PS5 (Land Acquisition and Involuntary Resettlement) is not applicable because the project is an expansion within existing hospital and on land already owned and occupied by Company. The project sites are located well-developed urban areas, therefore, impacts related to PS6: Biodiversity and Natural Resource Management, PS7: Indigenous Peoples and PS 8: Cultural Heritage are not expected.                                                  

This is a Category B project according to IFC’s Policy on Environmental and Social Sustainability as the E&S impacts are mostly site specific and localized and can be avoided or mitigated by adhering to generally recognized performance standards, guidelines or design criteria and adequately managed through the implementation of an expansion work specific Environmental and Social Management Plan.

Lands (plots) for establishment of day surgery centre at Islamabad and new hospital at Faisalabad, Pakistan have been already acquired by the Company, whereas the expansion work will be limited within the premises of the existing flagship hospital. The hospital at Dar es Salaam, Tanzania would be established in an already constructed building which is owned by the Company’s local partner.  The shell and core including external finishing of the building are complete and all the technical drawings including Architectural, Electrical, Mechanical, Plumbing, Fire Fighting, Medical Gases, Furniture and Stairs Pressurization as required for a hospital are complete. All project sites are located within urbanized areas and no significant or major adverse impacts on biodiversity or natural resources are anticipated at this stage. Mitigation measures for the potential environmental and social impacts are identified and incorporated into the attached Environmental and Social Action Plan (ESAP).

Specific environmental and social issues identified include: i) project sponsor’s corporate level overarching policy and a framework for establishing and monitoring EHS&S management systems at project level, ii) E&S due diligence of incineration ash disposal site and of building acquired for establishment of hospital at Tanzania, and iii) adequacy of the Life and Fire Safety (LFS) systems at the SIH facilities to comply with the WBG EHS guidelines.         

Land and natural environment:

SIH’s flagship hospital is located in Sector H-8 in Islamabad, the capital city of Pakistan. The project has been developed according to the regulation of Capital Development Authority (CDA). Expansion work and construction of outpatient care and day surgery centre will be planned in compliance with the procedures specified by CDA. Company has acquired land for establishment of hospital at Faisalabad in an urbanized area. Hospital in Dar es Salaam, Tanzania will be established in a building which is located in main city area and civil structure is already complete. No land acquisition is required for project components and, being located in urbanized areas, no direct adverse impacts are anticipated on natural environment from the project.

Environmental and Social Assessment:

SIH will initiate environmental and social assessments of each of the new development under the project in Pakistan engaging external expert/consultant and being conducted according to the local regulatory requirements, IFC Performance Standards, and applicable WBG HSE guidelines. For expansion project at flagship hospital the Company will conduct a detailed environmental, health, safety and social risk assessment as required by law, and develop action plan to mitigate the identified risks. For the project in Tanzania, an environmental and social due diligence will be conducted engaging a qualified and experienced professional to understand the scope of related E&S liabilities and workout an action plan to ensure compliance. The E&S assessments will include a site specific qualitative and quantitative analysis, review of the anticipated impact of the project and will identify the mitigation measures needed to be implemented to mitigate the impacts. There will be a process of public consultation on the ESIA for new hospital in Pakistan as part of the process of approval by the local authority (EPA).

Identification of Risks and Impacts:

The EHS management plan for 2018 includes conducting health and safety risk assessment based on Facility Management & Safety (FMS) program for each departmental activity on annual basis. For the previous year, analysis conducted through risk assessment tool for various possible events under management of security, safety, hazardous materials, disaster preparedness, fire safety, medical equipment and utility system indicated threat level mostly as ‘low’, with only few as ‘medium’ and none to the level of high threat.

HSE policy and Management:

SHI has management system covering quality and safety SIH obtained ISO 9001:2008 certification (Quality Management System) for Hospital Services and Management System in August 2000 with a transition audit to ISO 9001:2015 completed in Sep 2018.  Certification for ISO 22000:2005 in Food Safety Management was acquired in June 2018. The company is planning to achieve certification on health and safety management systems. SIH was accredited for Joint Commission International (JCI) in May 2017, making it the second hospital in Pakistan to be accredited by this standard in healthcare quality. A multitude of initiatives for improving various structures and processes involving patient care, staff, equipment and facility were initiated by SIH in due course of JIC accreditation. 

Management procedures in place cover both construction and operation. The procedures include construction safety, safe working conditions, impact and risk analysis, incident investigation, log out tag out, emergency response and management review. Policy for General Guidelines of Safety is in place and applicable to all employees throughout the hospital. SIH has documented a Safety Management Program 2017 to comply with local laws and meet the requirements of JCI accreditation. The Facility Management Department (FMD) coordinates planning, development and implementation of safety management program.

Under EHS management plan 2018, the Company plans to conduct gap analysis to formulate EHS Management System. As described in ESAP item #1, the Company will develop an overarching EHS & Social Policy to develop a corporate level Framework for Environment, Health, Safety and Social Management System to respond to the EHS and Social management and mitigation actions, identified by risk assessment process, in accordance with the requirements of IFC Performance Standards, WBG EHS Guidelines and applicable local legislation. The framework will guide development of project-specific EHS&S Management Plan for new development/projects for construction and operational phases. The Company will conduct Environmental Impact Assessment (EIA) studies for the new projects in Islamabad, Faisalabad and Tanzania. 

HSE Team and Organization:

SIH follows the provisions contained in the Listed Companies (Code of Corporate Governance) Regulation 2017 notified by the Security Exchange Commission of Pakistan under the patronage and supervision of the Board of Directors.

SIH operations are managed through few core divisions, which include a quality division, facilities division and human resources. The quality division is headed by the Director Quality Assurance. The quality division includes responsibilities for regulatory and accreditation compliance, fair & just culture, and training & communication relating to data measurement & monitoring, clinical risks management, HSE, infection control, etc. There is a Quality Council that reviews the progress for quality plans in its quarterly meetings; monitors performance of Safety Committee, Infection Control Committee and Clinical Risk Committee; provide approvals of actions plans; and reviews Internal Quality Audit Reports.

Facility Management Department (FMD), headed by a General Manager, operates under Operational Management Division with responsibility of maintenance services, biomedical services, safety management, housekeeping, transport, etc. A Safety Committee, headed by COO, includes all divisional heads as member and Manager HSE as secretory of the committee. Manager HSE who interacts with Departmental Coordinators to implement procedures in daily routine operations of each department and monitor compliance status. The Safety Committee, under documented terms of reference, is responsible to develop, monitor and continue improvement of the Facility Management Program to ensure safe working environment. The committee meets on monthly basis to discuss Facility Management & Safety (FMS) related issues and to oversee compliance in management of safety, firefighting, hazardous materials & wastes, disaster preparedness, security, utility system, inspection & maintenance of medical equipment. Manager HSE also liaise with 46 safety champions (with other core responsibilities), one from each section of SIH, who support implementation of management system, within the main flagship hospital and at other healthcare facilities at distinct locations. The Safety Committee and FMD need to be engaged proactively in the decision-making on new projects to ensure a framework to meet both local regulatory and IFC requirements in planning stage.

SIH has a documented procedure to carry out review of all Management System at regular intervals to ensure continuing suitability, adequacy and effectiveness of each system to assess the opportunities for improvement and need for changes to the Management Systems.

During construction or development of new projects, the Company will be responsible for permits, architect and engineers responsible for design, Contractor(s) responsible for construction, and EHS section responsible for monitoring of EHS&S performance and implementation of EHS&S management plan.

As described in ESAP item #2, the Company will review the EHS related responsibilities and obligations under current operations and upcoming projects and develop a capacity building plan at corporate level to strengthen the EHS Section defining roles and responsibilities, organogram, functions, etc. The Corporate EHS team will be responsible to develop and implement project specific EHS&S management plans for both construction and operational phases in compliance with the IFC PSs, WBG EHS Guidelines and local legislation.

Training, Monitoring and Reporting:

Trainings are conducted on quarterly basis for SIH staff. Trainings conducted in 2rd quarter, 2018 were conducted on infection control, medical technology, ergonomics, disaster management, body mechanics at workplace, hazardous materials and waste management and fire safety. The Company will extend the scope of trainings to cover the important 3rd party service providers such as security management, waste management contractors, etc.

EHS monitoring rounds (internal audits) are conducted for each ward/section at main hospital as well as other SIH remote facilities according to an annual program. The monitoring is conducted by three teams having four members each from various departments. All audits, monitoring, performance reports undergo management review at various committees’ level and overall monitored by the Quality Council on quarterly basis. 

SIH has an appropriate internal monitoring and reporting procedures to track human resources issues, quality, and safety performance. SIH also publishes its annual report every year and share it with employees and shareholders and disclose these reports on its website. As part of the EHS&S Management Plans for construction described on ESAP #1 the company will monitor implementation of the mitigation measures during construction.

 Human Resource Policies and Procedures:

SIH has an HR management process for staffing the organization and sustaining high employee performance. The HR process includes management function that handles recruitment, performance, employee development, career & succession planning, compensation, benefits and employee relations related activities. The Policy manual of SIH includes around 58 documents outlining comprehensive details about HR policies, procedures, and related forms, being developed after due discussion and deliberation with management viz a viz current practices, prevailing concepts, various industry trends and practices in line with labor & industry laws.

The core HR policies which specify the terms of employment and working conditions at SIH include procedures for hiring and recruiting, competency assessment, trainings, transfer, promotion, insurance, salary and compensation, lay-off and firing, leave and vacation, gratuity and retiring which follow Pakistan labor laws. HR manual also includes staff health and safety program and Employees health services.

As described in ESAP item # 3, the Company will develop a corporate level HR policy statement specifying scope and applicability of HR policies and procedures to all of its existing and upcoming facilities/projects including the one at Tanzania.

The Company has a comprehensive Code of Conduct which requires all employees to maintain a work environment which calls for fairness, respect and integrity and to adopt ethical manners. The Code has provisions which include but are not limited to legal compliance, restrain on political activities & soliciting gifts, avoiding conflict of interest, non-discrimination or harassment on the basis of race, color, age, etc., maintaining confidentiality of information, complying with the laws, rules vis-à-vis environmental protection etc. The Code of Conduct is applicable to all the directors, officers, employees, consultants and agents of the Company.

Communication and Update:

All HR policies are uploaded on Hospital Document Management System (DMS) for communication to all employees. All concerned can refer to HR polices and procedures through internal web portal. Employees are issued with appointment letters at the time of joining which mentions essential information related to their rights including, working hours, remuneration, probationary period, notice period, compensation & benefits, code of conduct, etc. HR policies will be extended to the operations in Tanzania.

SIH has a policy on orientation of new employees through a 3 days mandatory session which enables them to get acquainted with core values and HR/HSE policies and employment terms are clearly communicated in writing. SIH strictly follows Pakistan labor laws. HR Department keeps the policies updated time to time as per labor and employment laws.

HR Management:

HR Department is headed by a General Manager HR, who reports to the COO, and is responsible for provision of quality healthcare professionals to enable the delivery of efficient and effective services to achieve patient satisfaction. Core functions of HR department include collaboration with sister organization (Tameer-e-Millat University) for development of capable and talented technicians, nurses and physicians; ensuring staff engagement and participation by maintaining respectful and healthy working relationship between the employees and management; and encouraging staff retention and succession planning. SIH has also partnered with external nursing institutes as a strategy to meet staffing needs. SIH has strong liaison with many nursing institutes having quality programs to acquire significant number of nursing resource every year and also has nursing internship program.

Workers’ Organization:

The Company has a combined staff strength of 5010 in its four healthcare facilities in Pakistan, with majority employed with main flagship (H-8) hospital (4684 staff positions) including: 734 physicians, 961 nurses, 1039 allied healthcare staff, 1950 others. Female staff ratio is about 35% (1754) of overall staff.  Management staff (officers category) which includes section Coordinators and above positions are 1650 whereas non-management staff (workers) are 3360. Contract workers are 314 dedicated mostly to project office, security, maintenance, laundry. In year 2017 Company had 4787 direct employees and 298 contract workers.

SIH has a procedure on working hours and overtime and record of the total number of hours being spent is maintained through an automatic time-in and time-out logging system. SIH has no registered labour union for collectively bargaining for both employees or contract workers. The company does not impede employees/workers from exercising freedom of association and collective bargaining. SIH management engages with the employees through grievance redressal processes described in the following paragraphs.

Non-Discrimination and Equal Opportunity:

SIH provides equal opportunities for its employees. All the hiring and promotion process are free of ethnic, religious and/or gender biases and are strictly on merit and performance basis. Hiring processes are carried out under the Company’s Policy of Recruitment. The HR manual includes policies on prevention of sexual harassment, training for clinical and non-clinical staff and competency assessment.

Protecting the Workforce:

There is no child or forced labor in SIH operations. Holding of national identity cards (issued at 18 years of age) is a mandatory requirement for any job at SIH. Age relaxation is for trainees only. SIH has a policy for medical monitoring of the employee, staff welfare, group life insurance.

Workers’ Grievance Mechanism:

SIH has a documented Policy of Grievance and communicated to the employees through internal web portal. Employees are encouraged to discuss grievances with supervisors and department heads to resolve. The written grievances are registered formally by the HR department and discussed at appropriate forum for redressal.

Occupational Health and Safety:

SIH has a Safety Management Program (SMP) in place to take actions to maintain a safe and healthy environment and comply with national laws and JIC accreditation requirements. The SMP is applicable to all facilities, people, contractors, processes and equipment of operation, including independent entities. Through Hazards Vulnerability Analysis level of workplace hazards are identified.

Considering the severity and sensitivity of certain job roles SIH has designed post medical monitoring program for examinations of workers to detect adverse health effects which could possibly be related to workplace exposures. The policy focuses on early detection of symptoms to help plan earlier treatment and prevent additional exposures that could aggravate a potentially serious medical threat to employee and patients. SIH also has procedure to acquire hot work permits from Safety and Security Department and coordinate with the FMD during the job execution. 

One week (48 hours) Lost Workdays (LWD) have been recorded in last three years of operations (data reviewed for 3 years only) at SIH by employees and contract workers and 32.4 million safe man-hours completed without a lost work incident.

OHS during construction would be managed according to the project specific EHS&S management plan being developed for the construction phase under ESAP item 1.

Workers Engaged by Third Parties:

The Company acquire services of 314 3rd party contractual staff to support its routine operations. These include 47 external security personnel engaged by Safety & Security department, 61 maintenance workers engaged by Facility Management Division, 37 workers for laundry services, 9 by Housekeeping, 12 for parking facilitation by Traffic Management, and 121 staff engaged at Project Office on daily wages. HR manual has a policy on contractual/daily wages employment and part-time employment. The Company will review the contractual terms with companies providing outsourcing services to ensure compliance of Shifa HR policy relating to, but not limited to, minimum wages, working hours, overtime, procedure for termination, grievance mechanism in engagement of the Contract Workers (ESAP #4).

Construction workers

Construction would be carried out by workers engaged by the Contractors. As project sites being located within urban areas, no workers camps would be developed at site.

Resource Consumption:

Energy: Primary source of energy at SIH is 5 generators of 4.8 MW total capacity being operated on natural gas supplied by the local gas authority whereas supply from the grid is considered as a secondary source. SIH consumes around 17,500 KWh of electricity from the grid supply and 49,000 KWh from inhouse installed gas generators. Two diesel fuel generators of 1 MW each are also installed as standby source.

Water Supply: The operations of SIH require approximately 28.8 m3 of water per day and is mainly used for heating, laundry, canteens, cleaning, washing, and in washrooms.  Bottled water is also used frequently for drinking purposes. Groundwater is extracted through boreholes to fulfill water demand. Extracted water is stored in RC tanks and is adequately disinfected using chlorine dosing prior to supply into the network. Water quality is checked inhouse on daily basis and through 3rd party laboratory on monthly basis. Some departments requiring further purified water, such as dialysis unit, have small RO plants installed for the purpose.

Resource Conservation:

SIH has installed two waste heat recovery boilers on the natural gas operated generators’ flue gases having 484 °C exhaust gas temperature at minimum load. The steam generated through these boilers is mainly used in laundry, washing, cleaning and heating purposes in routine activities. Boilers are of Simplex and Duplex design supporting single and double generator stacks, with steam generation capacity of 800 and 1600 kg/hr respectively. These boilers are providing 34.98 million Pak Rupees savings annually from energy bills reduction. Further use of the steam in CSSD, cafeteria, etc. is under planning to enhance savings.

Pollution Prevention:

Wastewater Treatment: The domestic nature of wastewater generated mainly from canteen, washing, cleaning and washrooms discharged into the public drainage network. The effluent from the laboratory area diverted to a two chamber septic/holding tank for neutralizing and disinfection through chlorine dosing, before disposal into municipality sewers. The final discharge quality is monitored regularly for compliance with local discharge standards for pH, BOD5, COD, TSS, Oil & Grease and are recorded compliant in analysis conducted in 2018. The EHS&S Management Plans developed under ESAP # 1 will define management of wastewater in the new facilities.

Air Emissions: Air emissions sources at SIH include stacks of power generators, incinerators and boilers. Stacks are monitored for basic pollution parameters (CO, SO2, NOx, PM) against the local emissions standards. Monitoring reports of 2018 shown compliance with local standards and IFC requirements. 

Solid & Hazardous Wastes: SIH produces monthly around 48,000 kg of general solid waste and 13,200 kg of food waste which is disposed of in municipal landfill site through an approved waste contractor.

SIH has a system of at source segregation of infectious and hazardous wastes with color coding. A waste management plan outlines the nature of waste being generated at departmental levels and specify method for their collection and disposal. All type of infectious waste, including sharps, is collected in yellow bags, sharps in boxes, and incinerated on site. SIH has two incinerators with 100 and 150 kg/hr capacities respectively, both operated on natural gas. SIH produces monthly around 37,000 kg of infectious waste and 2,850 kg of sharps.

Ash produced from the incineration process, around 5,600 kg/month, being hazardous in nature is disposed of in a landfill site developed on a piece of land located in a rural area having mostly agricultural activities in surroundings. As described in ESAP item #5, the Company will conduct a due diligence of the incinerator’s ash landfill site, identify measures to achieve compliance with IFC Performance Standards, WBS EHS Guidelines and local legislation and acquire approval from the local authorities for landfill operations. Management of wastes in the new facilities will be guided by the developed EHS&S Management Plans.

Hazardous Materials Management:

Hazardous Materials: Fifteen hazardous chemicals are identified as hazardous being used as scale/corrosion inhibitor, biocide, pH controllers, disinfectant, anti-germs, cleaner in SIH routine operation. SIH has a policy on hazardous materials and waste management program that requires maintaining an inventory and identify, handle, use, and dispose of hazardous materials and waste in a manner that protects the employees, patients, visitors and the environment. The procedure requires placement of Material Safety Data Sheets (MSDS) at the department level, where the chemicals are handled and used. SIH also has a Radiation Safety Program to comply with the national regulatory requirements for radiation control and includes equipment and waste disposal to ensure safety

Pesticide Use and Management: The Company has a policy on pest management and has outsources fumigation and pest management services to a qualified contractor.

Energy Efficiency & GHG Emissions:

Energy: Under the energy conservation policy, replacement of around 7,539 conventional lights sources with energy efficient savers/sources provided savings of 286 KW from 2013 to 2018. Removal of extra light sources from corridors and waiting areas help conservation of 141 KW. Replacement of common ASD, DOL motor starters with VDFs provided savings of 61 KW. Net savings achieved from these three actions is 488 KW.

GHG Emissions: GHG emissions for the SIH are mainly from operations of power generators, grid supplied electricity and fuel consumption by company owned vehicles. Based on electricity consumption estimates, emissions will be below 25,000 tonnes of CO2-equivalent annually, therefore GHG reporting requirements does not apply to this project.

  Community Health & Safety:

SIH projects are healthcare facilities that are accessed by the general public and are designed, constructed and operated in full compliance with local building codes, fire department regulations, insurance requirements and in accordance with an internationally accepted standard.

Healthcare facilities have minimal health and safety risks to the surrounding communities. At SIH, traffic disruption on the adjoining roads have been addressed with development of a several entrance gates facilitating access from various approach roads and large parking areas within the project boundaries. Exists are kept separate from entrances to facilitate smooth movement within the parking areas and to minimize disturbance to the traffic flow on adjoining roads.

Life and Fire Safety (L&FS):

SIH has a fire safety management program 2017 which defines processes to provide for a safe environment protecting patients, visitors, staff and property from fire and smoke. It consists of prevention, early detection, suppression, abatement, and safe exit from the facility in response to fires and non-fire emergencies. It is an interdisciplinary program primarily involving the Safety Committee, the Safety & Security Department, Facilities Management Department, all Divisional / Department / Section Heads, Staff, Vendors and occupants of independent entities operating under SIH. The plan defines the structure of firefighting team, their roles and responsibilities and includes training and procedures for fire prevention, fire preparedness and fire response. SIH conducts weekly inspections of its firefighting system as per the checklist which includes examination of firefighting equipment, fire warning system, escape routes and emergency lights. A training and mock drill calendar is in place for conducting weekly session at departmental levels.

SIH has one dedicated underground water tank of 100,000 litres capacity, one 20 HP electric pump and fire suppression system and facilities include sprinkler system (at sensitive locations), hose valves connected to internal standpipe system, portable fire extinguishers, automatic smoke detection and alarm installed at sensitive locations and project has emergency voice alarm communication system.

The Capital Development Authority (CDA), under Islamabad Fire Prevention and Life Safety Regulations 2010, conducted in May 2017 a fire audit of SIH to evaluate compliance against the CDA building standards for fire prevention and life safety 2010. The audit, conducted against a checklist of 31 items, identified majority of items as available, satisfactory or in place, however, also specified some improvements/corrective actions relating to arrangement of exits, emergency lights/signs, hose reels, fire extinguishers, smoke venting, fire lift, independent power source for emergency equipment, fire drills. SIH responded to all specified actions and submitted to CDA a report detailing corrective measured undertaken. The company will engage a suitably qualified and experienced professional to review the design and installation of L&FS systems of the SIH existing facilities and provide professional certification that the installed L&FS system complies with the requirements of the section 3.3 of the World Bank Group EHS General Guidelines, internationally accepted standards and local authority codes/standards

For the new healthcare facilities at Islamabad, Faisalabad and Tanzania, as s described in ESAP item # 6, the company will engage a suitably qualified and experienced LFS professional who will conduct a review, as part of project completion test, at the time of the L&FS systems testing and commissioning and will certify that the construction of these systems has been carried out in accordance with the accepted design and the L&FS section of the World Bank Group General Guidelines, internationally accepted standards and local authority codes/standards.

Disaster Management:

SIH developed a Disaster Management Program in 2016. The program provides procedures to respond to natural and manmade disasters/emergencies in a manner that protects health and safety of its patients, visitors, and staff. The plan provides structure, with roles and responsibilities, for disaster/emergency response and is overseen by Safety Committee and reviewed annually basis or as needed as result of drills/ real emergencies. For SIH located in Islamabad, the hazard vulnerability analysis identified earthquake as high threat leading to internal/external damages and patient influx. Responding to this risk, an Earthquake Disaster Management sub-Plan has been prepared. As strategic and tactical response to the challenges and situations encounter by the Emergency Department (ED) from events happening either within the hospitals or outside, SIH has also develop Disaster Management by Emergency Department. Annual drills are conducted for disaster management at hospital level, engaging all departments and sections.

Security Management:

To secure the SIH premises and to provide a safe environment to all its users, patients, visitors, employees, students and property and to comply with federal and provincial regulations and the requirements of accrediting agencies the Company has developed a Security Management Program 2017. The Security Management Program includes training and procedures for personal safety/security, handling security incidents, crime prevention, identification of patients, visitors, employee and students, security preparedness and response. Safety & Security Department is responsible for implementation of this program by carrying out risk/vulnerability analysis and developing action plan to control, controlling access at the gates and entrances at the SIH premises. deploying static posts, organizing foot patrols to keep the SIH Premises under surveillance, providing Emergency Response to security situations and taking instant action on security incidents, logging all security incidents, etc. The department also monitors city situation during strikes, riots and other civil disturbances to as proactive approach to response to emergencies and disaster management.

SIH has dedicated room for security management and premises remain under CCTV surveillance 24/7 by security personnel. Safety & Security Department have engaged 47 staff through a third-party security company to manage security at SIH.

 No direct impacts on community or nearby activities is envisaged from the new expansion work at flagship hospital (H-8), which would be carried out within the premises of SIH. For development of new projects, outside the main hospital, land has been already acquired by the Company and stakeholders consultation will be conducted during the environmental and social assessment (ESIA) process at scoping session and during due course of ESIA review and decision making process in compliance with local regulations. 

SIH Annual Report 2018:  https://www.shifa.com.pk/files/pdf/AR_2018.pdf