While all Performance Standards are applicable to this investment, IFC’s environmental and social due diligence indicates that the investment may have impacts which must be managed in a manner consistent with the following Performance Standards: PS1: Social and Environmental Assessment and Management Systems; PS2: Labor and Working Conditions; PS3: Pollution Prevention and Abatement; PS4: Community Health, Safety and Security; PS5: Land Acquisition and Involuntary Resettlement UHG facilities are located within urban areas, no issues have been identified in relation with PS6, PS7 or PS8, namely biodiversity conservation and sustainable natural resource management, indigenous people and cultural heritage. Nevertheless, UHG will incorporate all IFC Performance Standards on Social and Environmental Sustainability into its management system and will accordingly evaluate new expansion projects to ensure operation in full compliance with IFC requirements.

The key environmental and social issues related to this project include permits, regulatory compliance; environment, health and safety practices during construction, renovation and restructuring; structural design and safety; life and fire safety; emergency preparedness and response; control of air emissions from combustion and other operations; waste management particularly including medical, bio-hazardous and radioactive waste; waste minimization; energy and water conservation; treatment and disposal of liquid effluents; hazardous materials management; occupational health and safety including employee training and monitoring programs; adequacy of human resources policy and practices; community health, safety and security; prevention of nosocomial diseases; potable water supply and treatment; food safety; engagement with communities; respect for patient rights. The appraisal concluded that any impacts will be limited, site-specific and can be addressed by adhering to generally recognized performance standards, guidelines or design criteria. Therefore, this is a Category B project according to IFC’s Environmental and Social Review Procedure.

Key environmental and social issues and relevant mitigation measures are described in the paragraphs below. In addition, UHG agreed to implement an Environmental and Social Action Plan which is enclosed with this review. PS1: Social and Environmental Assessment and Management Systems Management Systems and Assessment: UHG is committed to operate under a quality management system established in accordance with ISO 9001:2008 as well as with the standards set by Joint Commission International, where applicable, which is an assessment and certification body originated from the USA and accredited by International Society for Quality in Health Care. JCI Accreditation is an authoritative organization specialized in accrediting hospitals that are in and outside the USA. According to the JCIA Standards which are also recognized by the World Health Organization; health care organizations must develop policies, systems and procedures addressing following areas: access to care and continuity of care, patient and family rights, assessment and care of patients, anesthesia and surgical care, medication management and use, quality improvement and patient safety, prevention and control of infections, staff qualification and education, management of communication and information, governance, leadership and direction, facility management and safety including but not limited to medical equipment management, preventive maintenance of equipment and utilities, monitoring of water quality, hazardous materials and waste management, emergency management. Three of UHG’s hospitals, located in Istanbul and Bodrum/Mugla (Taksim German Hospital, Vatan Istanbul Aksaray, Universal Hospital Bodrum) are certified to ISO 9001:2008 and Five more UHG hospitals (Universal Hospital Kadikoy, Italian Hospital, Camlica German Hospital, Karabuk Vatan, Diyarbakir German Hospital) are targeting certification within 2011. UHG’s Taksim German Hospital in Istanbul has also been accredited by JCI Accreditation. Related policy, procedures and programs are being adopted by other operational hospitals and UHG will gradually expand the certification and accreditation to its other hospitals. UHG’s hospitals are also subject to regular inspections by the Ministry of Health in Turkey and Albania. Upgrading activities are undertaken at UHG hospitals in order to ensure full compliance with the most recent regulations adopted from the EU directives. Development of new hospitals, includes planning and design, construction and start-up stages, and each is subject to assessment by regulatory authorities to confirm compliance with national standards and internationally agreed standards, particularly relating to EU regulations and norms. Construction safety, life and fire safety, wastewater discharge, handling and disposal of medical wastes all require specific permits and licenses. Radiotherapy and nuclear medicine equipment are under strict control of the Atomic Energy Institution of Turkey (TAEK). UHG will regularly provide IFC with the copies of the internal and third party assessment documents and licenses for its facilities and relevant action plans to remain in compliance. UHG will conduct social and environmental due diligence to ensure compliance to the IFC’s performance standards, for all new projects, acquisitions and operational changes. Organization: Establishment of overall quality, social and environmental management systems is the responsibility of UHG’s Corporate Quality Department based in Istanbul. Implementation is undertaken by competent teams being formed and supervised by each hospital and clinic manager. Key responsibilities of the management, medical, technical and administrative staff are documented in accordance with the ISO 9000:2008 standard and are being extended in accordance with the JCI standards where applicable. In accordance with the current operations and on-going expansion UHG will review its organization and management systems documentation and ensure that IFC Performance Standards are fully incorporated and assignments made to monitor performance at each facility and at the corporate level. Additional resources will be provided as necessary. Training: Training provisions for staff is organized by a training specialist working full-time for UHG. All staff receive induction training at hire and regular refresher trainings. Training includes, but is not limited to; management systems, service excellence, risk assessment and control, use of safety critical equipment and infection control. Monitoring: Quality and EHS (Environment, Health and Safety) monitoring programs at hospitals and clinics are set in line with the regulatory requirements, ISO 9000:2008 standard and JCI Accreditation requirements. UHG will regularly submit to IFC an Annual Monitoring Report on Environmental and Social Performance prepared in accordance with the IFC’s Performance Standards and guidelines. PS2: Labor and Working Conditions Labor Relations: UHG has an internal human resources procedure which describes in particular, hiring and contract making processes, promotions and general working conditions in line with the local regulations. The minimum age of employment at UHG is 18. There is no discrimination on the basis of personal beliefs or characteristics and company management reports no prohibition or discouragement of freedom of association. Actually, there is no union activity or collective agreement in the hospitals, employees working through individual contracts. Retrenchment is not anticipated in the near future; in fact, UHG is currently in a growth phase. Employees are free to communicate grievances directly to the hospital management. UHG has established mechanisms to address suggestions from the staff members and makes evaluations on a regular basis. Employee satisfaction surveys are regularly conducted at certain hospitals and will be extended to all group hospitals. UHG will review and enhance its Human Resources policy and procedures to include formally structured internal grievance redress mechanisms for its staff and contractors as well as to ensure that all IFC Performance Standard 2 requirements are formalized within the policy and procedures. UHG will ensure that resources are appropriately allocated for staff as defined in the contract agreements and taking into account employee satisfaction surveys. Occupational Health and Safety: UHG has in place several programs to ensure occupational health and safety for the employees in its hospitals and clinics. Infection control and emergency response committees conduct regular meetings, trainings and drills. All staff members receive training and are qualified to deal with specific risks of their workplaces. In the radiotherapy and nuclear medicine areas, staff are equipped with dosimeters and the exposure of relevant staff members to radioactivity is regularly controlled by the Atomic Energy Institution of Turkey. Periodic health monitoring programs will be developed and extended to all UHG staff based on their workplace risks. Workplace risks will be regularly assessed and mitigation measures implemented within an action plan. UHG will establish occupational health and safety control for the contractor work, particularly at construction sites. Occupational health and safety rules and other working conditions, in accordance with the IFC PS2 requirements will be included in contractor agreements as defined in the attached action plan. UHG will establish regular inspection mechanisms to ensure compliance to the contract requirements. PS3: Pollution Prevention and Abatement Hazardous Materials and Waste Management: Laboratory chemicals, cleaning and disinfection chemicals and other hazardous materials used in the hospitals and clinics are supplied from reliable, certified sources. Formaldehyde is not used in UHG for disinfection purposes, safer alternatives are used. New cooling systems at hospitals and clinics are based on non ozone-depleting HFC refrigerants such as R-134a and R-410a. Fire extinguishers at certain areas still include halocarbons. UHG will define replacement schedule for halocarbons and continue its efforts to replace hazardous chemicals as defined in the enclosed action plan. Infectious waste, cytotoxic waste, wastewater from radiology units and other hazardous wastes from laboratories are segregated at source, collected at labeled containers, appropriately stored on-site, then transported and disposed of by licensed contractors. Medical waste is handled by authorized agencies and incinerated at government approved facilities. UHG is developing further hazardous materials and waste minimization programs, for instance, has started to limit the consumption of x-ray chemicals by moving imaging diagnostics into digital solutions and this will be extended to all group hospitals and clinics. UHG has reported that wastes from radiotherapy and nuclear medicine units are managed in line with the regulations set by the Atomic Energy Institution of Turkey which is a member of International Atomic Energy Agency (IAEA). UHG will submit to IFC documented hazardous and radioactive waste management procedure to ensure compliance with national regulations as well as with IAEA standards and guidelines. Other Wastes and Effluents Management: Domestic wastewater is discharged to the municipal sewer system without any specific requirement for pre-treatment. Non-hazardous waste is collected and disposed of by the municipality. UHG will develop its waste management program towards waste minimization, collecting recyclable wastes separately, where feasible. Resource Conservation and Energy Efficiency: Water is supplied from the municipal networks and electricity from the city grids. Natural gas is the main source for ambient heating and steam generation. UHG is in the process of introducing energy conservation programs in its hospitals. New hospitals under construction will be equipped with computer controlled building management systems and HVAC to optimize energy consumption. UHG will continue to develop water and energy conservation programs, will benchmark with sector best practices and annually report to IFC about relevant initiatives and performance. PS4: Community Health, Safety and Security Community Health and Safety: UHG Hospitals are equipped with the new generation medical equipment strictly controlled in accordance with certified quality management systems. As previously mentioned, UHG is committed to follow internationally agreed good practices on infection prevention and control techniques. Life and fire safety design and installations at new hospitals are being provided in line with the national standards and regulations which are primarily adopted from EU norms and regulations. According to the recently published fire safety regulations in Turkey, hospitals must be equipped with fire detection and alarm systems and sprinklers. New hospitals under construction are designed in full compliance with the regulations and the constructions are on-going under supervision of the fire fighting authorities. There are on-going upgrades for operational hospitals in that context. UHG will provide IFC with third party verification documents on life and fire safety for each clinic and hospital which is operational and under construction in Turkey and in Albania. The group hospitals are in the process of revising its emergency management procedures in line with the national regulations as well as international color code system for specific to hospitals. UHG will regularly submit IFC about certification of its management systems, trainings and drills within the Annual Monitoring Report. UHG will provide IFC with third party verification documents on life and fire safety, building safety taking into account seismic risks for each clinic and hospital which is operational and under construction and relevant measures to remain in compliance with national and internationally agreed standards as defined in the agreed action plan. Procedures are established on water quality and food safety monitoring with regard to national regulations, ISO 9000:2000 Quality System and JCI standards, where applicable. Utilities and safety critical equipment also are subject to regular maintenance programs and the relevant preventive maintenance programs will be further developed as defined in the attached action plan. Security: UHG employs unarmed security forces in accordance with the IFC’s PS4 requirements. PS5: Land Acquisition and Involuntary Resettlement No issue related to PS5 Land Acquisition and Involuntary Resettlement has been identified in relation with current expansion projects as UHG declared that the projects are being developed mainly on uninhabited sites provided by the local municipalities. For instance, the hospital construction site visited by IFC in Bursa city center was previously an underground car parking area belonging to the municipality and the hospital will be operating while keeping part of the underground space as a parking facility. UHG will submit to IFC complete documentation and records related to the land acquisition of all on-going expansion projects and will establish a documented procedure for the review of land acquisition process in line with IFC PS5.

UHG has Customer Relations Department to establish strong mechanisms to receive and address community concerns and provide information about its operations. UHG hospitals (also known as German, Italian and Vatan hospitals) provide contact information at their web-site. A call center working 24 hours a day for the corporate will also be available to the public. The group will also establish a mechanism to timely provide information about its expansion projects to the local communities. UHG will be working in line with the agreements set with Social Security Institution of Turkey (T.C. Sosyal Guvenlik Kurumu) and is committed to comply with all regulatory requirements associated. Hence, its health care services can be reached to a larger community. UHG is targeting to go beyond regulatory requirements in health care sector and seeking for benchmarking opportunities with international healthcare institutions primarily for oncology treatment. UHG has been involved in a range of community engagement and social responsibility activities. Hygiene monitoring programs in catering services in cooperation with local municipalities, provision of trainings on hygiene management and control of drug abuse are among these activities. UHG will continue to perform and extend community engagement activities in a structured manner as defined in the enclosed action plan.

This Environmental Review Summary and relevant action plan will be available at all UHG hospitals in Turkey and Albania as well as at ADM local office in Turkey. For more information please contact: UHG Turkey Ms. Zeynep Dokumaci, Quality Coordinator Address: Kuloglu Mahallesi Liva Sok, No: 5 Kat:3 Beyoglu Istanbul Tel: +90 212 244 4106 e-mail: zeynepdokumaci@gmail.com www.uhg.com.tr Universal Hospital Tirana Albania Mr. Ibrahim Pozhari Address: Qyteti nxenesve, prane Birra Tirana Tel: +355 672 022 7111 ipozhari@hotmail.com www.uht.al