The Bahamas COVID-19 Response

MIGA has been requested to provide guarantees covering non-shareholder loans by Banco Santander S.A. (Santander) and additional lenders to be identified to fund part of the financing needs of the Government of Bahamas (GoB) COVID-19 emergency response. The occurrence of the COVID-19 pandemic that started in March 2020, came as The Bahamas was rebuilding from the devastation caused by Hurricane Dorian in September 2019. The MIGA-guaranteed loans will be used to support the Public Hospitals Authority (PHA) in upgrading its public hospitals to (i) expand service capacity; and (ii) enhance diagnostic and modalities of care provided by the Princess Margaret Hospital (PMH) and Sandilands Rehabilitation Center (SRC) both located in New Providence collectively referred to as the Project. Further information on the proposed MIGA guarantee is available in the Summary of Proposed Guarantee.

The Project consists of the following:

• At PMH:

1. Urgent renovation of a defined space within the PMH footprint to create an infectious disease unit to mitigate the spread of COVID-19 in a purpose-built environment that is designed for the initial triaging, assessment and longer term treatment of patients presenting with infectious disease in line with GoB, World Health Organization (WHO) and Pan American Health Organization (PAHO) guidance;
2. urgent renovation of priority wards and patient care environments (eye ward, female medical II, former physiotherapy unit/ former female surgical II, children’s ward and decommissioned intensive care unit) to address bed shortages while ensuring compliance with COVID-19 space requirements;
3. complete reforming access to urgent care and emergency care services by upgrading PMH’s outmoded Emergency department by expanding the area by 30% within PMH’s existing footprint;
4. Construction of a new maternal and child health four-story steel tower (approximately 8945 square meters (m2)) in the warehouse area of PMH that will be relocated onto existing vacant property on the PMH campus, to allow for this construction to accommodate inpatient care for maternal and child health, medical and surgical services along with a designated level for ancillary services with limited disruption to service delivery.
5. acquisition of new radiology equipment critical for identifying the presence and cause of disease and determining appropriate course of treatment; and
6. design and installation of negative pressure air conditioning systems.

• At SRC:

1. Urgent renovation of priority wards and patient care environments (psychiatric acute admission ward, geriatric ward, Tim McCartney building). The renovation and re-commissioning of the closed Pearce ward will reinstate in-patient bed allowing for the establishment of a dedicated space for the treatment and management of COVID-19 cases with appropriate space for donning and doffing of Personal Protective Equipment (PPE). The Tim McCartney Building is the hub of the country’s mental health and psycho-social response for COVID-19 and Hurricane Dorian. Persons expressing a need for these services seek assistance from the mental health professionals that operate from this location; and
2. design and installation of negative pressure air conditioning systems.

The proposed works include planned new construction, expansion and renovation of existing facilities. Renovation of the new infectious disease unit, reforming access to urgent care and emergency care services at PMH and renovations of priority wards at both PMH and SRC are expected to be completed within 12 months and will include millwork, central gases, windows, doors, flooring, lighting, plumbing among others. Construction of the new maternal and child health four-story steel tower at PMH will take approximately 24 months utilizing a modular design.

The Project will be developed and implemented by the PHA which was established in 1999 by an Act of Parliament. The PHA is an independent public entity guided by strategic directions and goals defined by the Ministry of Health (MoH), working in conjunction with the MoH and its agencies - the Public Health Department and the Department of Environmental Health Services, to achieve targets for the public sector health services system, as identified in the National Health Services Strategic Plan (2010 – 2020). The PHA is comprised of Corporate Offices, Agencies (National Emergency Medical Services, and Supply Management Agency) and public hospitals (PMH, SRC and Rand Memorial Hospital) and ten community clinics on Grand Bahama. The PHA is a quasi-government entity, governed by a Board of Directors, which is headed by a Chairman who is appointed by and directly accountable to the MoH. The PHA’s Board and corporate office responsibilities in the health care sector include strategic planning, policy formulation, monitoring, evaluation, central level fiscal and human resources management and project/program development and oversight for the management and development of the public hospitals and agencies.

As mentioned above, the use of proceeds from the MIGA facility will be used to improve healthcare modalities in two public hospitals of The Bahamas, PMH and SRC (the Rand Memorial Hospital is out of scope of this Project), established as follows:

• PMH is a comprehensive healthcare system as well as an academic/ teaching hospital providing primary, secondary and tertiary health services with neonatal intensive care capacity and level one trauma center. The hospital is a 420-bed facility divided into four major blocks (wings): medical, surgical, ambulatory care and administration, sub-divided into wards, units and departments.
• SRC is the Bahamas’ national resource for Psychiatric, Geriatric and Substance Abuse Services and consists primarily of two Hospitals: (i) Geriatric Hospital which cares for the elderly with medical, social and psychiatric problems consisting of 5 in-patient wards; and the (ii) Sandilands Hospital that cares for the mentally and physically challenged children, adolescent and adult clients consisting of 10 in-patient psychiatric wards with 505 bed capacity.

The Inter-American Development Bank (IDB) is also supporting The Bahamas COVID-19 response. MIGA and IDB are closely collaborating to ensure that where possible, synergies are promoted and complemented.

The GoB is working in close collaboration with PAHO[1]

The agreement between SMA and its suppliers is governed by General Terms and Conditions and Special Terms and Conditions of Contract

The Project is a Category B under MIGA’s Policy on Environmental and Social Sustainability (2013) because the potential E&S risks and/or impacts are limited, site-specific and readily addressed through mitigation measures. Key E&S issues during the construction include physical hazards related to the use of machinery and vehicles, management of hazardous substances, increase of dust emissions from excavation and noise emissions from vehicular traffic and machinery operation. During operations the main E&S risks include: occupational health and safety (OHS) risks resulting from the potential exposure and spread of infectious diseases including COVID-19, induced by handling of materials and improper waste contaminated with pathogens; exposure to hazardous materials and healthcare waste; and community health and safety issues due to the improper handling, transportation and disposal of healthcare wastes.

[1] PAHO acts as the specialized health agency of the Inter-American System and also serves as Regional Office for the Americas of the WHO, in support of COVID-19 relief.

While all Performance Standards (PSs) are applicable to this Project, based on our current information, the Project will have impacts which must be managed in a manner consistent with the following Performance Standards:

• PS1:  Assessment and Management of Environmental and Social Risks and Impacts
• PS2:  Labor and Working Conditions
• PS3:  Resource Efficiency and Pollution Prevention
• PS4:  Community Health, Safety and Security

The Project will be implemented within existing facilities owned by PHA therefore PS5 (Land acquisition and Involuntary Resettlement) does not apply. The hospitals are located in modified urban environments therefore PS6 (Biodiversity Conservation and Sustainable Management of Living Natural Resources) does not apply. The ethnic mix/ cultural groups in The Bahamas do not meet the PS7 definition of Indigenous Peoples. Therefore, PS7 (Indigenous Peoples) does not apply to the Project. PS8 (Cultural Heritage) also does not apply since the Project will be developed within existing facilities.

In addition, the following World Bank Group (WBG) Environmental, Health, and Safety (EHS) Guidelines are applicable to the Project:

• World Bank Group General EHS Guidelines (2007)
• World Bank Group EHS Guidelines for Health Care Facilities (2007)

Resource materials/ templates are also available on the World Bank Operations Policy and Country Services website in relation to COVID-19 World Bank operations, these include Stakeholder Engagement plan template, environmental and social management framework, labor management procedures among others.

The following documents were reviewed by MIGA:

• MIGA E&S Due Diligence Questionnaire, October 2020
• PHA, Contract Document template for contractors, July 2020
• Pan American Health Organization (PAHO) Working together toward Health for All – The Bahamas and Turks and Caicos Islands Annual Report, 2019
• PHA Functional Chart, October 2018,
• PHA Strategic Goals for the Period 2018 - 2020
• PHA Supplies Management Agency, Suppliers’ Standard Operating Procedures Manual 2017 – 2018
• PHA Human Resources, Training and Development Policies, November 2015
• The Commonwealth of the Bahamas, The National Health Services Strategic Plan 2010 – 2020
• PHA’s Quality Management System - Policies and Procedures

Due to COVID-19 travel restrictions, MIGA was not able to undertake a due diligence site visit. In addition to reviewing the above documents, MIGA carried out virtual E&S due diligence in November 2020, which included meetings with IDB, key PHA staff and management and public hospital’s staff and management.

MIGA’s due diligence review considered the E&S management planning process and documentation for the Project and identified gaps (if any) between these and MIGA’s requirements. Where necessary, corrective measures, intended to close these gaps within a reasonable time period, are summarized in the paragraphs that follow and in the E&S Action Plan (ESAP) attached to this ESRS. Through the implementation of these measures, the Project is expected to be designed and operated in accordance with the Performance Standards. Key E&S issues associated with the Project business activities are summarized in the paragraphs that follow.

PS1:  Assessment and Management of Environmental and Social Risks and Impacts

Environmental and Social Assessment and Management System: Within PHA, E&S management primarily falls under the responsibility of the Risk Patient and Quality Safety (RQPS) department with some cross functionalities with the Capital Services Development (CSD) department. The RQPS department’s primary functions include risk assessments, investigation, tracking and analyzing of data, infection prevention and control, safety management, quality management and clinical audit. All employee work related, and industrial claims are also processed through this department and appropriate measures to minimize and / or reduce accidents at work are prioritized. Construction related E&S risks and impacts are managed by the CSD Department, responsible for providing guidance, technical support, design, development and construction to all major capital infrastructure projects, including healthcare planning, architectural, engineering and construction. Additionally, the CSD department has a Corporate Building & Maintenance team that provides construction and maintenance services throughout the PHA.

Policy: The PHA is governed by a Quality Service Policy that strives towards the provision of ethical and excellence in health care service quality by a team of health care professionals. The Quality Service Policy is publicly available on PHA’s website, and is reinforced by the mission, vision and values of each public hospital. In addition, the Environmental Services department responsible for providing a clean, sanitary and safe environment at each public hospital has in place a mission and vision statement that supplements the Quality Service Policy.

Identification of Risks and Impacts: The PHA identifies and manages E&S risks and impacts associated with its activities through compliance with applicable national standards and E&S regulatory permits and requirements. Each public hospital is required to have the following E&S permits:

• Ministry of Works Building Permit – this encompasses the following approvals:

• Electrical;
• Mechanical;
• Structural;
• Geotechnical report;
• Zoning approval;

• Environmental health permit; and Demolition permit. 

All construction within The Bahamas is required to adhere to the Ministry of Public Works’ most recent edition of the Bahamas Building Code (2003).

In December 2019, The Bahamas Parliament passed a package of environmental bills geared towards developing, reinforcing and strengthening the laws which promote and support the management, protection, enhancement and proper use of the Bahamian environment, one of the most notable being the Environmental Planning and Protection Act (EPPA) 2019 (40/2019), which came into operation on 20 January 2020. The EPPA established the Department of Environmental Planning and Protection (DEPP) which replaced the Bahamas Environment, Science and Technology Commission (BEST) under the Ministry of the Environment and Housing (MoEH). The EPPA requires that no work on any project be commenced unless a certificate of environmental clearance has been issued in line with the Environmental Impact Assessment Regulations (EIARs). PHA submitted an application to DEPP that will determine if the proposed Project activities require an Environmental Impact Assessment and a Certificate of Environmental Clearance. PHA will submit to MIGA DEPP’s determination and comply with DEPP’s requirements and if require, a copy of the EIA and the Certificate of Environmental Clearance (ESAP #1).

Management Programs: CSD department will engage an external construction company with a dedicated project manager to oversee the proposed new construction, expansion and renovation of existing facilities (“construction works”). The PHA is responsible for ensuring that an environmental, occupational and community health & safety risk analyses for the construction activities is conducted, taking into account COVID-19 considerations, such as putting in place mitigation measures to avoid or minimize the chance of infection, and planning what to do if construction workers become infected) and will develop and implement a construction environmental and social management plan (CESMP) to address the issues raised in the risk analyses, and recommendations from the EIA, if required (ESAP #2).

The RQPS department is responsible for PHA’s Quality Management System (QMS) which is governed by a Document and Control Policy that provides a framework for the development, approval, dissemination and management of controlled documents including policies, procedures, plans, protocols, guidelines, among others, applicable to all corporate offices, agencies and public hospitals. Documents are standardized across the entire PHA to ensure clarity of information, consistency in operations and effective team functioning. The RQPS department at the PHA liaises with the Quality Manager from the RQPS department/ unit at each public hospital to oversee the development and implementation of its policies and procedures. Each department within the public hospital is responsible for developing and implementing its own departmental Policy and Procedures Manual in line with the QMS for managing the delivery and quality of healthcare services and staff and patient safety. E&S related policies, plans and procedures are developed and implemented per department in line with the QMS. Per ESAP # 3, PHA will develop and implement an Environmental and Social Management System (ESMS) integrated and centralized in one comprehensive system that builds and expands on its existing systems to include management of the public hospitals’ impact on the environment, staff and other stakeholders.  

Organizational Capacity and Competency: The day to day E&S aspects of PHA and of the public hospitals at the corporate level is overseen by the RQPS department, in liaison with the RQPS department at each public hospital. This includes aspects such as patient and workers safety, waste management, and hazardous materials management and grievances, whereas the E&S management of construction related activities fall under the CSD department. At the public hospitals level, the responsibilities for E&S performance is shared across the following departments: (i) RPQS department that includes the following units: safety management, risk management, quality management, clinical audit management, and infection prevention control unit;  (ii) environmental services department and (iii) institutional facilities management department. The institutional facilities management department is responsible for resource efficiency including monitoring of water consumption and energy efficiency at each public hospital and reports to CSD at the corporate level.  At the corporate level, the RQPS department has a staff of 20 people which among others includes Certified Professionals in Health Care Risk Management (CPHRM) and one Certified Professional in Healthcare Quality (CPHQ), the CSD department has a staff of 7 people.  

During construction, the CSD department delegates responsibility for day-to-day E&S management and compliance to the architect overseeing the civil works contractor, along with an onsite contractor Safety Officer that works in tandem with the safety management unit of the RPQS department at the - public hospital level. As per ESAP #4, PHA will designate a senior official from the RQPS department at corporate level, with the overall responsibility for ensuring and reporting on compliance with MIGA’s PSs, ESMS development and implementation, and implementation of the agreed ESAP.

Emergency Preparedness and Response: PHA has in place a Disaster Preparedness Corporate Plan (2017) for coordinating disaster mitigation within PHA’s managed facilities (including the public hospitals) in relation to: (i) natural disasters (hurricanes, extreme weather, floods and resulting threats); and (ii) manmade disasters (explosions, chemicals and bio-leaks). The Disaster Preparedness Corporate Plan also includes the public hospitals’ Life Safety and Disaster Preparedness plan and evacuation plan which all staff is made aware of. The CSD department and Building and Engineering Units (BEU) conduct an initial vulnerability and risk assessment (VRA) of all PHA corporate offices, agencies and public hospitals with regards to disaster threats and maintain a record of their findings. Data compiled during this initial assessment is disseminated to management teams in each facility and is used to assist in the development of capital improvement programs to bring all facilities up to an acceptable standard.

In February of each year, the CSD department and BEU with the management teams of each facility also undertake a review of the VRA, identifying critical issues to be addressed before the onset of the hurricane season. When there is likelihood that corrective measures cannot be taken in time, a short-term contingency plan is developed. Such a plan may include measures ranging from the closure and evacuation of buildings in the threatened period, or measures to mitigate or minimize against such incidents as flooding etc., where buildings must remain occupied. The pre-hurricane assessment includes mechanical and electrical analysis, architectural and non-structural analysis, structural analysis and environmental analysis.

The Life Safety Management Plan (2012) at each public hospital outlines: (i) compliance with applicable National Fire Protection Association (NFPA) standards for hospitals and the Bahamas Building code; (ii) education and training to personnel on the elements of the Life Safety Management Program including organizational protocols for response to, and evacuation in the event of a fire or smoke; (iii) testing and maintenance of the fire alarm, detection suppression systems; and (iv) interim life safety measures during construction or fire alarm or detection or suppression systems failures. The safety officer and facilities manager of each public hospital is jointly responsible for the Life Safety Management Plan.

COVID-19 designated hospital areas may have a slightly higher risk of fire because of increased oxygen levels from ventilators (the oxygen ventilator, tubing, and connections to the ventilator have the potential to leak oxygen into the room resulting in oxygen enriched air) which can result in fire starting more quickly, spreading faster and burning hotter than in rooms filled with fresh air. A fire and explosion risk assessment will be undertaken at the public hospitals to inform the review and update the Life Safety Management Plan of the public hospitals (ESAP #5).

In response to COVID-19 the GoB implemented an Emergency Operations Committee (EOC) in March 2020 led by MoH Chief Medical Officer, looking at all aspects of COVID-19 response in line with the Centers for Disease Control and Prevention (CDC), PAHO/WHO guidance to ensure the safety of the Bahamas population. The EOC worked with the hospitals on preparing and implementing guidelines on how to handle the COVID-19 pandemic, ranging from infectious control and prevention, acute care, laboratory management, inventory and procurement of PPE among others. Hospitals have also put in place measures to protect patients and limit the spread of COVID-19, such as implementing virtual tele-health appointments, limiting the number of visitors, wearing masks, hand sanitizing, respecting 2 meters distances. Hospital staff also go through a daily screening process of temperature control and checks. There has also been significant training of all staff and allied health care professionals which started at the onset of COVID-19 in March 2020, currently ongoing.

Monitoring and Review: The RQPS department conducts annual compliance assessments of the public hospitals, to among others, determine how well the public hospitals are performing in delivering healthcare to patients and assess factors and/ or barriers affecting the quality of patient services and provide recommendations for improvements and sustainability. Prior to the assessment exercise, meetings are held with the Executive Management Committee of each public hospital. Stakeholder consultation is ongoing throughout the assessment and managers observe staff performing various processes. As part of the exercise, the assessment also looks at E&S aspects such as adequate and up to date policies and procedures, life and fire safety, housekeeping, adequate communication to patients and other stakeholders among others. The CSD department monitors construction activities at least once a week through walkabouts and site inspections looking at HSE aspects among others.

PHA is in the process of putting in place a monitoring and reporting system which will be shared with MIGA as per ESAP #6 on waste, fuel, energy and water consumption. At the moment monitoring and reporting is carried out on an ad hoc basis. PHA will also be required to submit annual E&S monitoring reports to MIGA.

Stakeholder Engagement, External Communication, and Ongoing Reporting to Affected Communities: The PHA has a Communication and Public Relations Department comprised of four communication units, with one at each of the public hospitals and the fourth unit located at the corporate office. All units report to the Director of Communications at the PHA. The Communications and Public Relations department is responsible for internal and external communications, crisis communications, liaising with local and international organizations and collaborating with the MoH on national events.

Communication related to COVID-19 is in line with WHO/PAHO guidance and in close collaboration with the MoH. COVID-19 messaging is national in scope and adopted in its content, linguistic and communication mediums to effectively reach all segments of society. The Communication and Public Relations Department communicates with the general public via press statements/ releases, public notices (print and electronic), social media and internal publications (posters, newsletters), health information, education audio/ video programming. In the aftermath of hurricane Dorian, public notices also started to be translated into Creole and Spanish in order to reach all members of the population, in addition WhatsApp has also been deemed an effective tool of communication.

COVID-19 related information is geared towards building capacity and awareness of both internal and external stakeholders to play active and informed roles in preventing the spread of the virus while also understanding how to respond in cases of infection, and where to attain testing and medical attention. The communication and public relations department maintains a COVID-19 messaging tracking chart that lists all the different topics and modes of communication carried out to date regarding COVID-19.

Building on PHA’s existing communication strategy, a Stakeholder Engagement Plan (SEP) will be formalized (ESAP #7) to guide communication, coordination and social strategy. The SEP will define the needs, methods, tools, and techniques for stakeholder engagement with (i) directly affected parties; (ii) interested parties and institutional partners; and (iii) disadvantaged and vulnerable individuals and groups. The SEP will also address tailoring of messages in regards to social and physiological impacts related to social isolation, including those related to domestic and gender based violence through coordination with other institutions working in this area. The SEP will outline the resources, responsible parties, and plans for monitoring and reporting on its implementation.

Grievance Mechanisms: The PHA has developed and implemented a Patients’ Rights and Responsibilities Policy (2019) that describes how patients can raise concerns and complaints regarding health service complaints. Concerns can be raised directly to PHA Department heads, physicians, patient relations officers, or risk manager, nurse manager and/ or clinic administrator, and / or the Public Relation and Communications Department of each public hospital. Based on the Patients’ rights and responsibilities system, PHA will develop and implement a grievance redress mechanism that is fully accessible not only to patients but also the public with a supporting system to track grievances response and reporting, and also allows for anonymous reporting (ESAP #8).

PS2:  Labor and Working Conditions

Working Conditions and Management of Worker Relationship: PHA employs approximately 4000 staff (which includes workers from PHA corporate offices, agencies and public hospitals) of whom approximately 71% are women. Staff are categorized as direct, indirect and contracted workers. Direct workers are staff that are directly contracted by PHA and includes medical staff (nurses and physicians), administrative and support staff. Indirect workers include those hired by third parties to provide support services such as cleaning or private security.

There are approximately 1,927 direct and 214 indirect workers at PMH. At SRC, there are approximately 749 direct and 59 indirect workers. It is estimated that approximately 200 contracted workers will be involved in the construction activities at PMH and 80 contracted workers in the construction activities at SRC.

Human Resources (HR) Policies and Procedures, Working Conditions and Terms of Employment: Policies and procedures governing PHA’s human resources practices are set out in the HR Procedures and Processes Manual (2015) which is aligned with Bahamas Labor laws and is broadly consistent with PS 2 and adhered by each public hospital. Each public hospital has an HR department headed by a HR assistant director that reports to the hospital administrator and PHA corporate HR. The HR and Procedures manual complements the industrial agreements in place with the unions and includes working conditions and terms of employment, including but not limited to working hours (as well as provisions for overtime); salary; annual leave; dismissal process; responsibilities of the employee (including responsibilities related to environment, health and safety).

The PHA’s HR policies and procedures are currently being revised for ratification in early 2021 together with the unions and any changes will be agreed by both parties.  Key policy documents include Code of Conduct with mechanisms that support its application; an Employee Discipline Policy; Conditions of Employment; and Employee Handbook that is provided to each employee at the commencement of their employment. Per ESAP #9, PHA will update its HR policies and procedures to incorporate PS 2 requirements.

If there are deviations from the standard working terms and conditions in response to emergency needs posed by COVID-19 (e.g. requiring health care workers to work longer hours than normal) PHA will require that this be documented for each public hospital and mitigation measures be implemented to protect such workers (e.g. mandatory rest breaks, third party monitoring) (ESAP #10).

Workers’ Organization: The following unions are represented in the healthcare sector: (i) Bahamas Doctors Union (BDU) (representing junior doctors); (ii) Bahamas Nurses Union (BNU); and (iii) Bahamas Public Service Union (BPSU) and (iv) Consultant Physician Staff Association (CPSA). The BDU and BNU industrial agreements are expiring, and negotiation meetings are underway between the PHA and union representatives.  Temporary employees and the those employed at the management level are not represented by the Union’s industrial agreements. Workers not covered by the union’s industrial agreements have their terms and conditions of employment defined in their letters of appointment. There are no barriers to freedom of association through trade union membership and/or collective bargaining. Recurring monthly union meetings are held at the hospitals between Union representatives and the Hospital Administrator, Principal Nursing Officer, Medical Chief of Staff, Assistant Director of Human Resources, institutional Medical Affairs Committee, PHA Labor Consultant, Nursing Services Advisor, or Medical Advisor, as required. Quarterly union meetings are held with Union representatives and PHA’s Managing Director, Deputy Managing Director, Director of Human Resources, and PHA Labor Consultant along with the Hospital Administrator, as required. Issues raised by the unions are addressed at the hospital level. Reports are submitted to PHA Managing Director for intervention as required.

Retrenchment: No retrenchment activities are planned for the foreseeable future. There are shortages of medical, nursing and allied health professionals in key health sectors such as critical care nursing, emergency care, radiology, laboratory technology among others.

Non-discrimination and Equal Opportunity: The Employment Act of the Bahamas (2005) includes provisions on non-discrimination and equal opportunity whereby no employer or person acting on behalf of an employer shall discriminate (refuse to offer employment or affording an employee promotion, training or other benefit opportunities, dismissing or subjecting an employee) on the basis of race, creed, sex, marital status, political opinion, age or HIV/AIDS and paying the employee at a rate of pay less than the rate of pay of another employee, for substantially the same kind of work or for work of equal value performed in the same establishment. The HR procedures are being revised to explicitly incorporate provisions on non-discrimination and equal opportunity (ESAP #9).

Grievance Mechanism: Workers grievances are either raised through the public hospitals internal reporting structures or through the labor unions. PHA will develop and implement a workers’ grievance redress mechanism (GRM) per ESAP #11 to allow all workers (direct, indirect and contracted (including construction) workers) to quickly inform management of issues or concerns, such as a lack of PPE, unreasonable overtime, unsafe working conditions among others. The GRM will also allow for confidentiality and raising of anonymous complaints and issues.

Protecting the Work Force: PHA’s minimum age of employment is 18 years of age (as part of their training nurses can start working at 17 years of age) in line with the requirements of the Employment Act (2005). Provisions on what to do in the event of sexual harassment are captured in the BPSU and BNU industrial agreements but not in the BDU industrial agreement. Per ESAP # 9, PHA will update its HR policies and procedures to include reference to protection of the workforce, including the prohibition of forced and child labor and relevant provisions for workers engaged by third parties as well as provisions related to sexual harassment and incorporate measures to address gender-based violence (GBV) both at management and worker level.

Occupational Health and Safety: In line with the CESMP that will be developed and implemented for the Project, the external construction company will develop and implement an occupational health and safety management sub-plan taking into account, among others the recommendation specified in the World Bank’s Interim Note: COVID-19 Considerations in Construction/Civil Works Projects (April 2020).

Occupational health and safety during operations is a top priority for PHA. Overall occupational health and safety management is the responsibility of the RQPS department supported by the Employee Health Services department that provides medical advice and assistance to workers (direct, indirect and contractors) across facilities. Each hospital has an Employee Health Clinic and employees from PHA corporate office and agencies utilize PMH Employee Health Clinic. The Employee Health Services department performs annual physical exams of staff, medical assessments for new staff, immunization services and management of incidents. PHA has in place an Incident Reporting procedure that provides guidelines for all incidents, accidents, injuries and damages occurring to patients, staff, visitors and property.

PHA also has developed and implemented an infection prevention and control (ICP) manual to guide best possible ICP practices to prevent healthcare providers, staff and patients from being exposed to general infections, blood-borne pathogens and other potential infectious materials during (i) care and treatment and (ii) collection, handling treatment and disposal of healthcare waste. The ICP manual is approved by the Infection Control Committee, the Medical Advisory Committee and the PHA Board. Documents in the manual are reviewed annually and revised as needed. As mentioned above, in response to COVID-19 the GoB implemented the EOC in line with CDC, PAHO/WHO guidance which includes measures to ensure the safety of hospital staff, patients and visitors.

Workers Engaged by Third Parties: The CSD department oversees third party construction workers involved in construction activities whereas indirect workers are overseen by the Senior Executive of the department to which the service is provided and ultimately the Hospital Administrator. Indirect workers are mainly engaged in the services area providing cleaning, and security services. Indirect workers are obligated to adhere to PHA’s QMS at the hospital level. CSD and the Hospital Administrators will be responsible for ensuring that labor standards (namely forced and child labor and access to workers GRM) and treatment of workers including adequate compensation in line with GoB Labor laws and PS2 are incorporated in the third party contracts and enforced (ESAP #12).

Supply Chain: The procurement of goods and supplies is the responsibility of PHA’s Supplies Management Agency (SMA). SMA’s main responsibilities are: (i) procurement, warehousing and distribution of medicines, medical/surgical supplies, linen, cleaning materials, stationery, food, hospital equipment/furniture and other health commodities; (ii) monitoring and evaluation of the public sector supply chain; (iii) coordinating and overseeing quality control mechanisms at all levels of the supply chain; (iv) promoting a culture of continuous improvement throughout the supply chain; and (v) promoting and collaborating mechanisms within stakeholder groups.

The SMA operates a central warehouse and intermediate stores at each hospital facility for pharmaceuticals and medical surgical supplies. The agreement between SMA and its suppliers is governed by General Terms and Conditions and Special Terms and Conditions of Contract and the Standard Operating Procedures Manual which, among others includes requirements on product quality. At least one supplier’s representative is required to attend supplier meetings convened by the SMA or PHA. SMA monitors the performance of all suppliers through a Monitoring and Evaluation Tool. The Monitoring and Evaluation tool will be revised and updated to include compliance with national laws and PS 2 requirements as it pertains to forced and child labor and risk of significant safety issues (ESAP 13).

PS3:  Resource Efficiency and Pollution Prevention

Resource Efficiency: The PHA, through the CSD department, implements a systematic upgrade program of its facilities that is reviewed annually and includes the phase out of old systems and replacement with more efficient, up-to-date systems. In addition, every time that there are planned upgrades, refurbishments or renovations, the CSD department aims to, as much as possible, incorporate resource efficiency measures in the design. The systematic upgrade of PHA’s facilities is carried out in line with the Bahamas Building Code (2003) that provides guidelines for architects, engineers and contractors. The guidelines provide illustrations and design parameters to ensure that all systems meet the GoB’s standard. In response to hurricane Dorian, measures have been put in place to mitigate impacts, such as: (i) elevating generators three feet above ground level to prevent them from flooding; (ii) installing solar panels, (iii) installing double glazed and hurricane proof windows. PHA continues to explore opportunities to further promote water and energy efficiencies throughout the Project such as light sensor and water saving mechanisms.

Greenhouse gases (GHG) Emissions: GHG emissions are associated with energy and fuel requirements related to the operations of the hospitals. The healthcare facilities in the Bahamas are required by law to be connected to the national electric grid as well as have back-up diesel generators (most are less than 10 years old with 200 kVA power generation capacity) to run at 100% of the healthcare capacity. GHG emissions are estimated at approximately 20,025 tons of carbon dioxide equivalents per year (tCO2e/yr) for both PMH and SRC.

Water Consumption: Water to PMH and SRC is supplied by the Municipal Water system in New Providence through Water and Sewerage Corporation. Daily water consumption is approximately 113,753 gallons/day for PMH and 10,080 gallons/day for SRC. PHA continues to implement water saving initiatives in its facilities, such as rain catchment and recycling water from AC units that is used in the fire suppression systems.

Pollution Prevention

Air Emissions: During construction works, the primary air emissions are dust and particulate matter. Main risks associated with the refurbishment of old hospitals are asbestos. In the event that asbestos is uncovered, PHA will engage a local specialized asbestos abatement company to address the assessment, removal and disposal of asbestos in line with an asbestos management sub-plan taking into account MIGA requirements, WBG’s Good Practice note on Asbestos (2009) and GoB legislation to be prepared as part of the CESMP as required. In addition, construction workers will be required to wear appropriate respiratory protection and PPE, and follow appropriate hygiene and decontamination practices as required by the Department of Environmental Health Services from the Ministry of Environment and Housing. Generators may be used as backup power supply in the event of an emergency and power shut down. Generators follow a master maintenance program including comprehensive maintenance prior to hurricane season. Incinerators at PMH and SRC have been decommissioned.

Wastewater: Wastewater from the PMH and SRC hospitals are discharged into the municipal sanitary sewage treatment systems in compliance with applicable permits from the Ministry of works (building control division), Ministry of Housing and Environment (Department of Environmental Health) and the Water and Sewerage Cooperation. In line with the Medical Waste Management Plan, medical wastewater is first neutralized in the sluice room before being discharged into the sewer system.

Waste Management: Waste generated from construction works will comprise of nonhazardous waste such as scrap, damaged or spoiled materials, temporary and expendable construction materials, packaging materials, and waste generated by the workforce and hazardous waste such as demolition debris with constituents considered as hazardous such as asbestos in line with the Asbestos Management Plan, lead or other hazardous substances. Construction waste materials associated with the Project will be transported to a reserved area of the New Providence Landfill. As part of the CESMP, a construction waste management plan will be prepared prior to construction and includes waste handling, storage and disposal of non-hazardous and hazardous waste (ESAP 2).

PHA has developed and implemented detailed procedures on the handling, segregation, temporary storage, and disposal of non-hazardous and hazardous wastes. Wastes are collected, segregated in designated color-coded bins or bags, stored, and transported separately from other wastes based on their physical, biological and chemical characteristics.

Medical waste is considered hazardous and contained separately from other regular waste. Medical wastes are contained as close to the site of origin as possible and transported to designated storage areas by Environmental Services department. The storage areas are secured with closed and locked gates. Medical waste coming from the laboratory is treated through autoclave using steam sterilization to be rendered non-infectious before it is taken to the landfill. Radioactive waste streams are not produced by the hospitals. Clients requiring radiation therapies are referred to external, privately owned entities contracted by the PHA.

Given the highly infectious nature of COVID-19, medical wastes have a substantial potential of carrying micro-organisms that can infect people who are exposed to it, as well as the community at large if it is not properly disposed of. Measures and procedures for the safe handling, storage and processing of infectious waste is done in line with the Infection Prevention and Control Department Procedure on Medical Waste Management Plan, Regulated Medical Waste Safety and COVID-19 procedures implemented as part of the Emergency Operations Committee in line with PAHO/WHO guidance.

Currently, there is only one waste management company in the Bahamas (Bahamas Waste) that manages medical wastes and runs incinerators. As part of the contractual agreement, the public hospitals have the right to inspect and audit the waste management facility. A site inspection by RQPS is arranged for the first quarter of 2021 to ensure that the waste is being properly managed by Bahamas Waste. The findings of the site inspection will be shared with MIGA (ESAP 14).

Noise and vibration: Impacts from noise and vibration are expected to be moderate and temporary during construction resulting from the operation of construction equipment.

Pesticide Use and Management: Rodent control and mosquito abatement are conducted at PMH and SRC via contracted services.  A pesticide use and management plan will be developed that

outlines procedures to be followed to protect the health and safety of staff, patients and visitors from pest and pesticide hazards (ESAP 15).

PS4:  Community Health, Safety and Security

Community Health and Safety: The Project could pose risks to the surrounding communities, typically during construction activities caused particularly by increased traffic of heavy machinery; noise and dust levels exacerbated during construction; increased traffic flows; and fire and life safety related issues. Community health and safety management sub-plans for construction will also be developed in line with the CESMP and will include traffic safety measures and mitigation measures for noise, vibration and dust.

During operations, community health and safety risks associated with the project relate to the infection of community members if there are not adequate measures and adherence to infection control, self-quarantine and isolation. PMH and SRC which receive, test and treat COVID-19 suspected and confirmed patients may present risks for the people in the immediate area if proper infection control procedures are not followed. PHA and its institutions adhere to infection control and prevention protocols in line with PAHO/MOH guidance on COVID-19 to ensure that areas surrounding the institutions, and visitors are not placed at risk. COVID-19 treatment will be provided to all irrespective of residential status or health insurance coverage so that all segments of the population, including the vulnerable immigrant population have access to health care services as per the hospital’s duty of care.  

Security Personnel: the public hospitals rely on (i) internal security hired directly by the hospital and (ii) private security companies responsible for securing the hospitals’ perimeter. The Royal Bahamas Defense Force (RBDF) provides additional support to PMH to respond to crisis situations. The main purpose of the RBDF is to deter or prevent rather than respond. The RBDF are the only security forces that are armed. The security forces report to the Chief Security Officer. A Security Policy and Procedures Manual has been developed and implemented that takes into account code of conduct, use of force, escalation protocols among others.

A Broad Community Support determination is not required for the Project.

Please click below to view ESAP

• Environmental and Social Action Plan

For additional information on the Project, please contact:

• NAME & Title: CATHERINE WEECH, Managing Director – Public Hospitals Authority

Address: Third & West Terrace, Centreville

E-mail : ceweech@phabahamas.org

Phone : 242-502-1440

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MIGA supports its clients (as defined in MIGA Policy on Environmental and Social Sustainability) in addressing environmental and social issues arising from their business activities by requiring them to set up and administer appropriate grievance mechanisms and/or procedures to address complaints from Affected Communities.

In addition, Affected Communities have unrestricted access to the Compliance Advisor/Ombudsman (CAO), the independent accountability mechanism for MIGA. The CAO is mandated to address complaints from people affected by MIGA-guaranteed business activities in a manner that is fair, objective, and constructive, with the goal of improving environmental and social project outcomes and fostering greater public accountability of MIGA.

Independent of MIGA management and reporting directly to the World Bank Group President, the CAO works to resolve complaints using a flexible, problem-solving approach through its dispute resolution arm and oversees project-level audits of MIGA’s environmental and social performance through its compliance arm.

Complaints may relate to any aspect of MIGA-guaranteed business activities that is within the mandate of the CAO. They can be made by any individual, group, community, entity, or other party affected or likely to be affected by the environmental or social impacts of a MIGA-guaranteed business activity. Complaints can be submitted to the CAO in writing to the address below:

Compliance Advisor/Ombudsman
International Finance Corporation
2121 Pennsylvania Avenue NW
Room F11K-232
Washington, DC 20433 USA
Tel: 1 202 458 1973
Fax: 1 202 522 7400
E-mail: cao-compliance@ifc.org