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
In terms of land acquisition, Iso Health Limited will be sited on 2.5 acres of a 10 acre site off the Nairobi-Thika Highway. This land is owned by Dr. Githegi, a sponsor of Iso Health and will be sold to the Hospital. Thus PS 5: Land Acquisition and Involuntary Resettlement is not applicable to this Project. PS 6: Biodiversity Conservation and Sustainable Management of Living Resources does not apply as it is located within a suburban environment in Nairobi, and the land has already been cleared and transformed for previous agricultural and recreational purposes. The site does, however, have a tiny forested wetland area on it, which the Project plans to protect and develop as a recreational area for recovering patients. PS7: Indigenous Peoples does not apply due to its suburban location, where indigenous peoples, as defined by PS7, would not be found. For the same reason, PS:8 Cultural Heritage also does not apply.

This is a category B project according to IFC’s Environmental and Social Review Procedure because potential adverse environmental and social risks are limited, reversible and may be readily mitigated.
The key potential environmental, health and safety issues associated with this investment include; i) the building standards applied to the facilities, including those related to life and fire safety; ii) emergency adequacy of environmental and social assessment and management systems; ii) labor relations, human resources policy and practices; iii) worker health and safety, including training and housekeeping; disinfection, sterilization, hygiene ii) life and fire safety during operation, including and adequacy of emergency preparedness and response programs; iv) solid and liquid waste management and hazardous materials management; v) opportunities for energy conservation and efficiency as well as waste minimization; and vi) community health, safety and security.

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, Policy: The SOP has substantial experience in operating hospitals, Iso Health Limited will adopt the SOP’s management systems as the basis for their operating systems, including their Environmental Management Systems (EMS) and adapt them to the Kenyan environment. The SOP has a formalised Environmental and Social Governance (ESG) policy in place, and this is supported by various standard operating procedures (SOP) to guide implementation of environmental and social objectives. All SOP’s operations are currently designed to meet Indian legislative requirements.

Identification of Risks and Impacts: Certain new building construction in India would require an Environmental Impact Assessment, and will require the same in Kenya in accordance with the Environment Management and Coordination Act, 1999 (EMCA) and Legal Notice (LN) 101: Environment (Impact Assessment and Audit) Regulations, 2003. The SOP ensures that these requirements are met in India for their hospital projects and will provide guidance and endeavour to ensure that the same is done in Kenya for Iso Health, as per the attached ESAP. The Project is still in the design stage and the EIA will need to be conducted and approved prior to the start of construction.

Management Programs: The SOP has a formal ESG policy in place, and there are a number of environmental and social policies and procedures that have been developed and are applied at the SOP’s hospitals. These will be adopted at Iso Health Limited and adapted to the Kenyan context. These will include a set of management programs applicable to the Kenyan context and that meet the requirements of IFC’s Performance Standards 1 to 4. They will cover the applicable themes as issues relevant to this investment, as further detailed in the attached ESAP.

Organisational Capacity and Competency: The SOP has a team of experts responsible for construction of new projects and for ensuring that legislative and quality requirements are met in this process. As per their procedures in India, the SOP would recommend selection of independent consultants/design architects, construction contractor, construction manager and project manager based on their experience with similar projects for ensuring compliance with Kenyan building codes and legislative requirements, and international requirements. The SOP would send their project managers to Kenya to review the construction of the hospital and participate in review meetings to ensure that the SOP’s requirements are put forth for incorporation in the design and construction of the hospital.

With regard to operation, the SOP has a central Quality Management team which is responsible for formulating and issuing policies pertaining to quality. Each of the SOP’s hospitals has an Operations team and a Quality team which are responsible for implementing policies pertaining to environment, social governance and quality. The responsibility for mo
nitoring and review rests with the central Quality Management team and the SOP’s Group ESG Manager (in the process of being appointed), who have the authority to deal immediately and directly with any situation that may be hazardous or potentially hazardous to the environment, health or safety. Facility Directors at the SOP’s hospitals are ultimately responsible for resolving ESG issues locally and for ensuring that each member of staff plays a role in creating a safe and healthy working environment at the hospital. A team responsible for EHS issues would need to be put together for Iso Health, with specific requirements regarding these issues in their job descriptions.

Emergency Preparedness and Response:

During construction the SOP ensures that, all buildings and facilities are built to meet legislative requirements, including those around Fire Safety requirements such as emergency exits and fire escapes. Approvals will not be granted by authorities unless all these have been met, and annual inspections are undertaken by each municipality to ensure that requirements and equipment are in place. During operation, the SOP implements various life and fire safety plans and procedures, as described further under PS4. The same would be applied to Iso Health Limited.

Grievance Mechanism:

SOP has an electronic grievance/ complaints system called the ‘Electronic Patient Complaint Redressal System (EPCRS)’ that provides a single database for all grievances and complaints. It allows for centralized data gathering and monitoring, with the ability for top management to review staff complaints, systems and issues, and to track trends arising. Associated with this, the SOP has a policy on Complaints Management, ensuring that patient /visitor complaints are identified and addressed in a timely and efficient manner. The aim of this, in conjunction with EPCRS, is to ensure that complaints are reviewed/ investigated, tracked and trended, with responses addressed on an individual basis. This requires feedback to the complainant and an appeal mechanism.

The installation of EPCRS at all the SOP’s hospitals is standard, including the hardware and software IT system, training for staff in its use, hospital and sms mapping to ensure appropriate categories, allocating appropriate manpower and resource for its functioning, and allocation of finances for the effective running of the system. For Iso Health, the SOP will review and if necessary, adapt the Policy on Complaints Management to the Kenyan context and implement the EPCRS system. This must be done in conjunction with training for staff and an organizational structure that supports the timely identification and resolution of complaints, as well as the gathering of data for purposes of monitoring and improvement.

The SOP has a Human Resources (HR) system in India and a Human Resources and Training Department, which ensures that they comply with all labour law. All employees of the SOP have contracts setting out their working terms and conditions, and are provided with copies of these contracts. In order to ensure that there is no discrimination in the workplace, the SOP has a ‘Fairness at Workplace Policy’. This policy states that the SOP ‘is committed to provide a workplace that is free of harassment, discrimination, victimization, regardless of gender, race, caste, creed, religion, place of origin, sexual orientation, pregnancy, childbirth or related medical conditions, disability or economic status of the person employed or engaged by the SOP. According to the Policy, ‘SOP employees have the right to work in an environment free from any form of discrimination and conduct, which can be considered harassing, coercive, or disruptive, particularly behaviour that tantamount to sexual harassment as defined in this policy’. This policy will be broadened to cover all aspects of discrimination as per the requirements of IFC Perfomance Standard 2. A Human Resources System will be developed for Iso Health using the SOP’s existing system as a basis, adapted for the Kenyan context and most importantly, to meet Kenyan legislative requirements. It must also meet the requirements of IFC’s Performance Standard 2. These will be incorporated into a Policy and Procedures manual for easy reference and implementation within the Project.

Occupational Health and Safety (OHS)

During construction of its hospitals, the SOP ensures that the construction contractor complies with national laws. Contractors will only be commissioned if they are licensed and compliant with all labour legislation and associated OHS requirements. These contractors then have to submit evidence that workers are receiving contracts and that they have been provided with and are wearing the required personal protective equipment (PPE). The SOP’s Projects team monitors this compliance during pre-construction, construction and the commissioning phase. The project management team at Iso Health Limited will be guided by the SOP to follow similar processes and include contractual obligations in this regard into contractors’ contracts to ensure compliance with Kenyan legislation and the requirements of this Performance Standard.

For operations phase, the SOP has a policy on Occupational Health & Safety and Community Health & Safety, both of which are covered under the ESG policy. Further, the SOP has processes and protocols for the provision of a safe and healthy workplace for all stakeholders, including patients, visitors and employees. The document covers aspects including facilities inspection, hazardous materials handling, community emergencies, maintenance of medical equipment, utility management, and staff training. Under each of these headings, a brief commitment is made to certain procedures,
to develop a plan for addressing the issue, or a reference to more detailed plans. The SOP also has policies on handling and disposal of hazardous waste and for monitoring the health of certain identified categories of employees. The policy of hazardous material handling and disposal provides for a team and respective responsibilities for the management of hazardous materials, and procedures in this respect. It classifies hazardous materials into different classes and provides guidance on the labelling, storage, receiving, inventory and handling of the materials. It also provides procedures for spills associated with various types of materials. The Policy on the Health Needs of the Employee covers the requirement for pre-employment check-ups, medical benefits, radiation safety leave and annual and regular health check-ups. It also provides high level objectives for protecting employees against occupational health hazards.

Iso Health will be required to compile a comprehensive OHS management system based on existing and required written procedures. This will require appropriate organisational capacity and formalised systems for monitoring performance in this respect. This is defined in the ESAP.

Training and Development: The SOP implements a standard onboarding and training procedure for various levels and categories of staff when they begin working at one of their hospitals or facilities. In general this takes 3 days to a week and includes health and safety training, while for those working in radiology, this takes up to a month due to all the health and safety requirements and specific standard operating procedures associated with this particular activity. All staff get trained in fire prevention and the health and safety requirements. Fire drills are conducted on a regular basis and refresher training takes place annually. The SOP will design a rigorous training programme that ensures that the Iso Health staff are trained in all of the relevant requirements. In order to facilitate training of the Iso Health staff in the SOP’s policies, the SOP will facilitate on-the-ground training through its Indian operations team and also, if required, train the Iso Health Limited staff in its hospitals in India. This is defined in the ESAP.

Grievance Mechanism: The SOP has a well-documented process for staff grievances. The process provides clarity on the escalation mechanism should a grievance arise. At any point, workers of the SOP and any contracted of subcontracted staff can access the EPCRS system (as described under PS1) in order to lodge grievances and complaints. As described under PS1, this is managed by the Quality Control team, ensuring that feedback is provided and the appropriate actions are taken. Reports are generated from EPCRS which are reviewed by management. Iso Health Limited will be required to ensure that an internal grievance mechanism is available to staff. This will be based on the SOP’s current system, ensuring that
it meets the requirements of this Performance Standard.

Workers Engaged by Third Parties

The SOP contracts out services such as cleaning, security, medical waste collection and food supply. SOP ensures that these suppliers meet both legislative and its organizational requirements in terms of labour and working conditions Iso Health will be required to incorporate legislative labour requirements and those related to PS2 in their contracts with suppliers. Furthermore, this will need to be incorporated into the hospital’s HR policy and procedures. This is further described in the attached ESAP.

General

Pollution minimization and resource efficiency is captured in the SOP’s ESG policy. Furthermore, the SOP complies with all legislative requirements with regard to environmental performance.

Resource Efficiency

The SOP ensures that, all construction and design decisions are driven by resource efficiency due to the long-term cost saving measures associated with doing so. The SOP’S hospitals are designed to provide natural ventilation and natural light and to avoid air conditioning except where necessary. The SOP implements energy efficiency measures wherever possible, including LED lighting and solar geysers for hot water generation. The SOP also promotes recycling of water and harvesting of rainwater at its hospitals in line with its ESG policy. While the SOP does not actively seek out LEED certification, many of their materials and activities would be in compliance with LEED requirements.

Each of the SOP’s hospitals has a Utility Systems Plan that covers all the main utilities within the hospital and whose implementation is the responsibility of the Engineering Department. This provides an overview and procedures for utilities including electricity supply, water supply, the HVAC system, central medical gas system, steam supply, hot water supply, sewage water treatment, the communication system, lift/ elevator services and pneumatic services.

The SOP’s electricity supply is from the national grid, with transformers on site, as well as standby back up diesel generator sets and emergency alternative power supply generators. The system is set up as an Uninterrupted Power Supply (UPS) system for provision of power to critical areas such as the operation theatres, intensive therapy units (ITUs) and major diagnostic equipment. The SOP would take the same approach in Kenya, while using the Kenyan legislative requirements as the minimum standards.

Each of the SOP’s hospitals sources water from different providers and have three types of water supply, including raw water for flush toilets; reverse osmosis (R/O) water for potable water, operating theatres and ITUs; treated water for the wash basins and showers, softener water and demineralised/purified water. Water is kept in underground and/or overhead water tanks, with a cleaning schedule as set out in the Utility Plan, water quality monitoring is the responsibility of the Infection Control team. There are different parameters that are tested for different types of water. Internal testing is undertaken once every month and samples are sent to an independent 3rd party testing agency as a good practice and as a control measure

Iso Health Limited would be required to monitor consumption of electricity, fuel and water at the premises and, where possible, implement measures to improve efficiency. In particular, electricity and fuel use will be monitored such that quantification of GHG emissions can be conducted on an annual basis.

Pollution Prevention

Water and Wastewater Management
: For its hospitals, the SOP has a waste water and sewage treatment plant within the hospital premises. Bio-hazardous liquid wastes are decontaminated prior to treatment. The SOP complies with regulatory and statutory requirements pertaining to liquid waste treatment and disposal. Iso Health will be required to have a liquid waste treatment system that meets the Kenyan regulatory requirements, those of this PS3, and the World Bank Group (WBG) EHS Guidelines for Healthcare Facilities. Regular monitoring of waste water discharges must then be incorporated into the overall monitoring plan for the EHS system.

Hazardous Materials Management: The SOP’s ‘Management of Hazardous Materials Policy’ classifies hazardous materials into different classes and provides guidance on the labelling, storage, receiving, inventory and handling of the materials. It also provides procedures for spills associated with various types of materials. These considerations will be incorporated into Iso Health Limited’s overall EMS.

Solid Wastes: Biomedical waste management procedures were provided to IFC during the E&S appraisal, which provides colour-coding for segregation of biomedical wastes, their collection and disposal. It also covers the safe handling and disposal of sharps. According to the SOP management, each department is responsible for handling their own biomedical wastes, with overall responsibility by the Biomedical Infections Control Department. Biomedical waste from various areas is collected by the housekeeping staff using designated trolleys and the colour coding system is maintained throughout the collection process. Appropriate personal protective equipment is provided to the housekeeping staff who collect the biomedical waste including gloves, aprons, masks, and caps. The waste is kept in a designated area and it is then collected by an outsourced, authorised and licensed contractor. The SOP will guide Iso Health Limited to develop and implement a Waste Management Plan, with particular focus on collection, segregation and disposal of biomedical wastes in line with the local Kenyan regulatory requirements and incorporating duty of care elements with regard to a licensed contractor for disposal of these wastes.

Community Health and Safety

Infrastructure and Equipment Design and Safety: When new SOP hospitals are constructed, these are all designed according to the Indian National Building Codes and other Indian regulatory requirements related to construction activities. This includes life and fire safety requirements as described below. For Iso Health, it will be a requirement for the facilities to be built according to the Kenyan Building Code (KS Code) as a minimum, and either BSI or IBC or another international standard. Life and Fire Systems in the hospital should be designed in accordance with NFPA or other internationally recognized standards. This will be monitored by an independent party and certified for operation.

Emergency Preparedness and Response (Life and Fire Safety): The SOP has a comprehensive Fire Safety Plan that is applicable across all of their hospitals, as well as any independent entities. This covers standard operating procedures for all firefighting equipment, including fire extinguishers; wet riser- cum- down comer; manually operated fire alarm systems; automatic fire detection systems; sprinkler systems; public address systems; fire safety plans and staff awareness programmes. It also includes various evacuation procedures, describing the order of patient evacuation and guidelines for patient evacuation.

It also outlines the organisational/ staff requirements for implementation of the Plan, including roles and responsibilities and associated team duties. The fire safety team is headed by a Safety Officer, deputized by a Fire Safety Officer, and supported by a Fire Fighting Team, a Salvage and Cordon Team, and a First Aid and Evacuation Team. According to the SOP management, this plan is strictly adhered to at all hospitals. This includes Fire Safety Awareness Training for all staff at least once a year. The types of awareness trainings provided include Fire Fighting Training (annually for each employee); mock fire drills (annually); Fire Marshal Training (once a month); Refresher Training (annually); and Induction (when employee joins the company).

In addition to the Fire Safety Plan, the SOP has a Safety and Risk Management Plan implemented by the Safety Committee and requiring that a Safety Risk assessment is done on an annual basis. The Safety and Risk Management Plan includes the identification of high risk indicators through proactive risk assessment and the early identification of events. There is an incident reporting system, including reporting on falls, medication, treatments, procedures, equipment and facility functions. This is designed to identify events that are not consistent with the routine care of patients and/or the routine functioning of the Hospital. The way in which information is gathered is through information from a variety of sources both internal and external to the Hospital. This includes incident forms from staff, occurrence screens (reported through record review or analysis), outcom
e-based performance improvement indicators, complaints to the hospital, reports from liability insurers, results of surveillance rounds , amongst others. The Plan itself is then reviewed on an annual basis. The types of errors that are identified are related to diagnosis, treatment, failure of communication, equipment failure, and other system failure.

The SOP also has an Internal Disaster Plan, providing guidelines in the case of bomb threats to the hospital, and to be used in conjunction with the Fire Evacuation Policy. It describes responsibilities and procedures in case of bomb threats, and guidelines for searching a hospital in cases where a threat has been received.

Security Personnel:

The SOP has a Security Management Plan which provides instructions and procedures for security at their hospitals. It provides roles and responsibilities for the security department, including those for the facility director, chief security officer, assistant security officer, security supervisor and security guards. It also provides for CCTV operation and monitoring. The Plan also provides a policy and guidelines on the selection of an outsourced agency for the provision of security services.

Prior to construction, the affected community, as identified through the EIA, will need to be informed about the construction of the hospital, through disclosure of the EIA. This will be done in accordance with NEMA requirements that the immediate neighbours are informed of the impacts in writing and that these are advertised more broadly. In addition, the construction contractor will be required to have a form of grievance mechanism such that any grievances can be expressed and timeously resolved. A dedicated telephone number and email address will be advertised on the site for the public to utilize in case of any grievances. It will be a requirement for the contractor to implement this mechanism, and to make the Iso Health construction team aware of any grievances arising. During operation, the SOP undertakes engagement with the community through its EPCRS and patient feedback system. The same will be implemented for Iso Health Limited, as described in the attached ESAP.

Shakir Merali
The Abraaj Group
1st Floor, Norfolk Towers
68 Kijabe Street
P. O. Box 19558 - 00100
Nairobi, Kenya
Office: +254 (20) 222 8870

Broad Community Support is not applicable for this project

Title	Anticipated completion Date
Develop a formalised Environmental and Management System (EMS): Undertake a detailed gap analysis of strategic operating partner’s policies and procedures against Kenyan National requirements, the requirements of this PS1 and the World Bank Group Environmental Health and Safety (EHS) Guidelines, including the General EHS Guidelines and the EHS Guidelines for Healthcare Facilities.	03/31/2016
Based on the results of the above analysis, augment the strategic operating partner’s existing system with those missing components and develop an EMS that integrates environmental, social, and occupational, health, and safety (OHS) requirements. This system must include policies, procedures and monitoring and reporting protocols for the various environmental, health and safety aspects of the hospital. Management programmes must include, but not limited to: A Construction Environmental Management Plan (including a grievance mechanism)	03/31/2016
A Human Resources system; Standard contractual conditions regarding labour and OHS requirements for suppliers; A Waste and Wastewater Management Plan; A Hazardous Materials Management Plan; An Energy and Water Monitoring Plan	12/31/2017
Develop and implement an organisational structure for implementation of the EMS with roles, responsibilities and authority to implement the environmental and social management system. This will include specific personnel, including management representatives, with clear lines of responsibility and authority	12/31/2017
Determine and implement an appropriate disclosure process for the construction of the hospital, ensuring that affected communities are adequately informed about construction activities, schedule, timelines etc	12/01/2015
Grievance Mechanism: Ensure that the construction contractor has an adequate grievance mechanism such that any grievances during construction can be expressed and timeously resolved	12/01/2015
Grievance Mechanism: Review and if necessary, adapt the Policy on Complaints Management to the Kenyan context and implement an electronic patient complaint redressal system. This must be done in conjunction with training for staff and an organizational structure that supports the timely identification and resolution of complaints, as well as the gathering of data for purposes of monitoring and improvement.	12/31/2017
EHS requirements to ensure that staff are trained in all aspects required through this ESAP must be incorporated into the strategic operating partner’s training programme associated with the start-up of ISO Health Limited.	12/31/2017
During construction, include contractual obligations regarding labour and OHS requirements into contractors’ contracts to ensure that compliance with Kenyan legislation and the requirements of this Performance Standard.	12/31/2015
Where there is ongoing permanent provision of contracted workers for purposes of fulfilling specific tasks e.g., cleaning / security, require such contractors via the associated contract documentation to comply with the requirement of this Performance Standard.	12/31/2018
Develop system for recording, reporting and analysis (including benchmarking) of energy and water consumption data at the hospital.	12/31/2017
Determine the Kenyan legal requirements for waste water management and design this into the building, ensuring that discharges meet the requirements of the World Bank Group (WBG) EHS Guidelines for Healthcare Facilities.	12/31/2015
Develop and implement a waste management plan for ISO Health Limited. Particular attention is to be paid to the management and disposal of medical wastes. This is to include requirements for duty of care into the contract with a medical waste disposal service provider and indicators for monitoring of the provider.	12/31/2017
A certification by a qualified professional acceptable to IFC shall be provided that the design of life and fire safety systems is fully responsive to one international life safety code and the host country life safety code.	12/31/2015
Upon completion of construction, a professional certification shall be provided affirming that facility construction faithfully incorporates all elements of the engineering design.	12/31/2017
Develop a site-specific Life and Fire Safety Plan and Emergency Response Plan that meet the requirements of this PS4 and the World Bank Group (WBG) EHS Guidelines for Healthcare Facilities.	12/31/2017