While all Performance Standards are applicable to this investment, IFCs 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. If IFCs investment proceeds, IFC will periodically review the the project’s ongoing compliance with the Performance Standards

PS 1 – Assessment and Management of Environmental and Social Risks and Impacts
PS 2 - Labor and working conditions
PS 3 - Resource Efficiency and Pollution Prevention
PS 4 – Community Health, Safety and Security
If IFC’s investment proceeds, IFC will periodically review the the project’s ongoing compliance with the Performance Standards

This proposed investment is an E&S Category B project according to IFC’s Policy on Environmental and Social Sustainability, because potential adverse environmental or social risks and/or impacts are limited, few in numbers, site-specific, largely reversible and readily addressed through mitigating measures.

Key environmental and social issues considered in the appraisal included quality and sustainability of potable water supply; handling and disposal of hazardous and non-hazardous health care waste; wastewater treatment; adequacy of disinfection and sterilization programs; occupational health and safety (OHS), and implementation of good Health Care Facilities management practices and employee training programs to prevent nosocomial diseases; Life and Fire safety; and OHS during the construction phase.

IFC's appraisal considered the environmental and social management planning process and documentation for the project and gaps, if any, between these and IFCs requirements. Where necessary, corrective measures, intended to close these gaps within a reasonable period of time, are summarized in the paragraphs that follow and (if applicable) in an agreed Environmental and Social Action Plan (ESAP). Through the implementation of these measures, the project is expected to be designed and operated in accordance with Performance Standards objectives.

Environmental and Social Assessment and Management System

Clinique La Providence has no formalized Environmental and Social Management System. In its Internal Regulations (‘’Règlement intérieur’’), there are some Health and Safety provisions related to Personal Protective Equipment, accidents reporting, security, etc. There are no procedures related to emergency preparedness and response, resource efficiency, pollution prevention, and community health and safety. As set forth in the Environmental and Social Action Plan (ESAP), to be in line with IFC’s requirements, Clinique La Providence will need to develop an Environmental and Social Management System (ESMS) incorporating the following elements: (i) policy; (ii) identification of risks and impacts; (iii) management programs; (iv) organizational capacity and competency; (v) emergency preparedness and response; (vi) stakeholder engagement; and (vii) monitoring and review.

Policy

There is no overarching policy defining the environmental and social objectives and principles that guide Clinique La Providence to achieve sound environmental and social performance. To comply with IFC’s Performance Standard 1, Clinique La Providence will develop such a policy to provide a framework for the environmental and social assessment and management process, and specifies that the project will comply with the applicable laws and regulations of Chad, including those laws implementing host country obligations under international law. The policy will be consistent with the principles of IFC’s Performance Standards. Clinique La Provide will develop and implement such a policy that will be an integral part of the ESMS described above.



Identification of Risks and Impacts

The project was not subject to any Environmental and Social Impact Assessment and a building permit was delivered by the Chadian Land Use Ministry in May 2005 in line with the Environment Law no 014/PR/98. The future clinic will be equipped with its own incinerator engineered to neutralize and eliminate infectious tissues, biological remains, and all types of pathological waste. The acquisition of the incinerator is not part of this project and no information is currently available regarding technical specifications. To be in line with IFC’s requirements related to associated facilities, the client will ensure that air emission levels of the future incinerator will comply with IFC/World Bank Group (WBG) EHS Guidelines for Health Care Facilities and will not result in pollutant concentrations that exceed local and IFC/WBG General EHS Guidelines ambient quality values, as set forth in the ESAP.



Management Programs

Existing management programs found in the clinic’s Internal Regulations are generic and are not specific to health care facilities, and do not cover construction. The clinic currently applies some operational unwritten procedures related to the following: providing staff and visitors with information on infection control; standard p
recautions to treat potentially infectious materials; and radiation exposure control. To be in line with requirements of IFC’s Performance Standards, the ESMS will include provisions related to the following: exposure control to blood-borne pathogens, to infections, to hazardous material and waste; disinfection and sterilization programs; occupational health and safety; health care; waste management, including incineration; employees training programs to prevent nosocomial diseases; wastewater treatment; energy and water efficiency; emergency preparedness and response; environmental performance monitoring.



Organizational Capacity and Competency

Clinique La Providence will nominate an Environment, Health and Safety Officer responsible to develop and implement the ESMS. This officer will have clear lines of responsibility and authority. Sufficient resources will be provided to the officer on an ongoing basis to achieve effective and continuous environmental and social performance. This person will have the knowledge, skills, and experience necessary to perform his/her work, including current knowledge of the host country’s regulatory requirements and the applicable requirements of IFC Performance Standards 1 through 4.



Emergency Preparedness and Response

There is no emergency preparedness and response plan for the existing clinic. As set forth in the ESAP, to comply with IFC’s requirements, the ESMS will establish and maintain an emergency preparedness and response system so that the client, in collaboration with appropriate and relevant third parties, will be prepared to respond to accidental and emergency situations in a manner appropriate to prevent and mitigate any harm to people and/or the environment. This preparation will include the identification of areas where accidents and emergency situations may occur, communities and individuals that may be impacted, response procedures, provision of equipment and resources, designation of responsibilities, communication, including that with potentially Affected Communities and periodic training to ensure effective response. The emergency preparedness and response activities will be periodically reviewed and revised, as necessary, to reflect changing conditions.



Monitoring and Review

Clinique La Providence will adopt a structured EHS monitoring and reporting system on environmental and social impacts of its operations. Monitoring frequencies and methodology will be defined by the above mentioned ESMS and monitoring data will be stored in a centralized database for annual report production. Clinique La Providence will define Key Performance Indicators (KPIs) in order to monitor the following EHS parameters: a) Safety – Lost Time Incidence Frequency Rate (LTIFR), Accident Free Days; b) Resource Efficiency – Water Usage (kiloliters), Energy Usage (kWh), general waste (kg) , hazardous health care waste (kg), wastewater effluents monitoring and air emissions parameters from generators,
and on-site incinerator in line with IFC/WBG General and Sector specific EHS guidelines; potable water quality; c) Staff - Retention and training days. Monitoring data will be analyzed and reviewed at regular intervals and compared with the operating standards so that any necessary corrective actions can be taken.



Stakeholder Engagement

Although no formal consultations took place prior to construction of the new clinic, an informal stakeholder engagement process started in 2004 when the sponsor started to look at project feasibility. Numerous meetings were held with a number of stakeholders in order to get input on the project and to obtain the necessary authorizations (Ndjamena’s Mayor; representatives of the following Ministries: Land Use, Finance, Health; members of the Land Use Commission of Ndjamena; Ndjamena residents, etc.).



To be in line with IFC’s Performance Standard 1 as set forth in the ESAP, Clinique La Providence will establish a grievance mechanism to receive and facilitate resolution of Affected Communities’ concerns about its environmental and social performance. This mechanism will receive, document and address any issues and/or complaints raised by surrounding stakeholders.

Human Resources Policies and Procedures Clinique La Providence has currently a total of 35 employees, among which 9 medical doctors, 15 nurses, 3 laboratory technicians, and 8 non specialized staff. On the long term, there will be 85 staff, among which 14 Medical Doctors, and 8 Interns. The normal working week is composed of 40 hours and overtime is paid. The minimum wage is about 50% more of what is prescribed by law. Most workers have permanent written contracts. Contracts are checked by the Ministry of Labor. All employees are covered by the National Insurance (‘’Caisse nationale de prévoyance sociale’’).There is one employees’ representative although the Chadian Law obliges only organizations of over 50 employees to have workers’ representatives. According to the Labor Law, workers’ representatives have the following roles: to convey grievances to management; to make sure occupational health and safety measures are enforced; to inform the employer about potential improvements to the economic and social organizations of the work; to communicate grievances to the Ministry of Labor. No union is present in the clinic. Management meets once a month with the workers’ representative to discuss and solve employees ‘grievances.



At the construction site, there are between 10 to 97 daily workers and 2 site managers. The sponsor has agreements with 2 contractors (responsible for carpentry, plumbing, electricity, and paint) who in turn hire the workers. These workers are not covered by the clinic’s Internal Regulations.



The legal working age in Chad is 14 years old. The sponsor will review and retain copies of verifiable documentation concerning the age and employment profile of all people under 18 years old. The work of persons under the age of 18 will be subject to an appropriate risk assessment and regular monitoring of health, working conditions, and hours of work. To be in line with IFC’s Performance Standard 2, any people under 18 are allowed to work up to a maximum of 40 hours per week subject to the work being age appropriate.



The clinic has Internal Regulations (‘’Règlement intérieur’’) covering working conditions work schedule, holidays and leave, and disciplinary measures. These Internal Regulations are in line with the requirements of the Labor Law (‘’Code du travail Loi n°038/PR/96 du 11 décembre 1996’’) but not in compliance with IFC’s Performance Standard 2. To comply with the requirement of IFC’s Performance Standard 2 as set forth in the ESAP, the sponsor will develop a Human Resources Policy that will cover all type of workers, including direct workers, and contracted workers. At a minimum, the Human Resources Policy will include the following provisions: working relationship, working conditions, terms of employment, workers’organizations, non-discrimination and equal opportunity, retrenchment, grievance mechanism, child and forced labor, occupational health and safety, workers engaged by third parties, and supply chain.




Occupational Health and SafetyOccupational health and safety hazards for the health care providers, cleaning and maintenance personnel, and personnel involved in handling, treatment and disposal of health care waste are associated with exposure to infections and diseases, hazardous material and fire. During the appraisal, the sponsor has confirmed that there are no formal written procedures to control exposure to blood-borne pathogens, to infections, to hazardous material and waste. The Environment, Health and Safety Officer will develop occupational health and safety procedures for the health care center. This person will also be responsible for developing and implementing among other things, a health care waste management system. 

No illnesses or work related accidents have been recorded at the clinic in the last 5 years. During the visit of the construction site, most workers did not wear their personal protective equipment (PPE). Statistics on incidents were not documented although no major incidents occurred since the beginning of the works (10 reported minor incidents since March 2011). To comply with the requirements of IFC’s Performance Standards, an Environment, Health and Safety Officer will be nominated to ensure training of all workers on Environmental, Health and Safety issues on the construction site. The Environment, Health and Safety Officer will be responsible to develop and implement procedures for briefing visitors and accessing the construction site, procedures for reporting injuries, rules for PPE, transport safety practices, and waste management.

Resource Efficiency

Power at the actual facility is provided by the national grid most of the year. However, during the hot season (March-June) power cuts are frequent and backup generators (40 and 100kva) are used more often. The new clinic will be connected to the national grid and equipped with two new generators of 120 and 250 kva, and a fuel tank. The clinic has an ambulance and an utility vehicle. In total, 6,500 L of diesel was consumed in 2012.



In the new clinic, rooms will be equipped with LED and individual AC splits (from 1 to 2.5 hp). Operation wards will have unidirectional flow ACs to reduce contamination. Solar panels will be installed during the second phase of the project.



Water Consumption

The municipal water utility provides water for the clinic. A 40 m deep borehole and a water tank (2,500 L) is used as backup but the water is not treated. For the new facility, municipal water will be treated to ensure that its quality meets applicable national and international standards. A borehole providing 5.5 m3/s and a water reserve of 45,000 L will be built on site. Rooms will be equipped with water efficient tap showers and dual flush toilets.



Pollution Prevention

On the construction site, fuel is stored in a 3,000 L tank without any secondary containment. To be in line with requirements of the IFC/World Bank Group General EHS Guidelines, as set forth in the ESAP the sponsor will install appropriate secondary containment containing 110 percent of the tank.



Wastes

At the actual clinic site, management of waste is done in the following way: non-hazardous waste such as paper and cardboard, glass, aluminum, plastic, and food waste are collected by the municipality. Glass, plastic and metal is apparently sent to Nigeria for reuse and recycling. Sharps like needles and scalpels are kept in puncture-proof containers and sent to the General Hospital for incineration in a single-chamber incinerator (Series C Incinerator). Infectious waste suspected to contain pathogens is also incinerated. The management of waste will be described in the health care waste management system.



There will be no radioactive waste managed in the course of this project. Should there be radioactive waste in a later phase, it will be managed according to national requirements and current guidelines from the International Atomic Energy Agency. Projectional radiography (‘’plain film’’) for bones and lungs is used at the existing facility.

In the actual clinic, wastewater is disposed in a septic tank that is emptied regularly by a local contractor. In the new facility, process and sanitary wastewater will be treated in a 3-compartment sewage treatment plant. The sludge will be recuperated by the local contractor. In about two years, the sponsor intends to add further treatments to reduce soluble organic matter. The water will then be used for irrigation and the surplus will be discharged in the city sewage system. 

To be in line with requ
irements of this Performance Standard, Clinique La Providence will comply with emissions and effluent standards of national laws and regulations, and with IFC/WBG EHS Guidelines for Health Care Facilities. It will also develop and implement a health care waste management system as set forth in the ESAP.

Community Health and Safety

There are some residents living across the new building site. During the appraisal most of civil work had been completed. Interviews with a few residents and former users of the land confirmed that construction did not entail any major disturbances (dust, noise, traffic, etc.). During operation of the new clinic, potential adverse impacts would be limited to induced increased traffic which should not represent a significant risk for the local population. As set forth in the ESAP, a grievance mechanism will be developed to facilitate resolution of Affected Communities’ concerns about this issue.



At the actual clinic, municipal water is used during operations and cleaning purpose. It is tested quarterly by laboratory technicians. Bottled water is given to patients. In the future clinic water will be treated and disinfected as set forth in the ESAP.



Community hazards associated with health care facility environments, particularly related to hazardous health care waste, necessitate that members of the public receive adequate information regarding potential hazards within the facility, and at associated waste disposal sites. To comply with requirements of and IFC/WBG EHS General Guidelines and Guidelines for Health Care Facilities, the Environment, Health and Safety Manager will be responsible to develop and implement procedures for briefing visitors of the health care facility.



Infrastructure and Equipment Design and SafetyThe actual clinic is in need of much improvement in regard to Life and Fire Safety. Among others, the clinic lacks the following: detection and alarm systems, signing, emergency lighting, compartmentation, and emergency preparedness and response plan. Manual portable extinguishers are available. For the new clinic, engineering and Life and Fire Safety design have been drafted by ATAR (‘’Agence tchadienne d’architecture et de réhabilitation’’). To be in line with requirements of IFC’s Performance Standard 4 as set forth in the ESAP, the Company will engage a suitably qualified professional, acceptable to IFC, to conduct Life and Fire Safety review of the new clinic. In case of any deficiencies identified, the Company will agree to the Corrective Action Plan to meet IFC’s Life and Fire Safety requirements as specified in the IFC/WBG General EHS Guidelines. This action is an integral part of the ESAP.

Clinique La Providence provides health services to a minimal cost to the general public. The price for consultation is slightly higher than that of the public health system. In case of strikes of public hospitals, the clinic provides free health service to the most vulnerable people on a case by case basis. Depending on availability, the clinic offers sometimes free medicines to rural health centers.

The clinic will make available for the public this ESRS and Action Plan at the local building site in Ndjamena.

Broad Community Support is not applicable for this project

Chad Clinic (32607) Supervision Disclosure Snapshot – Version 2
Description	Anticipated Completion Date	Status	Comments	Completion Date
Hire or designate an Environment, Health and Safety Officer to develop and implement an Environmental and Social Management System.	31-Dec-2013	Completed	Completed	12/31/2017
Develop and implement an Environmental and Social Management System	31-Dec-2020	In progress	Due date revised as agreed with IFC Client
Develop an emergency preparedness and response plan	31-Dec-2013	Completed	Completed	9/2/2019
Establish a grievance mechanism to receive and facilitate resolution of Affected Communities’ concerns	31-Dec-2013	Completed	Completed	9/30/2019
Prepare a Human Resources Policy	31-Dec-2014	Completed	Completed	9/30/2019
Appropriate secondary containment capable of containing 110% of the fuel will be installed around the fuel tank	31-Dec-2013	Cancelled	Changed project circumstances mandated cancellation of this task
Have a wastewater treatment system to ensure wastewater is treated to local and IFC/WBG General EHS Guidelines requirements prior to discharge	30-Jun-2014	In progress	Under discussion with IFC Client
Develop a health care waste management system	30-Jun-2014	In progress	Under discussion with IFC Client
Treat potable water to ensure that its quality meets applicable national and international standards	30-Jun-2014	Completed	Completed	9/30/2019
The Company will engage an independent professional, acceptable to IFC, to conduct Life and Fire Safety review of the new clinic.	01-Oct-2013	In progress	Under discussion with IFC Client