This is an E&S category B project because, based on information reviewed by IFC, this investment will have limited adverse social and environmental impacts that are few, are generally site specific, largely reversible and readily addressed through mitigation measures, as outlined in the Environmental and Social Action Plan (ESAP) attached to this ESRS.

Specific key environment, social, health and safety issues identified during the appraisal included environmental and social (E&S) management capacity of the sponsors to undertake the project and operations in a manner consistent with IFC Performance Standards; working conditions for employees and contract workers during both construction and operation of the hospital; company’s staffing and systems for E&S management of its operations in compliance with legal requirements as well as IFC PSs; assurance of fair, safe and healthy working conditions during construction and operation including gender-based violence and harassment (GBV&H) policies; management of wastes (esp. biomedical waste), air emissions and effluents as per World Bank Group (WBG) Environment, Health and Safety (EHS) Guidelines; life and fire safety management for proposed hospital in accordance with WBG EHS Guidelines; and security management.

Environmental and Social Assessment and Management Systems: The project is in its initial stages of planning and design and, per local regulations, the development required Environmental Impact Assessments for the hospital expansion and for the WWTP. These studies have been concluded and approved by local environmental authorities. The process included risk evaluation with a proposed Environmental and Social Management Plan (ESMP) describing the key environmental impacts and mitigation measures of the project in construction and operation phases. Some of CSE’s units have ISO 9001 certification and during the next five years CSE is working towards a company-wide ISO 9001 certification and has obtained certification of quality assurance and occupational health and safety (OHS) by AENOR. Additionally, CSE is planning to start the process to obtain the Joint Commission International (JCI) certification for the new hospital after construction is finished.

Environmental and social impacts in the CSE are managed per the current corporate procedures, including EHS Policy (i.e., Politica de Saude, Seguranca e Medio Ambiente – in Portuguese), quality handbook, and several other programs and procedures to address key issues such as patient safety, occupational health and safety, hazardous and healthcare wastes, accident reduction, efficient use of energy and water quality aspects of the operations. The hospital will improve the current operational framework within their social, environmental procedures and management systems to ensure adequate management of its impacts during the operation of the expansion of the hospital. For this, and based on the proposed ESMP of the two ESIA’s completed for the project, CSE will develop and implement an environmental and social management system (ESMS) to incorporate the following: i) E&S Policy statement, ii) E&S risk assessment, iii) EHS management and plans, iv) HR and ethical management, v) external and internal grievance mechanism, vi) OHS leading and lagging indicators (KPIs); vii)internal and external audit of appropriate E&S management programs, including, the improvement of existing management of biomedical waste, energy and water, and viii) stakeholder engagement plan (ESAP 1). The company will request the construction license once the project has detailed engineering plans and financing is complete.  

The Company has commissioned the design of the hospital to a recognized local architecture and engineering company specialized in the design of health care facilities with experience working with international architecture firm based in Portugal. The planned design aims to achieve international standards for patient safety, life and fire safety and environmental protection. The new hospital is being designed to be in compliance with the local standards, and to adhere to Energy and Environmental Design programs and European codes, among other applicable standards.

Organizational Capacity and Competency: CSE has appointed an Engineering Procurement and Construction (EPC) contractor and construction manager who is responsible for the coordination of the development of the new portion of the hospital and the rest of facilities. The EPC contractor has an extensive footprint in Angola, operating with certifications in the areas of Safety, Quality, Environment, Social Responsibility and Research, Development, and Innovation (ISO 45001, ISO 9001, ISO 14001, SA 8000 and NP 4457 respectively). Also, specialized firms for structural safety, life and fire safety, ventilation, sanitary systems, other are providing technical input in the planned design of the hospital. As part of the supervision and construction management, during construction, the Company is assigning, a responsible supervisor to verify that environmental and OHS measures are addressed as described in the Environmental Management Plan (ESMP) and to ensure compliance with contract requirements.

For the operations of the hospital, the current structure will be retained and reinforced to manage for E&S aspects, with an environmental coordinator, human resources manager, EHS/OHS manager, security coordinator, and operations manager who interact with other divisions to manage E&S issues in an integrated way.

Emergency Preparedness and Response: CSE has in place emergency response plans including basic mechanisms to inform affected communities. The emergency plan includes a safety training program for all employees and for the internal emergency brigade. The hospital has a private fire brigade that is permanently on site (24/7), with a team of six professional firefighters that are trained and prepared to control fires and to assist with the evacuation of patients, visitors and hospital personnel during emergencies. The company will modify the current emergency preparation and response plan (EPRP) to adapt it to the conditions of the new development, with the identification of potential new hazards (e.g., high rise hospital tower, heliport, parking garage, WWTP, other), with the respective new mitigation measures and response to emergencies. Particularly, the new EPRP will address the communication with the nearby communities (ESAP 2), aligned with the stakeholder engagement plan (SEP, per ESAP 6) that will be developed by CSE.

Monitoring and Review: The Company will implement the monitoring measures defined in the Environmental Management Plan presented in the project ESIA’s. Before construction starts, the Company is preparing a detailed E&S implementation and monitoring plan during construction. The supervision company (Portuguese) will report on the results of the plan directly to CSE. The Hospital will ensure monitoring plans and targets are aligned with the applicable sections of the WBG EHS Guidelines for Health Care Facilities and the EHS General Guidelines.

During operations, CSE will continue monitoring the E&S aspects of their operations with periodic internal audits, water and energy use, waste generation, OHS, and liquid effluents, among other indicators; including the ESMP action items, as they are implemented.               

Human Resources Policies, Procedures and Terms of Employment:

CSE currently employs over 1,900 people, 56% are female workers (25% in supervisory category positions). Additional 15 workers are third party employees working at the premises (e.g., security service). The project is expected to create jobs during construction and approximately 250 new direct jobs during the operation of the new hospital expansion.

CSE has corporate procedures regarding human resources management. These procedures include a basic HR policy and the code of ethics. In addition, labor contracts define the working conditions and elements such as rights of the employees, working hours, compensation scheme, and minimum age of employment among others are described in the procedures. All employees receive copy of the employment contract and additional details are provided in the induction training that is mandatory to all employees.

The company’s HR department is in a process of reorganization and modernization, and the policies are not yet defined in the form of an internal regulation. Based on this, the company will update their Human Resources Policy and Code of Ethics to be aligned with Angolan laws and the requirements of IFC’s Performance Standard 2 regarding labor and working conditions (ESAP 3), particularly on aspects of freedom of association and collective bargaining, non-discrimination and equal opportunity, prohibition of child and forced labour, and grievance mechanisms. 

Non-Discrimination and Equal Opportunity: The company’s HR policy and Code of Ethics don’t have explicit reference to principles of non-discrimination based on sex, race, nationality, political affiliation, etc. This item will be developed under ESAP 3 (re. HR Policy) explained above.

Workers Organizations:  part of the workforce of CSE does belong to workers organizations or unions. Additionally, the management team of hospital confirmed that they would not prevent employees to organize or participate in any workers’ organizations or union; this statement will be also part of the renewed HR Policy.

Grievance Mechanism: The company uses HR as vehicle for grievances. Direct access to supervisors and directors is available to all employees and/or through a suggestion box administered by HR (Direcção de Gestão de Competências). The initial review of the grievance is performed by the HR, Chief of Service, utilizing the services of CSE’s legal group (i.e. attorneys).  No other formal mechanisms have been established. The company promotes an open-door policy, through which employees can bring all kinds of concerns and the company has a procedure to respond and assigned responsibilities. Going forward, as part of ESAP 1 (re. ESMS), CSE will develop a set of Grievance Mechanism (GM) procedures aligned with PS2, for general grievances and complaints related to GBV&H. The client will then inform the workers of the grievance mechanism at the time of recruitment and make it easily accessible to them and will ensure that there is an appropriate level of management, and the concerns are responded promptly, utilizing an   understandable and transparent process, providing timely feedback to those concerned, without any retribution. The mechanism will allow for anonymous complaints to be raised and addressed and not impede access to other judicial or administrative remedies that might be available under the law or through existing arbitration procedures.

Protecting the Workforce and Workers Engaged by Third Parties: Policies regarding age of employment and compensation are based upon national law. All employees should be at least 18 years to be employed; salaries paid are above minimal salary. No child labor or forced labor is used by the Hospital; these practices are not suspected in their supply chain. The company contracts with reputable companies the outsourced services to ensure compliance with Angolan laws and regulations. The Hospital has mechanisms, via the construction supervising company, to ensure that contractors performing construction activities for the project are in compliance with local legislation and IFC requirements regarding Performance Standard 2, in particular regarding working conditions and terms of employment and compliance with Occupational Health and Safety obligations according to local law and PS2.

Occupational Health and Safety: CSE has in place a detailed and comprehensive Occupational Health and Safety (OHS) program consistent with the requirements of the Angolan legislation and best practices for health care facilities. The OHS program is aligned with quality programs and patient safety requirements, the program covers among others biological hazard safety (e.g., nosocomial infections, needle stick injuries), detailed program for prevention of accidents, handling hazardous drugs and materials, radiation protection, ergonomic practices, preventive medicine, workplace monitoring and medical examination of employees, all within a continuous improvement program.  The new portion of the hospital, as part of the E&S Management System, is expected to follow the current OHS management system to manage all the expected occupational risks and will set and implement, within the current OHS program, a set of leading and lagging indicators (KPIs) for the hospital.

A joint workers-employer health and safety committee (i.e., Gabinete de Saude Ocupacional) is in place and operational. The committee meets periodically, and part of its tasks is to identify potential risks, address workers concerns regarding OHS and ensure proper implementation of the OHS program. The Hospital has a comprehensive training program, and all incidents are investigated with the implementation and follow up of corrective actions.

Existing radiology facilities have the approval of the local authorities and a full monitoring program for ionizing radiation is in place, and during the design, installation, acceptance testing, and operations of all the radiology facilities in the future facilities, the company will ensure the guidance and verification of qualified experts and the clearance of the local authorities.  The protective measures installed were designed on keeping occupational doses and public doses “As Low As Reasonably Achievable” (ALARA) which aims at radiation safety and avoidance of all unnecessary exposure. 

Resource Efficiency: CSE has implemented internal programs for management of water and energy and will continue with such programs in the future for the complete campus. CSE monitors and controls the current use of water and electricity. The project water and electricity usage has been estimated as 1.2 m3/bed/day and 25,000 kWh/bed/year respectively; these indexes are well below industry benchmarks (e.g., USAID Eco III-project report: Energy Efficiency in Hospitals Best Practice Guide). The new hospital tower will integrate energy and greater efficiency in the design and selection of equipment. The design is in early stages but selection of HVAC (Heating, Ventilation, and Air Conditioning) system; lighting and sanitary facilities will consider energy and water efficient criteria; also, all patient rooms will have natural light and there will be natural ventilation used in most areas of the building. 

Domestic water will be sourced from the municipality, treated, and monitored by the hospital for quality of all parameters.

Liquid effluent management: liquid effluents are mostly of sanitary type; there is an onsite segregation process for potentially contaminated materials which are disposed of via hazardous waste.   Effluents at the hospital are presently discharged to the municipal sewage in compliance with local regulation, periodic effluent monitoring is performed, and the results show compliance with local requirements. The hospital residual wastewater, including domestic wastewater, will be treated by the hospital in the future WWTP. The plant will manage the residual water generated in the activities of the hospital and support buildings (parking garage, services, and technical area buildings). Also, the unit will treat the domestic wastewater from residential buildings in the vicinity of the hospital complex, that are not treating water at this time, and presently goes directly into the sewage system and to the sea.

The company developed a detail ESIA for the WWTP, as part of the overall Hospital project, which covers the construction and operations phase. The WWTP was designed with two independent treatment systems, one for the hospital water and one for the domestic water.

The implementation of the WWTP will allow for the treatment of effluents generated by the operation of the infrastructure of CSE Expansion Project, which will have prior treatment before discharge into the Luanda Bay. The mitigation of public health risks associated with water quality of the Luanda Bay certainly will be one of the most relevant positive environmental impacts of the Project.

At appraisal, design parameters are based on European regulation, and showed compliance with local law and most parameters of the applicable WBG EHS Guideline limits, however, some of the design parameters specified in the ESIA differ from those limits on the WBG EHS Guidelines for Healthcare facilities. For this, as per ESAP 4, CSE will modify its current project of the WWTP and will provide modification to achieve compliance with the applicable WBG EHS Guideline limits for all required parameters, considering the final discharge point into the sea. Also, as part of the ESMS procedures, the Company will establish the protocols to monitor effluents and verify the chain of custody documentation for the waste derived from effluents treatment (sludge, other) which, per the ESIA, will be disposed by local licensed contractors and added to the ESMP during operations.

Greenhouse Gas Emissions: Greenhouse gas (GHG) emissions resulting from operation of the future Hospital tower will be estimated based upon actual resource consumption. The new building will have similar space dedicated to clinical offerings, the GHG emissions during the operational stage have been estimated as 1,825 tons CO2 equivalent per year for the complete hospital. Actual records will be used to review amounts of tons CO2 equivalent per year that will be emitted from the complete hospital once the new phase is operational.

Wastes: Functional procedures to manage wastes are implemented in the existing hospital. Wastes are segregated at the point of generation by risk, including segregation of organic, recyclable, biological, infectious, and hazardous health care waste. Procedures for handling materials are defined in the hospital solid waste management program and are mostly aligned with WBG EHS Guidelines.

Wastes are stored temporarily for periodical pickup by specialized and licensed service companies or processed via autoclave by CSE. During the COVID19 pandemic situation, the company was disposing the wastes from COVID19 areas with the use of incinerators (approximately 15 kg/day). Presently, the company stopped the use of incinerators and are utilizing autoclave to treat this type of waste and will remove the incinerators as part of the construction project.  For other medical waste and hazardous materials, CSE uses contractors licensed by the relevant local authorities to handle the wastes and obtains chain of custody documentation to the final disposal.

Hazardous Materials: Hazardous chemicals in the hospital are limited to small volumes of laboratory reagents, chemicals, solvents, drugs, medicinal gases, and anaesthetics. Hazardous chemicals are handled in accordance with acceptable practices; only trained personal handles the materials, precautions are taken when using and handling the materials, required protection equipment, such as ventilation hoods and personal protective equipment is provided. The respective Hazmat Material Safety Sheets are available on site. Radioactive material used in the radiology labs are controlled through internal procedures and only approved personnel access and manipulate the materials. Similar practices for management of hazardous materials will be implemented in the proposed project with detailed recording of quantities and final disposal (location, methodology) by final certified companies.                                                        

As explained under PS1, CSE will be establishing procedures and practices to prevent the spread of infectious disease to patients and the community at large. Comprehensive administrative and engineering controls will also be put in place to manage the risk of community exposure to communicable diseases in accordance with relevant norms, regulations and GIIP.

The hospital has established COVID 19 management protocols for the facility which include but not be restricted to vaccination of staff, disinfection protocols, screening, testing and segregation of infected patients.

Infrastructure and Equipment Design and Safety: CSE will comply with Angolan structural/seismic and fire protection codes for the design of the new portion of the hospital and improve existing fire safety conditions in the hospital. The existing hospital facilities are low rise buildings with low fire risk. The requirements of life and fire safety will be aligned with local legislation and the requirements of an international standard or code of reference (the company is aligned with the Portuguese codes and the use of European Standards). In order to confirm compliance with IFC requirements, CSE will engage the professional services of a qualified Life and Fire Safety Engineer acceptable to IFC to prepare a Master Plan (engineering design) and verify existing conditions of the hospital that will remain integrated with the new portion of the hospital after the construction project is finished;  particularly, the L&FS master plan will propose the use of fire sprinkler system for the new hospital tower and healthcare areas, and will integrate the other L&FS systems and architectural features (means of egress, compartmentation, fire alarm, fire  separations, other) already proposed in the project’s preliminary technical documentation in  the subject. Later, upon physical completion of the building, the L&FS engineer shall verify that the systems were installed as designed and in line with good installation practices (ESAP 5). 

The new hospital will be designed to provide universal accessibility measures and to facilitate the mobilization of patients, including, areas of refuge, ramps, and elevators for access.

The radiology area will be planned considering the requirements of the local authorities and good international industry practices (GIIP). The company will engage a professional to verify compliance with radiation protection measures and obtain certification of these areas.

Community Exposure to Disease: CSE has a basic program relating to patience safety, which includes control of nosocomial infections. CSE has in place comprehensive engineering and administrative controls such as proper ventilation systems, architectural segregation, decontamination practices, and controls on water, food, and waste, among other preventive and corrective measures. The future portion of the hospital will be designed and operated under updated criteria to manage and control infections.

Potable water for the existing operation is provided by the municipality and the hospital has water treatment plants for the various water qualities and uses. CSE monitors periodically the potable water to confirm physical and microbiological parameters. CSE performs periodic maintenance to the storage tanks.   

Security Personnel: CSE employs unarmed security guards managed via a third party, for access control and emergency response purposes at the hospital. The security service is trained following the local regulations and Code of Conduct on how to engage with company’s personnel and the public and on special role and functions during emergency situations.