Established in 1989, Regency Hospitals Limited ("Regency" or the "company") is a healthcare provider in Uttar Pradesh ("UP"), India. Regency currently operates three healthcare units in Kanpur in UP:Regency Multi-Specialty hospital - Established in 1995, this is the flagship unit of the company and currently operates a 175 bed facility. The hospital has a quality management system accredited by National Accreditation Board for Hospitals and Healthcare Providers (NABH) and is the first NABH accredited hospital in UP.Renal Science Center - Established in 2012 (in an owned building), this 75 bed hospital super-specializes in nephrology and urology.City Clinic - This is a satellite outpatient center established in August 2014 (in a leased building) to decongest the multi-specialty hospital. It focuses on premium OPD and preventive health checkups.The company also has a nursing school, Regency School of Nursing, which was established in 2009 to train nurses to meet the captive demand of the company. The school is located in a separate building owned by the company. The current batch size is 40 and total 120 students.The company has identified following five new expansion opportunities, two of which i.e. a secondary care hospital in south Kanpur and a cancer hospital under the HCG Joint Venture (JV) are in advanced construction stages.Secondary-care facility in Govind Nagar, south Kanpur: This will be a secondary care facility with 125 beds. This was a shopping center building, which has been leased by Regency and is being converted (by the owner as per Regency's specifications) into a hospital. The building main structural system will remain as existing. The total built-up area is about 39000 ft2 (~3623 m2) with two basements, ground and six other floors. The floor area would be around 5500 ft2 (~511 m2) each.HCG Regency Oncology Healthcare Private Limited's Oncology Center - This is a JV with HCG, a pan-India chain of super-specialty cancer care hospitals. HCG owns 51% of the JV while Regency owns the remaining 49%. Construction is underway for the first oncology hospital under the JV, a greenfield 100 bed unit (located in an owned building on a plot purchased by the JV) adjacent to the existing Regency multi-specialty hospital. The total built-up area is about 65000 ft2 (6252 m2) with two basements, ground and six other floors. The floor area will not exceed 800 m2.Expansion of existing multi-specialty hospital -The company has plans to expand the existing 175 bed hospital with a new block (in an owned building) having 150 beds on an adjacent piece of land. Land purchase has been completed and construction will begin soon. It is expected to start operations by April 2018.Regency Nephrocare Private Limited - This is a Joint Venture (JV) with Fresenius Medical Care India Private Limited. The JV plans to set up 14 dialysis centers over the next five years. Currently, two dialysis centers at the existing Renal Science Center and City Clinic are part of the JV.Nephrology Shop-in-Shops - Regency plans to enter into agreement with existing hospitals for management of their nephrology departments, where dialysis would be outsourced to Regency and Regency's existing Renal Center will be utilized for transplant cases.IFC proposes to invest Indian Rupees 615 million (approximately US$ 9.45 million equivalent) through equity for the above expansion ("the project"). The remaining funding needs will be provided by other investors and external debt/internal cash generations.
OVERVIEW OF IFC'S SCOPE OF REVIEW
IFC's review of this investment consisted of appraising technical, environmental, health and safety (EHS) and social information submitted by Regency including policies and standard operating procedures under its existing hospital management systems, EHS permitting documents of existing hospitals, and National Accreditation Board for Hospitals and Healthcare Providers (NABH) accreditation documents.The appraisal included site visits to company's operational hospitals (Regency Hospitals, Renal Science Center and City Clinic), Nursing School and under construction hospitals (Oncology Center and Govind Nagar hospital) in Kanpur, in UP, in India in August and September 2015. During the appraisal visit, discussions were held with company's senior management including Vice President - Strategy, HR Manager, General Manager - Operations, Regency Hospital, Quality Management System Coordinator, Project Managers for the under construction hospitals i.e. Govind Nagar and Oncology Center.IFC's review considered Regency's management of EHS risks and impacts in development and operation of its hospitals, environmental and social management plans for the project, and gaps, if any, between these plans and IFC requirements. Measures included in the management plans and, where necessary corrective measures intended to close these gaps within a reasonable period of time, are summarized in the paragraphs that follow and in the agreed Environmental and Social Action Plan (ESAP) disclosed in this review summary. Through implementation of these management plans and the ESAP the Project is expected to be designed and operated in accordance with Performance Standards objectives.
IDENTIFIED APPLICABLE PERFORMANCE STANDARDS**
While all Performance Standards are applicable to this investment, IFC's environmental and social due diligence indicates that the investment will have impacts which must be managed in a manner consistent with the following Performance Standards.PS 1 - Assessment and Management of Environmental and Social Risks and ImpactsPS 2 - Labor and working conditionsPS 3 - Resource Efficiency and Pollution PreventionPS 4 - Community Health, Safety and SecurityIf IFC's investment proceeds, IFC will periodically review the the project's ongoing compliance with the Performance Standards
As mentioned above, the company is operating and establishing the hospitals either in leased buildings or on land/buildings purchased on willing buyer-willing seller transactions. Therefore, no land acquisition is envisaged for the project and no physical or economic displacement has been/expected to be caused by the project consequently, IFC Performance Standard (PS) 5 (Land Acquisition and Involuntary Resettlement) is not applicable.The existing project sites are and proposed ones will be located in urban or sub-urban areas and the type of risks and impacts envisaged in PS6 (Biodiversity Conservation and Sustainable Natural Resource Management), PS7 (Indigenous Peoples) and PS8 (Cultural Heritage) are thus not applicable. Going forward, as part of the management systems and procedures (discussed below under PS1), Regency will screen future projects with respect to IFC PSs requirements.
ENVIRONMENTAL AND SOCIAL CATEGORIZATION AND RATIONALE
This is a Category B project according to IFC's Policy on Environmental and Social Sustainability because a limited number of specific environmental and social impacts may result which can be avoided or mitigated by adhering to generally recognized performance standards, guidelines or design criteria.Key E&S risks and issues related to this Category B Project include: adequate social and environmental assessment of the impacts of the project; the company's capacity and systems to manage social, environmental, health and safety aspects of its existing and proposed operations in compliance with legal requirements as well as IFC Performance Standards (PSs) and World Bank Group (WBG) Environment, Health and Safety (EHS) guidelines; engagement with local communities in accordance with local requirements and IFC PSs; assurance of fair, safe and healthy working conditions during both construction and operation; management of wastes (particularly biomedical and hazardous waste), emissions and effluents; life and fire safety (L&FS) management for all hospital buildings in accordance with WBG EHS guidelines; and resource efficiency (water and energy efficiency).
**Information on IFC's Policy and Performance Standards on Environmental and Social Sustainability can be found at www.ifc.org/sustainability
ENVIRONMENTAL AND SOCIAL MITIGATION MEASURES
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 the implementation of these measures, the project is expected to be designed and operated in accordance with Performance Standards objectives.
PS 1: ASSESSMENT AND MANAGEMENT OF ENVIRONMENTAL AND SOCIAL RISKS AND IMPACTS
E&S Policy: Regency's flagship hospital has formulated Quality Management Policy and instituted quality management system (QMS) that is accredited to India's NABH. QMS covers certain E&S aspects including employee and patient safety; emergency management; human resource (HR) management; security; infection control; engineering and maintenance. Renal Science Center and City Clinic follow a similar quality management processes, however, currently not accredited through NABH.As per the ESAP, in addition to Quality Management Policy, Regency will establish an overarching corporate Environmental, Health and Safety (EHS) Policy defining the E&S objectives and principles for all operations that will guide the company to achieve E&S performance in compliance with the applicable legal requirements and IFC PSs. The EHS Policy will provide a framework for the environmental and social assessment and management process for all existing and future hospitals. The company will extend their QMS to the management of hospitals' impact on the environment, workers and other external stakeholders.Identification of E&S Risks and Impacts: The built-up areas under construction hospitals and other centers are less than the regulatory threshold level of 20,000 m2 beyond which the company is required to undertake a formal Environmental and Social Impact Assessment (ESIA) study and seek prior environmental clearance. The company, however, identifies and manages E&S risks and impacts associated with its operations through compliance with applicable E&S regulatory permits and requirements.As per the ESAP and as discussed below, Regency will develop a corporate procedure on screening of new projects (either greenfield or brownfield acquisitions) to identify any risks with respect to IFC PSs and legal requirements and preparing a management plan for the same.Management programs: To manage and mitigate the E&S risks and impacts of their operating assets consistently with IFC's PS, Regency will develop and implement additional E&S procedures as identified as gaps in the specific sections of ESRS. These will include, but not be limited to the following pollution prevention and health and safety issues: (a) wastewater management including contaminated storm water; (b) solid and hazardous waste management; (c) life and fire safety management; (d) resource efficiency management; and (e) monitoring and management review. As set forth in the ESAP, for the development of the policy, procedures and management programs, Regency will engage a qualified consultant (acceptable to IFC) and agree with IFC on terms of reference (ToR) for the consultant. The policy, procedures and management programs will be developed (as per the ToR) and implemented within agreed timelines for all existing and proposed hospitals.Organizational Capacity: The Deputy Medical Superintendent (DMS) is responsible for implementation of QMS at the hospitals. Quality coordinator (reporting to DMS) manages the QMS processes on a day to day basis in coordination with other departments. Key EHS related departments such as engineering/ maintenance, housekeeping, laundry, security and L&FS are under the responsibilities of GM - Operations, who is responsible for all existing hospitals. The proposed hospitals will each have GM - Operations and Quality Coordinator. The biomedical waste management is the responsibility of the housekeeping department. Operating the L&FS infrastructure and its systems is the responsibility of security department and fire safety officer in each of the hospitals.As set forth in the ESAP, Regency will appoint/assign a person at the corporate level, within agreed timelines, who is dedicated to E&S management of all hospitals/centers in order to ensure continued compliance with national legal requirements and IFC PSs and WBG EHS Guidelines.Emergency Preparedness and Response: Under NABH accredited QMS, Regency has identified different emergency scenarios for which color codes, response team and emergency response plans have been formulated including external disasters (Yellow), Fire (Red), missing person (Pink), bomb threat and physical threat (black) and dangerous individual (Purple).The emergency response preparedness includes periodic trainings, reviews and mock drills. Currently the drills are being conducted for fire. However, drills are not being conducted for all the other identified scenarios and for evacuation on a regular basis. As per the ESAP, regular mock drills (including evacuation drills) shall be conducted for all types of expected emergencies covering all shifts. The drills shall also cover preparedness for total building evacuation and patient triage process especially for non-ambulatory patients. Fire safety systems are discussed in detail under IFC PS 4 below.Monitoring & Reporting: As part of the NABH systems, the Regency hospital is monitoring 56-58 indicators out of the 64 NABH indicators which includes OHS KPIs such as patient falls, needle stick injuries, incidents, near-misses, variation in mock drills and major spills. However, currently the company does not have a procedure of a management review. The same will have to be implemented and integrated with the E&S management review.A team of internal auditors have been identified across various departments who conduct internal audits as per NABH standard checklists, coordinated by the Quality Department in each of the hospitals. After every audit, the audit findings are shared with concerned Heads of Departments (HODs) for closure. Also, safety rounds are conducted on an annual basis. External auditing is limited to NABH surveillance and recertification audits.However, most of the activities are focused on hospital operations and quality in line with NABH requirements. Therefore as per the ESAP, Regency will develop a corporate environmental, health and safety (EHS) monitoring procedure which will specify minimumEHS KPIs/parameters to be monitored, monitoring frequencies for all hospitals, type of monitoring and the definition of thresholds that signal the need for corrective actions. In addition to applicable legal requirements, the monitoring thresholds will include thresholds specified for ambient air quality, stack and effluent quality in the WBG EHS Guidelines (both general as well as sector specific on Health Care facilities). The monitoring procedure will also define and require monitoring of defined KPIs/parameters for under construction and operating hospitals. Regular monitoring will be conducted for the defined parameters at existing and new hospitals as per the procedure and Regency will ensure corrective actions are taken as necessary based on the results. The EHS performance of hospitals (both existing and proposed) will be regularly documented in an integrated format as per the defined management system processes and reviewed by the management.
PS 2: LABOR AND WORKING CONDITIONS
The company has a total workforce of about 960 including corporate office staff and clinical and non-clinical staff at operational hospitals. Regency Hospitals, Renal Science Center and City Clinic have a workforce strength of 777, 104 and 37, respectively. Approximately 30% of the workforce is women employees across various levels. The company keeps most of the workforce on its payrolls and outsourced staff is limited to services such as housekeeping and security.HR Policy and Management: The company has a HR manual that describes company's policies various aspects including recruitment, induction and orientation, training, attendance and leave management, resignation and separation, disciplinary action, grievance redressal and occupational, health and safety (OHS). The policies are communicated as part of the induction to all employees. To align with the HR policies with the PS2 requirements, as set forth in the ESAP, the company will develop additional procedures/policies on managing retrenchment, freedom of association, protecting work force (child labor and forced labor) and procedures for workers engaged by 3rd parties. Also, the policies will be displayed/made available in each of the hospitals for easy access of the employees. The same HR policies will be applicable for the proposed hospitals/dialysis centers as well.Freedom of association and grievance mechanism: Currently there are no staff unions at Regency hospitals. However, the company does not restrict formation of employee unions. As discussed above, the company will document a specific policy on freedom of association.As per the documented grievance redressal policy, employees can raise their grievances to their immediate superior followed by the HR Manager. In case the complaint/grievance is against the immediate supervisor, the grievance is submitted to the HR manager directly. HR manager will forward the grievance to the Grievance Redressal Committee. As per the ESAP, the company will improve the grievance mechanism by addition of provisions on anonymously raising grievances. Also, the communication about the policy will be supplemented with all other new HR policies as discussed above.The company has also formulated and implemented a prevention of sexual harassment policy in line with regulatory requirements. As per the policy, the company has constituted a committee to handle any sexual harassment related complaints. Currently the committee has more male members than females and the company will change the same as part of the ESAP to ensure female majority in the committee.Prevention of child labor and forced and bonded labor: No instances of child, forced and bonded labor were observed. As discussed above, as per the ESAP, Regency will develop and implement a specific policy on prevention of child labor and forced and bonded labor.Occupational Health and Safety (OHS): The OHS management systems followed at Regency's hospitals are in line with NABHrequirements. The key OHS concerns covered include needle stick injuries, infectious diseases, radiation exposure, chemical management and noise exposure. The key safety instructions on these aspects are communicated to the employees during induction. Also, as per company's OHS policy, all employees undergo health checks prior to joining and on an annual basis as well as vaccination. Under the NABH requirements, the hospitals have a safety manual which describes procedures on emergency response and evacuation, laboratory safety, spill management, patient safety, radiology safety, and accident/incident investigation and recording. AERB (Atomic Energy Regulatory Board of India) guidelines are followed with respect to radiation equipment installation, operation, maintenance, and workplace safety across all its hospitals.The hospitals have a safety committee which monitors the implementation of safety procedures. Regular safety rounds are conducted to inspect the implementation on-site. Additionally, periodical NABH surveillance audits and internal audits are undertaken. The data on patient falls, needle stick injuries, incidents, near-misses, variation in mock drills and major spills are recorded. All accidents and incidents are recorded and investigated through a root cause analysis process. As per available data (only for Regency Hospital), there have been two minor fire incidents (however, no injuries or damage took place) and four needle stick injuries in 2015 (till date). The company will roll out same OHS procedures to all hospitals.Third party workers and Construction Safety: The company proposes to develop hospitals under two different models - (a) an asset-light approach where the construction work is in the scope of land owner (e.g. at the under construction Govind Nagar hospital) and Regency has no responsibilities and limited management control; (b) construction in the scope of Regency e.g. under construction Oncology center. During the site visit, it was noted that the construction practices at the Oncology center site had scope for improvement in use of personal protective equipment (PPE) by construction workers especially while undertaking dangerous works like work at height, welding etc. and access to the site by children of construction workers.As per the ESAP, for projects where construction is managed by the company, Regency will develop an OHS manual for construction to ensure contractors' compliance with EHS requirements and legal requirements on working conditions, labor camp facilities, and labor law requirements. The procedures will include monitoring procedure, check-list and other documentation of OHS performance on-site by the company. The manual will be included in the contracts signed with various contractors and Regency will monitor its implementation on-site.Third party workers are employed at the hospitals for housekeeping and security. As per the ESAP, as discussed above, Regency will developand implement procedures on managing the 3rd party workers for meeting the applicable legal requirements as well as PS2 requirements.
PS 3: RESOURCE EFFICIENCY AND POLLUTION PREVENTION
Energy Supply and Air Emissions: Electricity is sourced from the public grid. As standard back-up systems for grid failure, diesel generator (DG) sets and UPS battery back-up systems are installed. At critical medical service centers (e.g. ICU, OT), individual battery back-up systems are installed in addition to the overall back-up systems. The DG sets are provided with acoustic enclosures and stack height as per regulatory requirements.Resource Efficiency: As described above, the existing hospitals were developed in leased buildings (except the Renal Science Center). Resource efficiency measures integrated into the designs of new greenfield hospitals include rain water harvesting, solar water heaters, LED lighting, and installation of building management systems (BMS).Annual resource consumption data for year 2014-15 for operational hospital indicates consumption of 3.57million units of electricity and 83,194 liters of diesel. The estimated consumption of electricity and diesel for the proposed hospitals starting December 2016 will be 2.5 million units and 108,000 liters respectively. Based on the current and future energy consumption, the per bed energy consumption for Regency hospitals is about 12,000 kWh/bed, which is lower than the global benchmark of 30,000 kWh/bed and also is close to the lowest consumption noted in the Energy Efficiency in Hospitals - Best Practice Guide where the energy consumption ranged from 5415 to 25,781 kWh/bed for private multi-specialty hospitals. The guide was prepared in 2011 by USAID and Bureau of Energy Efficiency (BEE), India as part of Energy Conservation and Commercialization (ECO) III Project signed between USAID and Government of India.Greenhouse Gases (GHG) Emission: Based on the data available from Regency hospitals, the estimated GHG emissions from its current operations are 3,600 tons CO2 eq/annum and are expected to increase to 6,200 tons CO2 eq/annum after the proposed hospitals are fully operational.Water and Wastewater: Water for all the hospitals is sourced from the bore wells installed inside the hospital facilities. Reverse Osmosis (RO) plants have been installed to meet drinking water needs, dialysis and other clinical purposes. RO water quality is regularly monitored to confirm that it meets the applicable water quality standards.The Oncology Center has a sewage treatment plant (STP) included in the design. However, the operational hospitals - Regency Hospitals and Renal Sciences Center currently do not have any sewage or effluent treatment plants before effluent is discharged into the public sewer. Also, the design of the Govind Nagar hospital does not include any sewage or effluent treatment. As per the ESAP, the company will install a STP and effluent treatment plant (ETP), as required, at its operational hospitals as well as new hospitals to meet national standards and WBG EHS guidelines. Specific treatment provisions shall be ensured for infectious wastewater, andany wastewater containing any radioactive or genotoxic contaminants. The treated wastewater quality shall be regularly monitored by the company to ensure compliance with the national standards and WBG EHS guidelines for Health Care facilities.Bio-Medical Waste (BMW) Management: Regency has BMW management procedures (as part of the Infection Control Manual) which describes the system of appropriate sorting, labeling, handling, storage and disposal of BMW from its hospital facilities and is consistent with the applicable legal requirements. Every facility has a segregated BMW storage area where waste is stored in color coded bags. BMW generated at medical areas are segregated at source as per the waste management procedures and bagged into color coded bags. Segregated BMW is removed from the medical areas to BMW storage area from where it is collected by an authorized external agency for disposal.The radioactive wastes are managed as per AERB guidelines.
PS 4: COMMUNITY HEALTH, SAFETY AND SECURITY
Traffic management and Parking facilities: All hospitals visited during the appraisal have made provisions for parking and vehicular movement. The security team of the company is responsible to guide incoming and outgoing vehicular traffic and parking at all its hospitals. The under construction hospitals include parking arrangements in the basement.Life and Fire Safety (L&FS) Systems: The existing hospitals have been provided with basic L&FS infrastructure and systems including fire water storage tanks at ground level and overhead tank (OHT) at terrace level; fire water pumping system, sprinkler systems in the basement (at Main hospital and Renal Science Center); smoke detectors; fire exit signages; different types of fire extinguishers; fire hydrants; manual call points; fire hoses/reels at every floor; fire alarm control panel and public address system. All hospitals were noted to have the required fire no-objection certificates from the local authorities. The under construction hospitals (considered existing as major part of construction is completed) are additionally being provided with sprinkler system covering all floors, pumping systems with main pump, jockey pump and diesel pumps and smoke extraction systems.However, based on a preliminary review of the L&FS systems for the existing and under construction hospitals, the systems need to be upgraded to meet the requirements as per applicable national and local L&FS code. As a priority, the company has commissioned a qualified L&FS consultant (acceptable to IFC) to review L&FS infrastructure provided at the existing hospitals with respect to requirements under applicable legal and national code provisions. Based on the consultant's review, the company will prepare and agree with IFC on an enhancement plan of making suitable modifications in the L&FS infrastructure to comply with these requirements in a reasonable time frame.For all future new hospital projects (e.g. the new block at the Main hospital, dialysis centers), at the design stage, the company will commission a L&FS consultant (acceptable to IFC), to review the site specific architectural brief and confirm that all the L&FS-related aspects of design are consistent with an internationally recognized L&FS code (e.g. United States National Fire Protection Association (NFPA)), as required under the L&FS section of the IFC General EHS Guidelines. Following construction, the L&FS consultant will inspect the newly constructed buildings. The company will submit to IFC professional certifications that each hospital is constructed in full compliance with previously approved engineering design, and that all L&FS systems were installed as designed and tested in accordance with international requirements. Any remedial measures needed to bring the building into compliance with IFC guidelines will be completed within a timeframe agreed with IFC.Community Exposure to Disease: Regency has an Infection Control Program and procedures to prevent hospital associated infections for the patients which includes control of nosocomial infections. In addition to the engineering and administrative controls such as proper ventilation systems with independent air handling units (AHUs) for critical care rooms and architectural segregation, the company has documented procedures on various aspects related to infection control including cleaning, disinfection and sterilization, access control, kitchen, sanitation and food management, hand hygiene, etc. Each hospital has an infection control committee to monitor implementation of the program and procedures.Security Personnel: All hospitals are guarded round the clock with unarmed security guards from private security agencies. Security personnel are trained to manage the entry/exit gates, vehicular movement, pedestrian movement, lifts, parking areas, hospital floors, assist in emergency evacuation and overall movement of visitors inside the hospital premises.Food Safety: Food materials are procured from sources that provide assurance that the food is processed under regulated quality and sanitation controls. All food items are protected from contamination and spoilage. Refrigerators are adequately cleaned and maintained at required temperatures. All cooking and food storage areas are regularly cleaned and all equipment and utensils are washed regularly. The company has provided adequate hand washing and hand- facilities throughout the food service areas. Unauthorized personnel are not allowed inside the food service area and only persons employed by food services are allowed behind the serving line or in the areas where food is being prepared.