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

PS 5, Land Acquisition and Involuntary Resettlement, was not identified as being applicable as no involuntary economic or physical displacement has been required; PS 6, Biodiversity Conservation and Sustainable Management of Living Natural Resources, was likewise not identified applicable as the site did not contain any valuable biodiversity or ecosystem services. PS 7, Indigenous People, and PS 8, Cultural Heritage, were not identified as applicable due to the absence of Indigenous Peoples and known cultural heritage elements at the project site. A chance finds during the construction phase will be managed through a Chance Find procedure as part of the required documentation under PS1.

The project may result in a limited number of potentially adverse environmental and social impacts, which can be avoided or mitigated by adhering to generally recognized performance standards, guidelines, or design criteria. On this basis, this project is therefore classified as a Category B according to IFC’s Policy on Environmental and Social Sustainability.

Key environmental and social issues for this project include: design and construction of hospital facilities according to international fire and seismic safety codes and standards; health and safety of 3,000 construction workers clear definition of EHS roles and responsibilities between private and public project partners; fair and safe working conditions for 2,023 service employee in hospital under the Service Provider sound management of medical waste and wastewater; prevention of fire and emergency preparedness during operation; and stakeholder engagement.

 IFC’s appraisal considered the environmental and social management planning process and documentation for the Project and gaps, if any, between these and IFC’s 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 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:

The project sponsors have previous experience with similar infrastructure projects, including health care facilities. RMI, which is responsible for construction, has ISO 9001: Quality Management; ISO 14001: Environmental Management; and ISO 18001: Occupational Health and Safety Management certifications.

According to Turkey’s EIA Regulation, at the time when the project started it was exempted from local EIA requirements; however, the company optionally submitted an EIA for approval from the Ministry of Environment and Urban Development and approval was obtained in September 2015. An Environmental and Social Impact Assessment (ESIA), developed in accordance with IFC requirements, was completed for this project in July 2015 and then updated in August 2015. The ESIA including Environmental and Social Action Plan (herein after referred to as Environmental and Social Management Plan-ESMP) for the project is disclosed along with this summary report. The ESMP focuses on the avoidance of impacts and, where this is not possible, presents technically and financially feasible and cost-effective mitigation measures to minimize or reduce possible impacts to acceptable levels. Also, the document provides a framework for developing required management and monitoring plans per the risks identified for both construction and operation phases. The construction phase ESMS, including associated plans and procedures that are generally compliant with IFC PS1 provisions, has already been prepared and put in place. As per the ESAP item 1, the company shall develop operational phase ESMS and associated plans and procedures, before commissioning the facility, consistent with IFC PS1 requirements and relevant provisions of World Bank Group (WBG) General and Health Care Facilities EHS Guidelines. The ESMS should include all relevant components as specified in the Elazig Project ESMP.

The project obtained excavation permit and right of construction but is in the process of obtaining a construction license. Excavation and construction works have commenced based on these permissions. The project will acquire one integrated environmental permit mainly covering water use and discharge permit, waste management operation permit, hazardous substance consent permit, noise permit and air quality permit. This integrated environmental permit will be completed once the facility becomes operational.

Organizational Capacity and Competency

ELZ Saglik has established an Occupational Health and Safety and Environment (OHS-E) department for the project consisting of a director, a supervisor, a chief, a trainer and 4 inspectors. The department, with responsibility and authority for all OHS and environmental matters, operates under the supervision of an OHS-E corporate coordinator of RMI. The company will increase the number of OHS staff, to an estimated 50 at peak construction time, gradually based on project progress and workforce increase. It will also appoint a full time Environmental Engineer to specifically oversee environmental issues. In addition, the company procured a credible environmental consulting services firm (Selin Ltd. Sti.), authorized by the Ministry of Environment and Urbanization, to check the company’s compliance with the local legal regulations and fulfill necessary reporting requirements to the national regulatory agencies during construction and operation phases as per ‘Environmental Officer and Environmental Consulting Firms Regulation’. As per the ESAP item 2, the company shall develop operational phase organizational structure to reflect the management structure including roles and responsibilities between the company and MoH, for environment, health and safety, social and human resources during the operation phase, establish management units and appoint related managers.

Emergency Preparedness and Response

An Emergency Preparedness and Response Plan was developed as part of the construction ESMS. The plan details management procedures for issues related to occupational accidents, fire, fuel and chemical spills, as well as relevant roles and responsibilities. Contractors and sub-contractors are also required to develop and prepare their own site specific emergency response plans in line with the overarching plan in the ESMS. The plan will be updated accordingly prior to the project operation phase.

Monitoring and Review

Quality and EHS monitoring programs were established in line with the regulatory requirements. An environmental monitoring program, which focuses especially on the construction period, is included in the project ESMP. During construction, ambient air quality, noise and ground water quality, and soil quality will be monitored at regular intervals against relevant Turkish standards and World Bank Group General EHS guideline limits as defined in tables 1.1.1. WHO Ambient Air Quality Guidelines and 2.3.1. Noise Limits for Various Working Environments; and WHO Drinking Water Guidelines and Soil Quality Guideline (Lijzen et al. 2001). When operation begins, monitoring will be expanded to include wastewater quality, solid and hazardous waste disposal as defined in tables 1. Treatment and disposal methods for categories of health care waste and 2. Effluent Levels for Health Care Facilities in WBG EHS Guidelines for Healthcare Facilities.

Reporting of EHS indicators is being done internally, as per requirements of the certified management systems, and externally to the national regulatory agencies requiring EHS monitoring. The latter is being done by a licensed consultant company (Selin Ltd.)

Human Resources Policies and Procedures

ELZ Saglik has developed a construction phase Human Resources (HR) management plan in accordance with local legal requirements and IFC PS2 provisions. It outlines legal and policy context, general conditions, such as recruitment, employment contract, working hours, leaves, and specific conditions, such as accommodation and health and safety. It promotes equal opportunity for employment and remuneration for men and women. The company requires contractors and sub-contractors to comply with ELZ Saglik HR procedures and guidelines. The plan also contains a staff grievance mechanism applicable to all direct and contracted employees. As per the ESAP item 3, the company shall revise the HR Policy and grievance mechanism as specified in the ESMP for the operational phase in accordance with IFC PS2 requirements and ensure that it is communicated and accessible to all employees including those hired by MoH.

Working Conditions and Terms of Employment

At the time of the appraisal, the construction workforce consisted of 490 employees: 87 RMI employees and 403 from subcontractors. At the peak of the construction phase, it is expected that around 3,000 workers will be on site. Workforce, including subcontractors, will be recruited locally as much as possible.  The expected workforce requirement during the operation phase is anticipated to be 1,609 health service personnel and 303 administrative personnel to be employed by MoH, 20 administrative personnel to be employed by ELZ, and 2,023 service employees to be provided through third party service providers of the project company

A worker camp has already been located on site to accommodate nonlocal workforce. Currently the camp has a 640-bed capacity dormitory but is expected to reach up to 2,620 bed-capacity. During the site appraisal it was observed that the camp site has services and utilities in line with IFC’s Guidance on Worker’s Accommodation. In order to provide health care services, such as first aid and emergency treatment to the personnel working during the construction phase, an infirmary unit was established at construction site and the company signed an agreement with a nearby hospital for clinical services. Ambulance service is also outsourced.

The company does not employ child or forced labor and maintains a record of all workforce of contractors and sub-contractors, including information about age and social security coverage.

Occupational Health and Safety

ELZ Saglik developed an OHS management plan containing the company’s OHS policy, functions and procedures, hazard identification, risk assessment and management; and various health and safety instructions about safety signs, labor camp safety, personal protective equipment, trainings, emergency preparedness, safety education and first aid. A structured OHS organization is in place; it includes an OHS director and specialists and designated staff for continuous monitoring and implementation of OHS practices. In order to provide practical training to workers about safe construction practices, a small building was constructed at site; the structure is used to demonstrate safe OHS practices and allow workers to get hands-on training on specific tasks that they will then have to perform on the job site. Workers are provided with appropriate induction and occupational health and safety trainings. Personal protective equipment were provided to relevant workers and periodic checks of use are conducted in accordance with the local regulations.

OHS-E Management Plan, Subcontractor Management Plan and OHS-E Disciplinary Procedure define the contractor’s and subcontractors’ roles, responsibilities and penalties to enforce implementation of OHS requirements during the construction. The OHS obligations imposed on the construction contractor include taking all required occupational health and safety measures and fulfilling the provisions of OHS laws, legislation and regulations in force. The contractor is also responsible for ensuring implementation of OHS requirements by the subcontractors. The company has contractual right to stop construction if unsafe conditions are observed; and has a right to terminate the contractor’s and subcontractors’ contracts if corrective actions were not ensured.

Accident reporting, including near misses and root-cause analysis, procedures and documentation are available. Two lost time accidents within 959,520 man hours worked were reported from the beginning of the construction start date (June 2016).

For the operation period, an OHS manager will need to be appointed by the company and OHS Management Plan and relevant procedures will be developed before the commissioning of the facility. Employees will be provided training in all relevant environment, social, health and safety management topics, in particular OHS for handling hazardous materials and medical waste. As per the ESAP item 4, the company shall develop and implement relevant environmental, health and safety training as part of the operational phase ESMS as described in the ESMP.

Retrenchment

It has not been confirmed at this stage whether any retrenchment will occur as a result of the Elazig IHC project and potential closure of existing hospitals in the area. According to the Provincial Directorate of Health, rehiring of a significant number of staff may take place once Elazig IHC becomes operational.  .  Should there be any retrenchment as a result of hospital closures triggered by the operation of the Elazig IHC Project, MoH will develop a retrenchment plan in accordance with its own labor policy and Turkish labor requirements applicable to all MoH employees. Retrenchment of non-MoH employees will be managed in accordance with Turkish labor law as per their employment contracts. Although the project enterprise is not directly responsible to conduct retrenchment activities, it bears a responsibility to oversee that any relocation and integration of workforce to the Elazig IHC is done in line with IFC’s PS2 requirements. 

Contractor Safety and Workers Engaged by Third Parties

ELZ Saglik has a mechanism, integrated in its ESMS, to assess sub-contractor’s compliance by conducting an assessment study in accordance with relevant items delineated in the ESMP and relevant management plans. ELZ Saglik has also developed procedures to manage sub-contractors, as part of the ESMS, to ensure that they are aware of and abide to environmental and social, OHS, and labor policies. Evidence of good practice, such as use of appropriate personnel protective equipment and safety measures were observed during the visit to the construction site. As per the ESAP item 5, for the operational phase, the company shall prepare conditions for third party service contracts to ensure proper coverage of all relevant environmental, health and safety, social, and human resources issues and ensure that third party workers have access to the workers grievance mechanism.

Baseline conditions were established for the project area through field measurements for air quality, noise, hydrology, hydrogeology, geology, soil quality, and terrestrial ecology. As a consequence of its previous use as a military training ground, the site has been highly intervened and has significantly lost many of its original natural characteristics.

Resource Efficiency

Drinking water during the construction and operation phases of the project will be provided from the Elazig municipal water system. A 150 liters/day per capita consumption rate was estimated yielding a daily water requirement of 300 m³/day during the peak time of the construction. Water will be required for other construction-related activities such as dust suppression, spraying concrete, site clean-up, etc. An additional 210 m³/day water consumption rate has been calculated for construction activities. During the operation phase, there will be water uses related to general domestic and sanitary use, food preparation, sterilizers and autoclaves, etc. The water consumption rate for the Elazig IHC was calculated based on the daily water consumption value per bed (between 1.25 m³ and 1.60 m³) according to data for large hospitals in the United States (US Energy Information Administration, 2007). Thus, the water consumption is estimated to fluctuate between 1,297 and 1,661 m³/day. Municipal water supply has been deemed adequate to fulfill these estimated requirements.

In the operational phase of the project, electricity will be produced on-site via a tri-generation plant. This plant, with total rated capacity of 5.5 megawatt (MW), and a three boiler system with rated capacity of 10 MW each will supply all energy, heating, and cooling needs during the hospital operation. According to the yearly electricity consumption data for large hospitals in the US (250 kWh/m²), the yearly electricity consumption of ELZ IHC was calculated as 50,750,000 kWh. Diesel fueled emergency generators located within the central energy plant will be used to provide backup power supply for the hospital buildings. Each generator will be equipped with a day fuel tank that will be sized to operate for a minimum of 2 hours continuous operation at full load. The main energy source during construction will be diesel fuel for construction equipment, vehicles and generators to supply construction camp with electricity; the ESMP includes procedures to safely handle and store diesel fuel on site.

Energy efficiency will be considered in the design and operation of the project. Energy and water resources management plans have been recommended as part of the ESMS, in conformance with PS3, to optimize resources use.

Wastewater

Elazig’s domestic wastewater is collected and undergo primary (mechanical) and secondary (biological) treatment at the Elazig Municipality Wastewater Treatment Plant (WWTP) where ultimately all wastewater produced by the project during construction and operation will be treated. The existing capacity of the WWTP is 69,984 m³/day and, although it has not reached its maximum capacity, according to the Elazig Municipality Director of Environmental Protection the current design capacity and efficiency of the plant are inadequate for projected urban growth. As reported by Elazig Municipality, a modular treatment system with 50,000 m³/day capacity will be added to the existing WWTP with the objective of increasing its capability to 120,000 m³/day. The WWTP expansion is expected to take place concurrently with the project construction.

During the project construction and operation phases the total daily domestic wastewater generation of the project is estimated to be 510 m³/day and 1,661 m³/day respectively, which will be within the current treatment capacity of the Municipality plant. ELZ Saglikwill obtain a wastewater connection permit since all domestic wastewater during all project phases will be discharged into the existing municipality sewer lines in accordance with Waste Management Regulation.

Wastewater from medical wards and operating theaters (e.g. body fluids and excreta, anatomical waste), laboratories (e.g. microbiological cultures, stocks of infectious agents), pharmaceutical and chemical stores; and cleaning activities (e.g. waste storage rooms) will be collected via different piping systems and monitored before discharged into the sewer system.

Wastewater contaminated with radioactive substances during operation of the health campus will be collected separately and monitored for the residual activity prior to being discharged into the sewer system as low activity liquid waste per conditions set under the Regulation on Wastes Generated upon Usage of Radioactive Substances. Approval from the municipality will be required prior to discharging radioactive wastewater, per the referenced law. This authorization will be obtained during the licensing process. As per WBG EHS Guidelines for Health Care Facilities, the capacity of the municipality to receive this type of wastewater must be confirmed and a wastewater management plan completed.

Solid Waste Management

The production of non-hazardous and hazardous solid waste, including medical and radioactive wastes, is expected throughout different phases of the project. Thus, a project-specific Waste Management Plan covering site preparation, construction and operation phases of the hospital has been completed. The plan identifies all waste streams and some anticipated waste quantities, describes transportation and disposal requirements, and outlines waste management responsibilities. All waste streams will be managed and disposed of in accordance with Turkish regulation and WBG EHS Guidelines for Health Care Facilities.

Site preparation and construction include soil excavation activities that have already started at the project site. It is estimated that 620,000 m³ excavation wastes will require off-site disposal, roughly 201,000 m³ has been excavated to date. Approximately 127,000 m³ of the excavated material has been transferred to an approved excavated material storage area of Elazig Municipality, located about 14.5 km away from the project area, while the rest is being stored on site to be used as filling material during construction. Soil sampling conducted at the project site during the ESIA phase did not show any sign of contamination.

Waste generation during construction will include contaminated soils, sanitary and domestic wastes, and clean-up materials from accidental spills. The estimated domestic waste generation during the construction phase is 2.2 tons/day. Domestic waste is stored in waste containers, collected by the Elazig Municipality, and transported to the municipal landfill 30 km from the site. Estimates for domestic solid waste generation assume that the hospital will produce approximately 2.4 tons/day during the operation of the Elazig IHC.

During the operation phase, infectious and pathological waste and other hazardous wastes from laboratories will be segregated at source, collected in designated containers, appropriately stored on-site, then transported and disposed of by authorized contractors. Collection and disposal of the medical wastes will be done in line with the Regulation on Medical Wastes Control. Once the necessary protocols are completed, medical waste disposal from operation phase will be made to Elazig Medical Waste Treatment Sterilization Center. The annual medical waste generation for Elazig IHC was estimated at 322 tons (or 882 kg/day, assuming 1,038 beds).

The radioactive waste stream is expected to include residual radionuclides proceeding from unused liquids used in radiotherapy or laboratory research; contaminated glassware, packages or absorbent paper; urine and excreta from patients treated or tested with unsealed radionuclides, etc. Clean-up materials such as spill kits will also be managed as hazardous waste.Disposal will be done by companies authorized by Turkish Atomic Energy Authorization in accordance with regulation on Secure Transfer of Radioactive Materials and the Regulation on Management of Radioactive Wastes. In addition to Turkish regulations, the project will follow waste management practices stipulated in WBG general and EHS guidelines for Health Care Facilities.

As per the ESAP item 6, the company shall provide IFC with documentation on the status of the existing and proposed improvements on wastewater treatment facility and landfill site of the Elazig Municipality. Documentation should include confirmation that existing systems are capable of handling all wastes streams produced by the Elazig IHC, and evidence of necessary approval for the discharge of radioactive liquid wastes has been obtained.

Air Emissions

Main sources of air pollution during the construction phase were identified as excavation works, movement of vehicles, and engine emissions from exhaust gas from construction equipment and road traffic. Principal pollutants resulting from these sources are particulate matter (PM) from soil excavation and removal; and nitrogen oxides (NO_X), sulphur dioxide (SO₂) and carbon monoxide (CO) from exhaust of vehicles. Measurements for PM₁₀ to establish baseline conditions and a dust dispersion modeling study were completed and potential impacts within the study area calculated. Test values are significantly below the associated limit values stipulated in the national regulations (Industrial Air Pollution Control Regulation – IAPCR - and Regulation on Assessment and Management of Air Quality - RAMAQ), European Union (EU) directive and World Health Organization (WHO). Additionally, a vehicle movement analysis was performed to estimate baseline conditions for NO_x, SO₂, and CO emissions associated with construction activities. All values were under the maximum permissible limits in the national regulation (IAPCR). Actual values will be monitored during construction and compared to modelled results. Mitigating measures will be implemented should recorded values exceed project and/or legislative standards.

Impacts on the air quality during the operation phase will be mainly related to the emissions from the tri-generation plant and boiler system. A dispersion modeling study was undertaken for NO₂, the most significant emission source from these systems. Hourly and annual values of NO₂ estimated from the tri-generation system are significantly below the associated limit values defined in the national regulations (IAPCR and RAMAQ), EU Directive and WHO Guidelines. Thus, impacts from pollutant and dust emission to the atmosphere is expected to be minimal during all phases of the project. Monitoring and implementation of mitigation measures for the control of exhaust from all vehicles will be adopted per the ESMP.

GHG Emissions

The project area is located within Elazig central district, where urban development is expanding to the west and southwest of the site. The site is near some individual houses located to the south, north, and west, and the residential areas of Ulukent and Dogukent neighborhoods. There are three schools in the close vicinity of the project and a minibus station located to the south. The site has been declared a “public area requiring large land use” according to the municipal zoning plan. Typical risks associated with the development of this project are increased traffic of heavy machinery, noise, dust, and hazardous material handling and fire and life safety. The ESIA concludes that with the proposed mitigation measures, those risks will be minimized to comply with relevant environmental standards.

Community Health and Safety

The risks and impacts of the project, in the context of health and safety of off-site communities, will be managed through a Community Health and Safety Management Plan developed and implemented by ELZ Saglik.

Community Health and Safety management procedures for the construction phase was developed according to IFC PS4 requirements and WBG General EHS Guidelines as outlined in the ESMP. These procedures contain traffic safety measures for the residents and mitigation measures for noise, vibration and dust in the nearby community in accordance with national and applicable international standards. A standalone traffic management plan was also developed to control times and routing of vehicles and traffic safety measures, including necessary signaling during the construction phase.

Emergency Preparedness and Response

The company commissioned a life and fire safety consultant (Karina Ltd.) with experience of international standards to work on Fire Safety Master Plan and site-specific design to ensure that all the life and fire safety aspects of the project design are compatible with an internationally recognized fire and life safety code (NFPA codes), as required under the life and fire safety section of the WBG EHS General Guidelines. The project is being designed and constructed in accordance with Turkish Regulation on the Protection of Buildings from Fire. Relevant technical requirements, including those delineated in applicable international standards, were integrated into the Elazig IHC design and construction tender documents, e.g. fire suppression systems will be available throughout the hospital and a fire alarm system will be designed and installed in accordance with the requirements of U.S. National Fire Protection Agency (NFPA) Code 72. Fire control and mitigation measures for the construction phase of the project are contained in the Emergency Preparedness and Response Plan and Fire Prevention and Protection Procedure prepared. As per the ESAP item 7, the company shall submit professional certification to IFC confirming that the designs are in accordance with internationally recognized LFS standards. This will include special measures taken for the forensic psychiatric hospital in order to avoid additional risks that can be posed by enforced security in case of fire.

Following construction, the company shall retain a qualified professional to ensure that testing and commissioning of the life and fire safety system are achieved in accordance with applicable national codes and NFPA. The consultant shall develop an audit report including corrective action recommendations for any issues identified (ESAP item 8).

Seismic Resilience      

The project is located in a 2^nd degree earthquake zone as per local classification. Necessary criteria (e.g. appropriate standards, regulations, etc.) are taken into account in the design of the facilities to address seismic risks and considering the specific parameters defined for the design of structures located in seismic zones. The hospital will be constructed in line with such criteria presented in the Geotechnical Survey Report within the ESIA, Turkish Regulation on the Structures to be Constructed in Disaster Areas, and the Turkish Regulation on the Buildings to be Constructed on Earthquake Zones. During the visit, the friction pendulum system was observed in the main building. It is indicated that the pendulum system can resist earthquakes up to 10 points in Richter scale while the most significant earthquake was 6.8 in Elazig center district until today.

The company has received structural design approval for the project from the MoH. As per the ESAP item 9, before the commissioning of the facilities, the company shall submit a letter certifying that constructions have followed the approved designs and necessary approvals were obtained from the relevant authorities.

Security

For the construction phase, the company outsourced security services to a licensed company that is currently deploying around 20 unarmed security personnel at site. The construction site is equipped with a video surveillance system that operates 24 hours. Security risks are considered to be low at the project area and no major risks to the workers or community (which is located at some distance) are expected. Security for the hospital will be provided by a contracted private company with unarmed security personnel. The buildings will be equipped with an access control system of electronic card readers and electronic identification cards for employees, alarms, telecommunication devices and closed-circuit television cameras. The high security forensic psychiatry unit will be enhanced with security guards to be managed directly by the gendarme, a branch of the Turkish armed forces, in accordance with a triple protocol between the Turkish Ministry of Justice, Ministry of Interior, and the MoH. The company shall conduct a security assessment and develop a Security Plan including security procedures for the High Security Forensic Psychiatric Hospital in collaboration with MoH and local authorities as per the project ESMP (ESAP item 10).

Stakeholder engagement activities for the project started during the scoping stage and continued during the preparation of the ESIA report. A public consultation meeting was held on December 18^th, 2014 in Elazig Central District, where 52 people attended. The meeting was announced via various advertisements in two newspapers and through handouts. Face-to-face meetings were also held with community leaders in 20 neighborhoods located within the project area. Project details, ESHS risks and impacts, project delays, and other relevant topics were discussed during the meetings. Additionally, public participation was sought through the distribution of feedback forms. No grievances or negative concerns were expressed by attendees or any of the contacted stakeholders.In general, local stakeholders are aware of public benefit of the Project. 

A Stakeholder Engagement Plan (SEP) has been developed for the project. The SEP clearly identifies all project stakeholders including government agencies, NGOs, neighboring communities, and the general public. It includes a grievance mechanism that provides an open channel for continuous and structured communication between management and the general public and describes a detailed strategy to place, investigate, respond, and file a given complaint as well as the expected timeline associated with these actions. Through this process, the public can express individual and collective concerns and issues regarding the construction and operation of the facility. The SEP also outlines communication methods appropriate for each project phase, including publications through corporate website.

Contact Person: Can BOZKURT

Company Name: ELZ Saglik Yatirim A.S.

Address: Aziziye Mahallesi Refik Belendir Sokak 110/3 Cankaya- ANKARA