlement COMAR has purchased the necessary land for the Tunis hospital and the Beja clinic on a willing buyer-willing seller basis in an open and transparent process. There are no economically or physically displaced persons or resettlement of any sort from the purchase of either of these land parcels. COMAR has confirmed that land for all other new facilities will be acquired in the same way.

Prior to establishing a new facility, COMAR enters into discussions with local authorities and community leaders to describe the proposed facility, project construction schedule, and timing for opening. The establishment of private hospitals has only recently been permitted in Tunisia, a development that appears to have solid government support and is positively greeted by the local population. Regionally-based clinics also appear to have the support of the local population, especially in underserved markets. The COMAR group is a well established corporate entity in Tunisia with a long history of corporate social responsibility. The Group sponsors the annual “COMAR d’Or” – a literary competition for school children across Tunisia. In addition, the Group sponsors sports teams and events, including the Marathon International de la COMAR, which has been run for more than 20 years. COMAR Health provides medical services and testing for underprivileged residents of the neighborhoods in which it operates.

In Tunis: Contact name: Dr Noureddine Cherni Address: Amen Santé- 3 Rue de Monastir- 2045 TUNISIA Telephone: (216) 70 736 736 Fax: (216) 70 736 266 In Beja: Contact name: Dr Noureddine Cherni Address : Amen Santé- 3 Rue de Monastir- 2045 TUNISIA Telephone: (216) 70 736 736 Fax: (216) 70 736 266 In Gafsa: Contact name : Dr Noureddine Cherni Address: Amen Santé- 3 Rue de Monastir- 2045 TUNISIA Telephone: (216) 70 736 736