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 classified as a Category B project in accordance with IFC’s Policy on Environment and Social Sustainability. Based on information reviewed by IFC, the proposed project will have limited adverse E&S impacts that are few in number, site specific, largely reversible and readily addressed through the adoption, adaption and implementation in the new clinics of the company’s existing practices regarding occupational health and safety and human resources management and matters of community, health, safety and security.

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:

PS1: Assessment and Management of Environmental and Social Risks and Impacts
PS2: Labor and Working Conditions
PS3: Resource Efficiency and Pollution Prevention
PS4: Community Health, Safety, and Security

Impacts related to the following Performance Standards were not identified during IFC’s review: PS5: Land Acquisition and Involuntary Resettlement (as the clinics to be financed are located on sites such as existing hospital complexes or in buildings that are already in existence and are to be refurbished); PS 6 Biodiversity Conservation and Sustainable Management of Living Natural Resource (as clinics are not impacting biodiversity given their locations); PS7: Indigenous Peoples and PS8: Cultural Heritage: No Indigenous People and/or sites of cultural heritage are impacted by any of the existing or proposed locations of the Company’s operations.

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.

PS 1: Assessment and Management of Environmental and Social Risks and Impacts



Environmental and Social Assessment and Management System, Policy and Identification of Risks and Impacts, Management Programs, Organizational Capacity and Competency



The Sponsor has been building and operating facilities that provide radiation therapy to patients for over 30 years, currently operating in 16 US states and 7 countries, with approximately 132 radiation therapy facilities. Assessment of the limited type and number of environmental and social risks and impacts associated with such facilities are well known to the Sponsor and the Company and managed from either the headquarters in Florida or from regional centers such as that found in Buenos Aires. Functions found within these centers include those related to project design, architecture and construction management and operational issues such as management of human resources. Supplemental resources (such as resident engineers or RE) are hired locally and act as the liaison between those designing the clinics and those constructing them. Contact between HQ and/or regional centers and project sites occurs on a continual basis with regular site visits and audits of projects undertaken; for example, visits are often timed to coincide with construction milestones such as the pouring of the high density concrete required to construct the vault that will ultimately contain the equipment to treat patients.





As noted above, responsibility for day-to-day management and oversight of construction (including the health and safety of contractor employees and their compliance with labor regulations) lies with the RE. IFC interviewed the RE at the construction site in the Plaza de la Salud as well as the contractor’s foreman and toured the construction site to review measures that had been put in place to provide for a safe working environment. Overall the measures were commensurate with the risks and impacts to be found on such a site, i.e., working at height was dealt with through the use of railings to prevent falling and personnel protective equipment (vests for visibility, steel toe boots, etc.) were being worn by construction workers. The RE maintains logs of operations (including records of any injuries – none had occurred on the site visited – and reports to the senior management located within the country (i.e. the Country Director.)



The design of the vault (the most demanding element of construction) and the overall clinic was discussed while on site as was the relationship that the clinic will have with the hospital that owns and operates in Plaza de la Salud (in effect the hospital is the ‘landlord’ for the radiation therapy clinic – the land being leased by the clinic from the hospital.) It was reported that the design is the responsibility of the Director of Projects (DP) based in Florida. This individual was later interviewed while the team visited Ft. Myers whereupon he stated that the design
s are responsive to industry norms regarding radiation and the NFPA with respect to Life and Fire Safety.



Operational management of clinics falls to the respective country manager and his/her team of facility managers. Working alongside these administrators are the clinicians (physicians and physicists) who are responsible for design and administration of treatment regimens. These individuals are licensed professionals (doctors and scientists) whose specialty is radiation therapy; as such they have qualified as medical doctors and are fully experienced in the dangers of radiation and its use in the field of oncology.



It is important to note that the equipment that is to be used in the clinics in the Dominican Republic and Mexico (i.e. those subject to IFC finance) are linear accelerators. This type of equipment, which has been in use for decades as part of cancer treatment, does not use a source of radiation per se (radiation only being generated when the machine is on.) As such issues of managing – and ultimately disposing of – a radioactive source are not encountered. The vault (treatment room) containing the equipment, however, is still required to be constructed using high density concrete walls, floor and ceiling and (depending on configuration) can require a very heavy door to prevent the escape of scattered radiation during treatment. Measures to prevent inadvertent exposure to such scattered radiation are described below.



Emergency Preparedness and Response



The company references the need for emergency preparedness and response (and the procedures developed and implemented to manage staff and patients in the event of such) in documents developed for Argentine operations that are described below in the section on PS2. These and other documents developed for use in operations in Argentina were provided to IFC as examples of the kinds of documents that will be adapted and adopted for operations in Mexico and Dominican Republic. The need for the new facilities to adopt similar practices, to include suitable equipment, exit signs and other related considerations in the event of a fire or earthquake (the Dominican Republic and Tijuana, Mexico being in a seismic area, for example), and to conduct drills to ensure staff are familiar with what to do in the event an emergency situation occurs is addressed in the investment agreement.



Monitoring and Review

The most important aspect of operations to be monitored and reviewed (beyond that of the dose applied to the patient’s tumor) is related to occupational health and safety; in particular, the risk of inadvertent exposure of staff and visitors to the clinic to scattered radiation. Whereas engineering solutions are employed to prevent scattered radiation from impacting these individuals and additional operational and administrative practices followed (e.g. the requirement to have a badge granting access to restricted areas) respective national regulation requires that staff are eq
uipped with dosimeters. Country-specific regulations require the use of these devices and the monitoring and submittal of data obtained from them. Successful demonstration of a lack of exposure (or exposure within allowable limits) is a condition of licensing and the continued ability of a clinic to operate. Example records showing exposure amounts experienced by staff were provided to IFC for review as part of the appraisal.



Other monitoring, for example related to environmental matters, is limited in scope as the clinics do not have many environmental risks or impacts. Clinics are small buildings; the typical layout of a clinic would include a reception area and waiting room, consultation room(s), staff facilities (toilets, kitchens) and the treatment room (within the vault.) Matters of energy efficiency and waste generation are described below.



External Communications and Grievance Mechanisms

Grievance Mechanism for Affected Communities



The clinics to be funded are to be located either in or on premises with existing medical services or are to be located in the general community. For example, the clinic in Santo Domingo will operate on the medical campus found in the Plaza de la Salud. This is a large (and growing) facility that is well suited to the addition of a facility providing radiation therapy. As such, there is virtually no contact envisaged between the clinic and the community beyond the boundaries of the hospital complex. Regular contact between the clinic and hospital management will occur according to both parties; any issues or complaints regarding clinic operations will be addressed through these meetings. Facilities in Mexico that are not associated with medical facilities will put in place and maintain a mechanism to receive and respond to complaints from the local community such as is already in existence in the operating facility that was visited in Santo Domingo. The combination of the above approaches is judged to be appropriate to this type of investment and as such meets the requirement under PS1.

Working Conditions and Management of the Worker Relationship



An example of an integrated human resources policy was provided from the regional offices in Buenos Aires, Argentina. Whereas it is country specific, it is indicative of the type of policy the company will employ in the facilities under construction in Dominican Republic and those to be located in Mexico. The policy describes the principles, requirements and standards applicable to employees and those of the company itself (such as promotion and that of non-discrimination in hiring.) It also includes how to conduct interviews, matters of health (and the need for pre-employment medical screening, testing and inoculation against various communicable diseases and ongoing medicals each year – all of which are regulatory requirements for workers in this field), training and professional development, payment of salaries and increases, compliance with tax and other labor legislation and regulation, the hours in a working week (according to national law), rights of contracted labor (stated as being the same as regular employees), conduct in the workplace, matters of health and safety (including workers’ compensation and insurance and provision of PPE including a dosimeter for those required to enter the vault), description of risks and reference to the sub-policies and procedures that have been developed and implemented to address such risks (including emergency response, fire and evacuation procedures and operation of the vault door – which is governed by an Interlock system alerting technicians if any problems arise with its operation), disciplinary procedures including actions that could lead to dismissal, employee benefits and, lastly, matters of corporate social responsibility.



The quality management system that has been implemented in the Argentine operations further describes practices and procedures related to labor (such as working conditions) and matters of OHS matters in a manual made available to employees.



A human resources coordinator’s manual has been developed for operations in Argentina; this document includes details and/or reference to supplemental procedures that describe interactions with regulatory authorities, measures to ensure compliance amongst staff with company policies and regulation, practices to verify applicant qualifications and credentials, and other matters of HR administration (e.g. employee time off, training and travel expenses, etc.) An induction booklet has also been prepared by the operations in Argentina; this document describes the history of the company, how radiation therapy works, introduces the quality management system, and describes the roles of the various technical and medical disciplines employed by the company.



Each clinic has in total approximately +/- 20 staff and management. The existence of worker’s organizations, committees and/or collectives differs according to where the clinics are located and the cultural norms to be f
ound within those countries. For example, in Argentina, collective bargaining is the norm. In the Dominican Republic, those ‘blue collar’ workers employed in clinics belong to unions. In Mexico, unionized employees belong to ‘Sindicato trabajadores y empleados de comercio e industria en general Estadio de Jalisco.’



The above documentation is in compliance with national labor law and PS 2. The need to develop and implement country-specific policies, procedures and practices akin to those above, in compliance with the national labor law in existence in the country of operation and those of PS 2 is addressed in through an affirmative covenant in the investment agreement.

The clinics to be financed have a small environmental footprint. For example, the facility being constructed in the Plaza de la Salud in Santo Domingo is a small, stand-alone one story building; another is to be located in an existing building in Tijuana, Mexico that is an existing health care facility and that will be minimally refurbished. As such both construction and operation of these facilities would be expected to be accomplished with relatively little generation of wastes and pollution and consumption of natural resources.



Traditional environmental issues associated with health care facilities (such as management of wastes, emissions to air and waste water discharges) either do not apply or if they do, only apply in a minimal fashion. For example, solid waste management in existing clinics is largely limited to general wastes, similar in composition to domestic waste, generated during administrative, housekeeping, and maintenance functions. Bio-medical wastes that may be generated are/will be in limited amounts; radiation therapy clinics do not generally provide medical services beyond that of radiation therapy, i.e. no chemotherapy. When generated, wastes needing special handling and treatment are treated either using autoclaves (such was reported from operations in Argentina) or are separated and disposed of through licensed contractors in keeping with the company’s environmental policy. In this instance the company would register as a hazardous waste generator and maintain records, including waste manifests, in keeping with regulatory requirements.



General wastes are managed and collected by regular waste removal services. As was already noted above, this is due to the type of medical services provided and the equipment used to deliver these services; there are no radioactive materials to be managed, nor are there wastes generated from imaging practices as these are all digitally produced. In essence, patients arrive, wait in the waiting room, move to the vault, are scanned and receive radiation therapy from the linear accelerator and, at the conclusion of treatment, they leave. Whereas consultations with doctors do occur these do not typically generate ‘red bag’ wastes. Drinking water used in clinics in the Dominican Republic is supplied by a bottled water supply company. Wastewater (from kitchens and toilets) is drained to municipal wastewater networks and subsequently treated at wastewater treatment plants.



Energy consumed by existing clinics comes from the national grid of the respective country in which the clinic is to be found. The company does meter electricity in these existing operations; this is done more for billing purposes than to drive efficiencies. The main consumer of electricity within clinics is that of the linear accelerators; the energy required to operate this equipment is fixed and not subject to reductions due to its link to dosing/patient treatment regimens. Despite these limitations, the company h
as retro-fitted fixtures (such as lighting with LEDs) and issued operational directives regarding other high consuming equipment (such as HVAC equipment) to reduce power consumption where it can be undertaken.



If the supply of electrify fails, the clinics rely on diesel-powered back-up generators; the project in the Plaza de la Salud for example would receive primary and back-up power (along with all other utilities, services and general waste disposal) from the main hospital in whose grounds the clinic is located. Back-up generators located at the stand-alone clinic visited in Santo Domingo were only small units (the larger of the two being less than 250kW in size) given the relatively little power required by the clinic.



The storage, handling and use of hazardous materials is limited; for example, only small amounts of supplies are used in building maintenance (e.g. paints, solvents, cleaning products, etc.). After being used empty containers are disposed of in accordance with local regulatory requirements. The company should ensure that even these small amounts of materials are properly managed; for example, the clinic already in operation in Santo Domingo could have benefitted from better storage of such items. In this instance, materials should have been stored according to physical hazard (e.g., flammable liquids, oxidizers, corrosives, etc.) and proper storage cabinets provided with respect to the physical hazard. Going forward, the company should review materials storage practices and ensure all operations are compliant with good international industry practices, commensurate to the risk posed by the use and storage of these materials.



GHG



A typical clinic will consume 357K KWh of electricity and 10,000 liters of diesel in one year in the Dominican Republic. With the operation of two new clinics this equates to approximately 500 equivalent tons of CO2.

As noted above, issues of community health and safety are addressed by incorporating design elements into buildings that then prevent inadvertent exposure to scattered radiation from the treatment rooms/vaults. That buildings have been properly constructed is assured by audit from the relevant regulatory authority charged with oversight of facilities using radiation. This is a highly regulated industry and no operating license or permit is issued to a facility until its construction has been assessed (i.e. the as-built condition is assessed) and then licenses are only reissued annually upon successful completion of subsequent audits. Audits include measurement of radiation at various points throughout – and outside – of a clinic to ascertain that these readings are below acceptable limits. Audits also verify the existence of emergency procedures and instructions. As noted above, access by unauthorized persons to treatment areas is prevented through the use of identity badges and electronic locks.



Transport of equipment from manufacturers to clinic locations is conducted by experienced shipping companies and entails no more risk to the community at large than any other transport operation given that there is no radioactive source present in the linear accelerators.



With regards to security, contracted security personnel were employed in facilities in both Dominican Republic and Mexico. Facilities use armed security personnel, hired from licensed security companies.



Regarding Life and Fire Safety, buildings are constructed to meet local fire codes and also reference the NFPA standard. Some limitations in building design are necessary with regards to layout (such as the requirement to only have one exit from the treatment room – to reduce the chance of scattered radiation escaping.) This issue is negated through the imposition of operational procedures, e.g. patients are alone in the treatment room only briefly during the actual delivery of treatment and are also under constant video surveillance during the treatment procedure. The nature of the clinics themselves – generally small one or two story buildings with public areas limited to the ground floor (that are provided more than one means of egress) that are delimited through the use of electronic locks – reduces the risk of exposure to fire danger. In addition, and as mentioned above, fire drills are carried out in the clinics already in operation. The need to replicate such measures related to Life and Fire Safety is addressed in affirmative covenants in the investment agreement.

For further information contact the following company representative:
Name: Frank English, Vice President International Finance and Treasurer
Address: 2270 Colonial Boulevard, Fort Myers, Florida, USA 33907
Tel: +1-239-461-8589
Fax:
Email: mailto:fenglish@rtsx.com

As per standard disclosure practice, this document will be disclosed on the company’s website, the address of which is (http://www.rtsx.com) and also locally (in an appropriate language).

Broad Community Support is not applicable for this project

Current client performance is aligned with applicable Performance Standards and EHS Guideline requirements. No ESAP is required.