Gaziantep Hospital PPP Project

This ESRS provides an update of project status since Meridiam Eurasia SAS, of France (“Meridiam”), acquired a stake in the Project Company, Gaziantep Hastane Sağlık Hizmetleri İşletme Yatırım A.Ş (Gaziantep Hospital Health Services Management Investment Inc.). Meridiam has requested the Multilateral Investment Guarantee Agency (MIGA) to provide political risk insurance for its equity and quasi-equity investment into the Gaziantep Integrated Healthcare Campus (IHC) Project (hereafter referred to as “the Project”) in Türkiye. The Project is part of the Turkish Health Public-Private Partnership Program (PPP Program) developed by the Turkish Ministry of Health (MoH) to increase capacity of public hospital infrastructure in the country.  

In the specific context of Gaziantep, the Project would increase the efficiency of health services in a rapidly growing region in Türkiye. Gaziantep has a high population density compared with the rest of the country and has experienced a significant influx of Syrian refugees (close to 500,000 at end June 2022), representing some 25% of the local population. MIGA has supported the PPP Program by issuing guarantees for investments in the Adana, Bursa, and Elazig Integrated Health Campus projects, and the Yozgat Education and Research Hospital project. MIGA’s Board of Directors approved the Gaziantep IHC project in 2016.

The Project is currently undergoing construction with the expected completion by July 2024. The site was previously a vacant land plot in the Sahinbey District of Gaziantep Province in southeast Türkiye, approximately 40 km from the Syrian border. The site was formerly under the ownership of Ministry of Finance and was given to the Ministry of Health (MOH) for construction of the Project. MOH has leased the land to the Project. The Project area is surrounded by five neighborhoods: Akkent, Karataş, Güneş, 75 Yıl and Dumlupınar. The key human receptors in the vicinity of the Project are the developed residential areas and the educational and recreational facilities that surround the Project site. There are large numbers of high-density existing residential properties located to the west of the site and to the south of the site. Recreational and educational facilities are also located to the west and on the site boundary. The closest sensitive receptor is TOBB High School, which is located immediately adjacent to the Project site. The High School has 600 students, including 200 boarders.

The Project involves the construction of a 1,875 bed Healthcare Campus over an area of 330,091 m2. The Project will include four tower buildings with a main hospital core with a total bed capacity of 1,625 beds; a 100 bed High-Security Forensic Hospital; and a 150-bed Rehabilitation Hospital. In addition, there will be administrative buildings, car parking areas, a helipad and a tri-generation plant (17 MWth capacity). The Project Company will be responsible for the construction, maintenance, and management of the facilities and for providing medical support services. Mobilization and early works commenced in March 2016, but construction was delayed and halted in late 2019. A new EPC contractor, RMİ Rönesans Medikal Taahhüt İnşaat A.Ş. (“Rönesans”) was selected in August 2022 to complete construction of the Project and received its construction license (building permit) in September 2022. Construction works completion rate stood at around 50% by end-October 2022 and is expected to be completed by mid-2024. The Project’s Management will be undertaken by MR Management Services Consultancy Co. (“MR”), a specialized company jointly owned by Meridiam and Rönesans. MR is also in charge of O&M of the four other projects supported by MIGA under the PPP Program. During operation, the workforce is anticipated to be approximately 6,000, of which approximately 3,000 will be healthcare professionals and 2,950 operational and maintenance staff. The MoH will deliver medical care services once the hospital becomes operational, and the Ministry of Justice will have a role in managing the High-Security Forensic Hospital. At the end of the Project’s operating 25-year period, the facilities will be transferred to the MoH.

The Project lenders include multilateral and bilateral financial institutions: European Investment Bank (EIB), the European Bank for Reconstruction and Development (EBRD) and The Export and Import Bank of Korea (Korean Exim Bank).

The Project is a Category B under MIGA’s Policy on Environmental and Social Sustainability (2013) because the potential environmental and social impacts are limited, site-specific, largely reversible, and can be readily addressed through mitigation measures. There are no material changes to environmental and social risks and impacts resulting from the change in the management structure of the Project.

Key environmental and social issues during construction include effects on air and water quality, soil and vegetation removal, increased noise levels and vibration, solid and liquid domestic and hazardous waste management and incidents related to occupational and community health and safety.  During operation, key environmental and social risks include generation of general solid and liquid waste, generation of hazardous waste (including medical waste and residual pharmaceutical waste), air emissions, life and fire safety risks, and adequacy of emergency response.

While all Performance Standards (PS) will be applied to the Project, based on current information, the Project is being managed in accordance with the following PSs:

• 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

PS5 (Land acquisition and Involuntary Resettlement) does not apply to this investment. The Project site is allocated to the MoH for the Project. No physical or economic resettlement was required. 

The development of the Project is not expected to have adverse impacts on biodiversity and PS6 (Biodiversity Conservation and Sustainable Management of Living Natural Resources) is not applicable. PS7 (Indigenous Peoples) is not relevant to this Project since indigenous communities are not present in the area. While impacts on cultural heritage were not anticipated, as part of the ESMS, MIGA required a chance finds procedure to be implemented during construction in accordance with PS8 (Cultural Heritage). No chance finds were discovered during excavation and groundworks.

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

• World Bank Group General EHS Guidelines
• World Bank Group EHS Guidelines for Health Care Facilities

MIGA’s review consisted of appraising environmental and social information submitted by the Project. The key following documents have been reviewed by MIGA:

• Environmental and Social Impact Assessment (ESIA) for the Gaziantep Integrated Health Campus (ERM, September 2016);
• Environmental and Social Action Plan for the Gaziantep Integrated Health Campus (ERM, September 2016);
• ESIA Annexes A – H for the Gaziantep Integrated Health Campus (ERM, September 2016);
• ESIA Annex I Stakeholder Engagement Plan for the Gaziantep Integrated Health Campus (ERM, September 2016);
• Monthly Construction Monitoring Reports (HSE Section) – Gaziantep IHC (2016-2019));
• Monthly Construction Monitoring Reports (HSE Section) – Gaziantep IHC (2022)
• Lenders' Technical Adviser's Construction Monitoring Report (Mott MacDonald, September 2022)
• Rönesans Human Rights Policy, 2022

In addition to reviewing the above documents, during the original E&S due diligence, MIGA’s environmental and social specialist visited the Project site in December 2015. The visit included a walk-over of the Project site and meetings with representatives of the Project sponsors, local government officials and local communities. Site visit also included a tour of the local medical waste facility and meetings with engineer in charge of the facility.  Since then, the Project has been subject to E&S monitoring by MIGA, including E&S monitoring site visits in August 2017, September 2019 and November 2022. In addition, Lenders' Technical Adviser (LTA)'s Construction Monitoring Reports have been prepared and routinely submitted to MIGA, together with annual E&S monitoring reports. These have been reviewed by MIGA.

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

Environmental and Social Assessment and identification of risks and impacts:

The Project does not fall under the scope of the Turkish Environmental Impact Assessment Regulation as hospital projects do not fall within the scope (Annex 1 or 2) of Türkiye’s EIA Regulation (Official Gazette Date November 24, 2014). However, as the production capacity of the concrete batching plant was greater than 100 m3, it is considered an Annex 2 project under the regulation. A separate ‘Project Information File’ (first step in obtaining an EIA decision) was prepared for the concrete batching plant and was approved by the Ministry of Environment and Urban Development (MEUD) at the end of June 2016.  Concrete construction activities have now been completed. An Environmental and Social Impact Assessment (ESIA), Environmental and Social Management Plan (ESMP) and Environmental and Social Action Plan (ESAP) were completed for this Project in September 2016. The Project Company retained an independent environmental consulting firm (ERM) to undertake the environmental and social assessment and prepare the documents in line with IFC Performance Standards (2012), EBRD Performance Requirements (2008) and applicable sub-sectoral environmental and social guidelines, and WBG EHS general and sector-specific guidelines. The ESIA presents baseline information, identifies potential impacts and risks, and mitigation measures for the Project. The ESMP provides a framework for developing required management and monitoring plans per the risks identified for both construction and operations. The ESIA also included consideration of potential cumulative impacts to determine the effect of the Project together with other planned and proposed development in the project area.  

The Project has obtained a construction permit, as well as permits for domestic wastewater discharge during construction, and will obtain the operational environment permit, as required per the MEUD, which will cover wastewater discharge, air emissions, noise, and the temporary waste storage.  Prior to excavation, the Project also obtained an excavation permit as required by local authorities. The Construction Monitoring Reports include a table of all of the environmental permits requirements for the Project, including the status of permits. This table is updated on a monthly basis.

Key risks and impacts identified for the remainder of the construction phase of the Project include health and safety risks intrinsic to construction activities such as physical hazards related to the use of machinery and vehicles; management of hazardous substances; increase of dust emissions from excavation; noise emissions from vehicular traffic and machinery operation; risks associated with the presence of the construction workforce (including the accommodation camp); and community safety risks associated with unauthorized site access and increased traffic. During operation of the Project, key potential environmental and social risks include: exposure and spread of infectious diseases induced by handling of materials and improper waste contaminated with blood-borne pathogens; exposure to hazardous materials and waste including specific toxic chemicals and gases used in sterilization of medical equipment, formaldehyde, mercury, solvents, etc.; inadequate solid and liquid waste management; and risks associated to inadequate discharge of contaminated wastewater. Traffic related accidents and security management were also identified as risks during operations. It is expected that effective implementation of the Environmental and Social Management System (ESMS) and ESMP during the construction and operation of the Project will continue to avoid and/or minimize risks and impacts to the extent possible ensuring safe working conditions for the workers and neighboring community. Potential cumulative impacts identified included the impacts associated with increased traffic, from both the project and other development in the area, and interactions between the local community and construction workers. Measures were identified to address these potential cumulative impacts.

Climate change:

The Project aims to finance and support a low carbon and climate resilient healthcare facility that incorporates energy efficiency measures, a trigeneration energy system, and flood drainage works. These activities are eligible for tagging as climate finance. Accordingly, the project is considered aligned with the climate goals of the Paris Agreement and consistent with Türkiye’s Climate Change Action Plan (2011-2023). A detailed description of the Paris Alignment assessment and climate finance accounting are provided below.

Climate Finance.

The Project will yield both climate mitigation and climate adaptation co-benefits. Based on the gross amount of investment to be covered by MIGA, the estimated climate finance share of the Project is 100%. This corresponds to a climate finance volume of €126 million, against Meridiam’s equity and quasi-equity totaling €140 million.[1]

Paris Alignment. The Project is expected to be aligned with both low-carbon and climate resilient development pathways for Türkiye. Türkiye’s Nationally Determined Contribution (NDC) outlines priorities for its buildings and urban sectors to integrate both mitigation and adaptation measures, which include, among other actions, construction of new, energy efficient service buildings. The project, which is expected to be Leadership in Energy and Environmental Design (LEED) certified, is aligned with Türkiye’s NDC.

The project’s location is characterized by climate risk factors such as increased temperature and variations in rainfall[2], which could result in increased incidence of droughts, heatwaves, and flooding, affecting the resilience and performance of existing and new infrastructure. The project considers these risks and aims to address them by integrating resilient measures in the design and operation of the healthcare facility.

On mitigation side, the project is incorporating design changes and seeking LEED certification, as described above. A 7.5 MW trigeneration system is also being constructed on site to meet all the energy, heating, and cooling needs of the facility, which is eligible for tagging as climate finance, as per MDB IDFC Common Principles for Climate Mitigation Finance Tracking methodology. This provides a reliable source of energy supply to the healthcare facility from cleaner sources. Estimation of GHG emissions is currently being conducted to determine the mitigation impact of the project by a project consultant.

On the climate resilient front, the project is addressing flooding risks due to its location being Gaziantep, which is susceptible to increased rainfall variability and flooding. The drainage capacity of the facility is designed to withstand 1 in 25 rainfall year event (with intensity of i = 283,356 lt/sec/ha). While this should minimize risk of flood damage to the healthcare facility, given the timeframe of the project (about 30 years), a drainage capacity to withstand 1-in-50-year event would have been preferred, and would make the investment more resilient. Per the ESAP, the client has committed to review and monitor the Project’s stormwater drainage system capacity to confirm whether the system is able to handle a 1-in-50-year event; where the drainage system review determines that stormwater drainage system modifications are required, such changes shall be implemented by the client to ensure that the infrastructure remains resilient. The timeline of this ESAP item is under discussion with the client. The Project is also consistent with Türkiye’s climate adaptation priorities as outlined in its National Climate Change Action Plan (2011-2023), This Project through its climate adaptation component is expected to improve the overall flood resilience for the newly constructed hospital and its users.

Management Program:

The Project Company has issued Health, Safety and Environment, Quality, Human Rights, Human Resources and Corporate Social Responsibility Policies. Rönesans has an integrated management system that incorporates all plans and procedures covering environmental, health and safety. The following management plans and procedures have also been developed in line with ESAP requirements, and are being implemented during construction: Health and Safety Management Plan; Emergency Preparedness and Response Plan; Environmental Leakage Management; Air Quality Control Monitoring Plan; Noise Control and Monitoring Plan; HR Management Plan; Grievance Management Plan; Protection and Security Plan; Traffic Management Plan; Archeological Chance Finds Management Procedure; Accident / Incident Investigation Procedure; Waste Management Procedure; and Annual Training Plan. These plans are supported by forms, follow-up charts, control lists, presentations and handbooks, as appropriate. A certification audit for the integrated management system (ISO9001, 14001 and 45001) is expected to be conducted in January 2023. This has been achieved previously at the other hospital projects. Prior to operations, an ESMS for the operations phase will be prepared and submitted to MIGA (ESAP item). This will also contain detailed environmental, social, health and safety (ESHS) management plans based on operations and PS 1 requirements.

Organizational Capacity:

The main EPC contractor, Rönesans is a highly experienced company that has successfully completed the other four hospital PPP projects. There is a team of 18 specialists onsite to implement the ESMS, together with around 100 health, safety and environment (HSE) personnel employed by sub-contractors. The Project HSE Team includes the HSE Manager, two HSE chiefs, six HSE supervisors, seven HSE inspectors and one Environmental Engineer. In addition to them, there are also two people responsible for documentation and training. As per the ESAP, an E&S Manager will be appointed to implement the ESMS during operations.

Emergency Preparedness and Response:

An Emergency Preparedness and Response Plan (EPRP) has been developed for the construction phase. The plan details management procedures for issues related to occupational accidents, fire, fuel and chemical spills, natural disasters such as flooding and earthquakes, as well as relevant roles and responsibilities. The EPRP also includes measures for management of Covid-19 risks. In case of any employee observed at site with symptoms, fever measurements are applied, and rapid antigen tests are used. Contractors and sub-contractors are also required to develop and prepare their own site-specific EPRPs in line with the overarching plan in the ESMS. The EPRP for operations will consider the forensic hospital in detail for all types of incidents, accidents and disasters.

Monitoring and Review:

The ESMP has been prepared in order to define key environmental, health and safety (EHS) and social aspects, and ensuring operation within the applicable laws and regulations of Türkiye, as well as the policies of international financial organizations for the Project. For the construction phase, detailed monitoring plans for air quality and noise have been prepared, as well as a procedure for monitoring waste generation and disposal. The Project has also developed a template for annual environmental and social reporting. The EPC Contractor's HSE team at the site is conducting regular inspections and meetings to manage day-to-day operations. Moreover, the LTA performs periodic HSE audits and monitors the E&S performance of the Project.

MIGA requires submission of an Annual E&S Monitoring Report (AMR) throughout the guarantee period on environmental, health & safety and social performance, regularly in accordance with the MIGA’s PSs and relevant World Bank Group (WBG) EHS Guidelines. These have been submitted and reviewed by MIGA.

Stakeholder Engagement, external communication and grievance mechanisms:

A Stakeholder Engagement Plan (SEP) has been developed for the Project and was updated in 2022. A Community Liaison Officer has been appointed by the EPC contractor, whose contact details are contained within the SEP posted on the Project webpage. The SEP clearly identifies all project stakeholders including government agencies, NGOs, neighboring communities, and the general public. It includes a grievance mechanism that provides an open channel for continuous and structured communication between management and the general public and describes a detailed strategy to place, investigate, respond, and file a given complaint and the expected timeline associated with these actions. Through this process, the public can express individual and collective concerns and issues regarding the construction and operation of the facility. The SEP also outlines communication methods appropriate for each Project phase, including publications through a corporate website.

Stakeholder engagement activities for the Project started during the scoping stage and continued during the preparation of the ESIA report. Face-to-face meetings were held with community leaders and focus group discussion meetings were held with Syrian refugees (one with men and one with women) to understand any vulnerabilities around employment and using hospital services. Project details, ESHS risks and impacts, and other relevant topics were discussed during the meetings.  Additionally, public participation was requested through the distribution of feedback forms. While some concerns over potential impacts, such as noise and dust during construction, were expressed by stakeholders, in general, local stakeholders are aware of the public benefit of the Project. All of the concerns expressed by stakeholders were addressed in the final ESIA.  A public grievance box and forms to complete have been made available at the main entrance of the construction area, together with a QR code, and an email address on the Project website. To date, there have been no grievances recorded from the public.

PS2: Labor and Working Conditions

The Project will create employment opportunities during both the construction and operation phases. It is estimated that the peak construction phase will require approximately 4,000 workers.  The expected workforce requirement during the operation phase is anticipated to be 3,000 health care professionals and up to 2,950 operational and maintenance staff. First priority will be given to a local workforce while providing equal employment opportunities to women. The Project has constructed worker camps (nine dormitories) on site for approximately 3,000 construction workers. Workers’ living conditions comply with Turkish law and the performance requirements of PS 2 as well as the joint EBRD / IFC Workers’ Accommodation: Processes and Standards Guidance Note (2009). The Camp Management Plan includes a Workforce Code of Conduct, reference to the Project’s Occupational Health and Safety Management Plan and provisions for induction and training. Workers’ accommodation arrangements do not restrict their freedom of movement or of association.  Drinking and potable water during the construction was expected to be provided from the Gaziantep municipal water system. Bottled water is currently used for drinking purposes as the water dispensers are not in use due to COVID19. Before the water dispensers are put back into use again, water analyses will be carried out.

As the Project is being constructed to address a shortage of hospital beds in Gaziantep, it is unlikely that the Project will result in any retrenchment or closure of existing hospitals in the area. 

Human Resources (HR) Policies and Procedures:
Labor practices in Türkiye are regulated by the Labor Law No. 4857 of 2003, which standardizes employees’ work-related rights, working conditions and stipulates obligations of employers and employees. The Project Company has in place a Human Resources (HR) Policy and HR Management Plan in accordance with Turkish law and PS2 requirements. The HR Management Plan includes an employee grievance mechanism. The HR Policy, Management Plan and grievance mechanism are communicated to all employees, including contractors and sub-contractors, during site induction training. The EPC contractor operates a zero-tolerance policy for sexual harassment, gender-based violence (GBV), and breaches of health and safety procedures. Provisions on prevention of GBV and sexual harassment are included in Rönesans Holdings’ Human Rights Policy which will be applicable to the Project. Training on gender inclusion, and on prevention of GBV and harassment have been provided to personnel by Rönesans and EBRD. Performance against the requirements of PS 2 is reviewed by the LTA on a regular basis, and as per the ESAP, an independent labor audit will be conducted in Q1 2023.

Occupational Health and Safety:

Türkiye has an Occupational Health and Safety (OHS) Law and a Regulation of Workers Health and Safety that stipulate detailed criteria for safe working conditions at job sites. A Health and Safety Management Plan, which is consistent with the requirements of ISO45001, has been prepared by the EPC contractor and is being implemented for the construction phase of the Project. This includes an accident/near-miss recording system.  Health and safety statistics are reported by the EPC contractor on a monthly basis in the Construction Monitoring Report. The Project Company provides staff with Personal Protective Equipment and employees are provided with training in all relevant environment, social, health and safety management topics, in particular OHS for handling hazardous materials.  A Health and Safety Plan will also be prepared for operations (ESAP item).

PS3: Resource Efficiency and Pollution Prevention

Resource efficiency:

Drinking and potable water during the construction and operation phases of the Project will be provided from the Gaziantep municipal water system. It is estimated that approximately 300 m3/day of water is required for construction. During the operation phase, there will be water uses related to general domestic and sanitary use, food preparation, sterilizers and autoclaves, etc. The water consumption rate for the Project during operation is estimated to be 3,000 m3/day, which is within the range of typical water use per bed for a hospital of this size. Municipal water supply has been deemed adequate to fulfill these estimated requirements.

During construction, the main energy source is diesel fuel for construction equipment and vehicles. Thus, safety instructions for storage, transportation and usage of Hazardous Materials have been prepared for the construction phase. Greenhouse gas emissions associated with vehicle use were expected to be a total of 1,340 tCO2e for the construction period. The estimated energy requirement for the hospital operation is 30 MW and the estimated annual electricity usage will be 262,800 MWh, equivalent to 446 kWh/m2 (which is below the average (591 kWh/m2) for health care facilities defined in U.S. Energy Information Administration. A tri-generation plant, with boiler capacity of 40 MW and tri-generation capacity of 17 MW will be constructed on site to supply all energy, heating, and cooling needs during the hospital operation. Diesel fueled emergency generators located within central energy plant will be used to provide 100% backup power supply for the hospital buildings. Generation of greenhouse gas emissions during the operation of the tri-generation and boiler systems is expected to be 138,644 tCO2e/year. The Project will be required to quantify the direct and indirect emissions annually per PS3 requirements, and to report results to MIGA.

Energy and water efficiency have been considered in the design and operation of the Project, for example, the Project includes solar panels as part of the design to support energy requirements. Energy and water resources management plans have been included in the ESMS, in conformance with PS3, to optimize resources use.

Pollution prevention:

Baseline conditions were established for the study area through field measurements for air quality, noise, hydrology, hydrogeology, geology, soil quality, and terrestrial ecology (see ESIA Annexes for more details). This section summarizes key ESIA findings and proposed mitigation measures to avoid and control potential impacts related to emissions and air pollution, noise and vibration levels, wastewater discharge, and solid, medical, and hazardous waste management among others, as identified in the ESMP.

Wastewater

During the Project construction and operation phases, the total daily domestic wastewater generation of the Project is estimated to be around 900 m3/day and 1,900 m3/day, respectively. All wastewater produced by the Project during construction is filtered through a decontamination tank and oil catcher before being discharged to the municipal sewerage system. Wastewater is treated by the Gaziantep Municipal Wastewater Treatment Facility. The existing capacity of the treatment facility is 400,000 m3/day, and it is currently treating 308,420 m3/day, and therefore has the capacity to manage the additional domestic wastewater during construction and operations. The Project Company has obtained a wastewater connection permit since all domestic wastewater during all project phases will be discharged into the existing municipality sewer lines in accordance with Waste Management Regulation (Official Gazette No: 02.04.2015/29314) and WBG EHS Guidelines. 

Wastewater contaminated with radioactive substances will be collected separately and will be monitored prior to being discharged into the sewer system per conditions set under the Regulation on Wastes Generated upon Usage of Radioactive Substances (Official Gazette Date/No02.09.2004/25571). Approval from the municipality will be required prior to discharging radioactive wastewater. This authorization will be obtained during the licensing process. Per the WBG EHS Guidelines for Health Care facilities, the Project Company will confirm whether the municipality has the capacity to receive this type of wastewater must be confirmed and will develop a wastewater management plan (ESAP item).

Waste Management and Disposal
The Project will produce hazardous medical wastes (from activities in labs, departments of pathological anatomy and expired medication), other wastes (including toners, neon light bulbs and batteries) and general wastes (such as kitchen and cafeteria wastes, paper, plastic, glass and aluminum). Estimated volumes of waste to be produced during construction and operations are provided in the ESIA.

A Waste Management Procedure has been developed for the construction phase, and a project-specific Waste Management Plan (WMP) will be prepared for the operations phase as part of the ESMS. The ESIA identifies all waste streams and some anticipated waste quantities, describes transportation and disposal requirements, and outlines waste management responsibilities. All waste streams are being managed and disposed of in accordance with Turkish regulation and WBG EHS Guidelines. Wastes are collected, segregated, stored, and transported separately from other wastes based on their physical, biological and chemical characteristics.

Site preparation and construction includes soil excavation activities which have been completed at the Project site. Some of the excavated material was reused on site for backfilling and levelling. The remainder was stored on site, and then transferred to an area identified by Gaziantep Metropolitan Municipality. Soil sampling conducted at the Project site during the ESIA phase did not show any sign of contamination.  

Generation of hazardous wastes, including medical and radioactive waste, will be a key impact during the operation of the hospital. Disposal of medical waste will be done by a third-party company and will consist of delivering it to the licensed Gaziantep Medical Waste Sterilization Facility prior to final disposal at the Gaziantep municipal landfill. The medical waste stream is expected to include infectious and pathologic, pharmaceutical, and sharp waste proceeding from various processes at the hospital. The annual medical waste generation for the Project is estimated at 1,556 kg/day. Collection and disposal will be done in line with Regulation on Medical Wastes Control-Official Gazette Date/No: 22.07.2005/25883.

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

Domestic waste during construction is stored in waste containers and collected by the Gaziantep Municipality garbage trucks for transport to the Gaziantep Solid Waste Disposal Facility. Removal of wastes generated by the previous EPC Contractor is ongoing and is planned to be completed within 2022. During operation, it is estimated that the hospital will produce approximately 4,406 kg/day. All domestic waste will also be disposed at the municipal landfill.

Air Emissions
Main sources of air pollution during the construction phase were identified as excavation works and movement of vehicles, and engine emissions from exhaust gas from construction equipment and road traffic. Principal pollutants resulting from these sources are dust and particulate matter (PM) from soil excavation and removal; and nitrogen oxides (NOx), sulphur dioxide (SO2) and carbon monoxide (CO) from exhaust of vehicles.  Measurements for PM10 and a dust dispersion modeling study, as well as NO2 were completed to establish baseline conditions and potential impacts within the study area. Ambient air quality monitoring data indicates that the site location is an undegraded airshed for NO2. For PM10 however, ambient concentrations are consistently above the Turkish, EU and WBG EHS Guideline air quality limit values, which is related to natural background dust associated with the arid environment.

Impacts on the air quality during the operation phase will be mainly related to the emissions from the tri-generation plant and boiler system. A dispersion modeling study was undertaken for NO2, the most significant emission source from the mentioned systems. Modelling indicated that emissions from the tri-generation plant had the potential to exceed the Turkish, EU and WBG EHS Guideline air quality limit values, and therefore modifications and mitigation measures were proposed in order to minimize the potential impact. Modelling further indicated that implementation of the proposed mitigation measures, including increasing the stack height and combining the stacks for the tri-generation and boiler plants, would ensure that the emissions would not exceed guideline values.

Noise and vibration
Baseline measurements were taken for three representative points at the Project site, which indicated that existing day and nighttime values exceed WBG EHS standards. Impacts from noise and vibration are expected to be moderate during the construction and operation of the hospital. Impacts during construction are temporary and result from earthworks, blasting, construction traffic and the operation of construction equipment. A Noise Control and Monitoring Plan was developed and is being implemented for the construction phase. The Project conducts monthly noise monitoring at sensitive receptors.

Impacts during operation of the hospital will be caused by traffic, helicopter movement and ambulance movements and will have longer lasting effects. Noise impacts will be mitigated through the construction of buffers and earthen bunds, enforcement of speed limits and road surface modification and maintenance.

PS4: Community Health, Safety & Security

Typical risks associated with the construction of this project are safety risks, increased traffic of heavy machinery, noise, dust, hazardous material handling, and fire and life safety. The Project Company is implementing construction area safety measures to protect the citizens, including barricading, control of the access, traffic safety, control of the construction vehicles, clear signage and demarcation of areas and provision of safety information to visitors.

Community Health and Safety

The Project is being designed and constructed in accordance with Turkish Regulation on the Protection of Buildings from Fire (issued on: 19.12.2007, Official Gazette (“OG”) No: 26735). Relevant technical requirements, including those delineated in applicable international standards, were integrated into the Project design and construction tender documents, e.g., fire suppression systems will be available throughout the hospital and a fire alarm system will be designed and installed. Fire control and mitigation measures for the construction phase of the Project are contained in the Emergency Preparedness and Response Plan that has been prepared by the Project Company.

A Life and Fire Safety Master Plan was prepared for the Project in accordance with Turkish regulations and WBG EHS Guidelines. A third-party L&FS audit was conducted in 2017 and identified some corrective actions that were completed. Design changes are being implemented to meet the life and fire safety standards. A new third-party L&FS audit is planned to be conducted in Q2 2023 to assess any gaps in local life and fire safety requirements and identify acceptable international standards to address such gaps. Per WBG EHS Guidelines, the Project will obtain the design and post-construction life and fire safety certifications from a professional acceptable to MIGA (ESAP item).

The project is located in the 3rd degree earthquake zone per local classification (with 1st degree zones being at the highest risk and 5th degree zones being the lowest risk). Necessary criteria (e.g., appropriate standards, regulations, etc.) were taken into account in the design of the Project facilities to address the seismic risks considering the specific parameters defined for the design of structures located in seismic zones. The hospital is being constructed in line with the Turkish Regulation on the Buildings to be Built in Seismic Zones (Official Gazette date/no: 06.03.2007/26454). 

The project location is in a relatively residential area and hence will result in traffic impacts during both construction and operation phases of the Project. During the construction phase, traffic increase in the local environment is one of the major impacts of the Project due to the construction vehicles and trucks carrying construction materials. In the operation phase, there will be significant increase in traffic load due to transportation of employees, patients and visitors.  The Project Company has developed a Health Campus Internal Traffic Management Plan for the Project in consultation with local authorities in order to manage traffic within the Project site.

Security

While there is no history of violence or negative interactions between security providers and local populations in Gaziantep, the Project Company has developed and is implementing a Security Plan during construction. Security guards are unarmed.

During operations, security for the hospital will comprise of an access control system of electronic card readers and electronic identification cards for employees, alarms, telecommunication devices and closed-circuit television cameras that are operated on a 24-hour basis. The high security psychiatric unit will be enhanced with unarmed security guards to be managed directly by the gendarme, a branch of the Turkish armed forces, in accordance with a triple protocol between the Turkish Ministry of Justice (MoJ), Ministry of Interior, and the MoH. A security plan, containing a security risk assessment, has been developed which details the company’s position and measures to address the use of force, training, equipping and monitoring security guards as well as investigating reports of unlawful behavior and preventing recurrence. Currently there are five security personnel available at site that have been trained and will operate in accordance with local laws and international codes of conduct (i.e., International Code of Conduct for Private Security Providers; Voluntary Principles on Security and Human Rights; UN Basic Principles on the Use of Force and Firearms by Law Enforcement Officials; and UN Code of Conduct for Law Enforcement).

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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

The following documentation is available electronically as PDF attachments to this ESRS at www.MIGA.org. 

• Environmental and Social Impact Assessment (ESIA): Gaziantep Integrated Health Campus, September 2016
• ESIA Annexes A – H: Gaziantep Integrated Health Campus, September 2016
  • Annex A – Administration Framework
  • Annex B – Social Assessment
  • Annex C – Air Quality
  • Annex D – Noise and Vibration
  • Annex E – Waste Management
  • Annex F – Traffic Assessment
  • Annex G – Water Resources
  • Annex H – Geography and Soils
  • Updated Environmental and Social Action Plan: Gaziantep Integrated Health Campus, December 2022

It is also available for viewing at the following location:

• http://gaziantepsehirhastanesi.com