1. Applicability

This Sector Profile is designed to help fund managers quickly familiarise themselves with the most frequent and important environmental, social and governance (ESG) aspects of investments in the healthcare sector. It aims to be a starting point for thinking about ESG risks and opportunities, and not a detailed technical guidance document.

  • Using this sector profile

    A company can be affected by non-sector specific issues such as impacts on Indigenous Peoples and cultural heritage. Therefore, each company must be carefully considered based on its specific characteristics and circumstances including scale of operation, location, technology utilised, management capacity, supply chains, commitment and track record. Additionally, the environmental and social (E&S) impacts, risks and opportunities in a particular company or sector can change over time (e.g. changes in the applicable laws, or expansion of a company’s activities or assets). Fund managers should have systems in place to identify such changes and manage any associated risks and impacts and, where possible, capitalise on new opportunities.

    This Sector Profile draws on internationally recognised good practice standards and guidance, particularly the International Finance Corporation (IFC) Performance Standards and the World Bank Group Environmental, Health and Safety (EHS) Guidelines. The Sector Profile identifies key standards that are generally applicable to each sector (refer to the ‘Standards, guidelines and other resources’ section below). It is not a substitute for such standards, which should take precedence as authoritative sources. Applicable laws and regulations must be taken into account and compliance with them should be regarded as the minimum acceptable performance standard.

    See BII Environmental and Social Checklist and BII Governance and Business Integrity Checklist for questions that fund managers should consider when evaluating a healthcare investment from an ESG perspective.

  • Scope of this sector profile

    Unless otherwise stated, the risks, impacts and opportunities outlined below relate to the operational phase of business activities. Generic guidance on ESG risks, impacts and opportunities associated with Project design and construction of healthcare facilities and services may be found in the BII Project Design and Construction Guide.

2. Key environmental and social aspects

This section outlines some of the key E&S risks and opportunities that can emerge from the healthcare sector. Weak management of these risks may result in financial, operational and reputational damage and limit the company’s ability to retain a good workforce and attract patients. On the other hand, once the company is able to demonstrate strong management and control of risks and compliance requirements, it may be in the position to explore a number of E&S opportunities related to resource efficiency, cost savings, revenue generation and improved patient quality of care and reputation.

  • Management commitment, capacity and track record (CCTR)

    Fund managers should ensure that at a minimum, companies operate in compliance with applicable laws and regulations. Additionally, fund managers should assess companies’ alignment with international standards and their ability to develop Action Plans to ensure that any gaps are addressed within a reasonable time frame. Where significant risks and impacts are encountered, it is likely that specialised advice will be required. For further advice, refer to BII Guidance: Assessing Companies’ Commitment, Capacity and Track Record.

  • Environmental and social management system (ESMS)

    Companies should develop and implement an ESMS commensurate with the level of risks and impacts associated with its activities. Healthcare facilities often have a number of assets under management which means E&S management is best organised under a decentralised structure. It is beneficial to have a clear ESG governance and monitoring structure set up with regular ESG committee meetings to ensure that there is a two-way dialogue between onsite facility/E&S managers and corporate-level monitoring and management of activities. ESG data management systems are also important to track areas of material importance to the company such as resource use, legal registers for all licences, and logging grievances and occupational injuries.

    As part of the ESMS, healthcare facilities should also build in mechanisms for effective stakeholder engagement and set up and clearly communicate how to use the grievance mechanism to address both internal and external grievances. This is particularly important given the business risks posed by inadequate patient quality of care and reputational risks posed through compromising community health safety and security.

    Companies should develop and implement an ESMS commensurate with the level of risks and impacts associated with its activities. For further advice refer to BII E&S Briefing Note: Environmental and Social Management Systems (company-level).

  • Labor and working conditions

    Note – Occupational health and safety is covered separately below.

    Risks for the business
    • Companies may face prosecution or fines (or have their licences removed) if they fail to comply with labour laws and regulations.
    • Financial, reputational and legal risks can result from poor staff morale or attitudes, industrial action, high staff turnover, theft and poor employee health (e.g. due to long working hours and working late at night).
    • High turnover of staff arising from poor labour standards and working conditions can lead to increased recruitment and training costs.
    • Quality customer service is a key factor for any healthcare business. Therefore it is critical to ensure that careful attention is given to training so that workers know how to appropirately treat patients and also how to engage with the patients and their realtives/friends.
    Opportunities for the business
    • Costs can be reduced and productivity enhanced through good labour standards and working conditions. In the service industry, staff performance, friendliness, competence and quality all significantly impact on the reputation, success and profitability of a business. Attention to good working and labour conditions can help to attract and retain motivated and competent workers.
    • Client base can be enhanced if a company achieves certain standards or related certifications covering labour and working conditions (e.g. SA 8000 or those related to the service industry including customer service and quality).
    • Developing skills of employees can help create a more efficient workforce, and may reduce turnover.

     

    Wages and working hours: This is an area which does require significant attention and management. The healthcare sector does employ workers with long and relatively unusual shifts, so attention should be paid to working hours and the nature of shift work. Care must be taken to ensure that workers are properly paid and compensated for longer working hours and certain shifts which may need to be paid at a higher hourly rate as per applicable legislation (e.g. night shifts).

    Freedom of association and collective bargaining: The rights of workers and the role of unions has previously been an issue within the hospitality sector. Extra care should be taken to ensure that the right to enter free and voluntary collective bargaining arrangements with management is respected. Failure to respect this and to establish a good relationship with unions could have negative impacts on a company (e.g. strikes). Collective bargaining can also be a constructive forum for addressing working terms and conditions and for improving worker/employer relations. It is often more effective and more flexible than state regulation. It can help in anticipating potential problems and can advance peaceful mechanisms for dealing with them that satisfy both employers and workers. Companies should adopt international good practice to help manage costs relating to recruitment, training and talent retention and to enhance productivity.

    Child labour and bonded/forced labour: A lack of stringent checks and balances at contractor selection and/or recruitment stages can lead to the company being associated with forced and child labour, particularly within the supply chain such as cleaning staff and catering services.

    Furthermore, in some regions there are high risks associated with bonded labour whereby original copies of certifications of nurses and other professionals are sometimes retained by the company as a security deposit for minimum length of service, which prevents the right and freedom of nursing staff to move on to other employment opportunities. This is unacceptable practice under international standards and urgent actions shall be taken to stop this practice.

    Equal opportunities and non-discrimination: Employment opportunities for women are generally high in the healthcare sector. However, sexual harassment poses a significant risk to women and companies should develop and implement employment policies to guard against this. Good practice in this area can help to manage costs relating to recruitment, training, and talent retention and enhance productivity.

    For further general guidance on Good International Industry Practice (GIIP) relating to labour standards and working conditions (in line with ILO Core Conventions), refer to BII E&S Briefing Note: Labour Standards, IFC Performance Standard 2: Labor and Working Conditions and IFC Good Practice Note: Non-Discrimination and Equal Opportunity.

  • Occupational health and safety (OHS)

    Risks for the business
    • Companies may face prosecution or fines if workers or contractors are injured or killed.
    • Poor OHS practices can lead to damage or loss of company assets, clients and business as well as increased insurance premiums and even legal claims.
    • Low workforce morale and erosion of trust can lead to higher staff turnover, lower productivity, additional training and recruiting costs, and reputational damage.
    • Workers especially in hospitals may risk exposure to infections and diseases
    • Life and fire safety is a key risk as patients can be less mobile. Oxygen, machinery and equipment further complicate emergency plans.
    Opportunities for the business
    • Proactively involving workers and contractors in key decisions can help to identify and maintain good OHS practices, and improve implementation if found to be significantly different to existing practices or new practices adopted.
    • Quality of service can be improved and insurance premiums for workers’ and compensation payments can be reduced.

     

    OHS is an important consideration for any business, regardless of sector and all companies should have in place appropriate OHS and emergency preparedness and response management systems, commensurate with level of risks. Measures should also be in place to ensure contractors work in accordance with applicable regulations and GIIP.

    Where contractors are involved in operation and maintenance activities, companies should implement measures to ensure contractors work in accordance with applicable regulations and GIIP. Such measures should be covered in companies’ OHS and emergency preparedness and response management systems.

    Specific OHS risks in the food and beverage industry include those in connection with:

    • Biological hazards (e.g. exposure to infections / diseases)
    • Physical hazards (e.g. long working hours, repetitive work, slips on wet or food contaminated floors, food preparation and sharp knives, strains and hard labour associated with grounds management/furniture movement/installation for conferencing).
    • Exposure to noise (e.g. laundry, entertainment facilities, facilities management).
    • Chemical hazards (e.g. chemicals used in cleaning/disinfection operations and cooling systems (ammonia), pesticides used in landscaping and grounds management, chemicals used in pool maintenance).
    • Fire (e.g. ensuring patients , staff and guests are protected and evacuated).

    For further general guidance on GIIP relating to OHS, refer to BII Briefing Note: Occupational Health and Safety, IFC Performance Standard 2: Labor and Working Conditions, World Bank Group General EHS Guidelines, World Bank Group EHS Guidelines for Health Care Facilities and BII Good Practice: Preventing Fatalities and Serious Accidents.

  • Resource efficiency and pollution prevention

    Risks for the business

    ·         Fines and penalties can be imposed for non-compliance with national pollution prevention standards and waste management.

    ·         Excessive expenditure on energy and water supply.

    ·         Excessive expenditure on management of emissions, solid waste and wastewater.

    ·         Reputational risks linked to poor waste management practices.
    Opportunities for the business

    ·         Lower operating costs, reduced environmental footprint and future proofing for resource shortages or increased resource costs can result from adopting energy efficiency, water efficiency and cleaner production measures.

    ·         Improved access to market and customers and enhnced reputation from adoption of certification standards such as EDGE green building certification and/or ISO 20121 (green event management).

    ·         Waste reduction: especially plastic waste reduction and waste-to-energy opportunities from food scraps

    ·         Renewable energies for example rooftop solar

     

    Energy efficiency: The healthcare sector can be a large consumer of energy. Companies often require continuous energy for medical devices, lighting, air conditioning, refrigeration, entertainment and security systems. Therefore opportunities for improved energy efficiency or the use of renewable energy should be explored and where possible implemented.

    To a large extent, this is often achieved during the design phase (see BII Project Design and Construction Guide) when energy efficiency measures can most easily be incorporated into the operational practices of hospitality facilities (e.g. training of staff, encouraging guest contribution to energy conservation, ensuring preventive maintenance and updating to more energy efficient products when replacing appliances. There are many organisations who can assist with the resource-efficient design of buildings ultimately leading to economic and environmental gain in the areas of energy, water and embodied energy.

    Companies in the healthcare sector can undertake a material process flow / input-output analysis to identify ways in which resource use and waste volumes can be reduced. The company may choose to engage external experts who would be able to conduct this type of exercise. Effective analysis could eventually lead to process optimisation, reduced spending on materials and, therefore, costs savings on procurement and ultimately waste disposal.

    Due to the nature of operations, healthcare facilities are very energy intensive. It is important to have good data-management systems in place to track energy consumption and identify hotspots. There is plenty of scope to implement energy-efficiency measures and reduce energy consumption. A reduction in kilowatt hours per occupied bed would not only save on electricity bills but also reduce a hospital’s carbon footprint. Solar water heating and optimal use of renewable energy sources are other measures that can be explored which may result in revenue generation, such as the company exporting excess energy to the grid.

    Some of these measures may require larger capital expenditure to replace old equipment (lighting, air conditioning units, chillers, medical machinery, heat pumps) and may have a longer payback period. Therefore, it is important conduct a good cost-benefit analysis before deciding on investments for energy efficiency. Other initiatives, including behavioural changes and campaigns, can provide fairly quick returns.

    Air emissions: The bulk of air pollution from healthcare operations stems from on-site power generation (particulate matter and GHGs), and ozone depleting substances from large HVAC systems. Particularly where older or poorly maintained equipment is used.. Air emissions control and monitoring measures should be implemented by companies in accordance with the applicable regulations and standards.

    Waste management: Effective waste management is material to the healthcare sector as operations often generate large volumes of hazardous and non-hazardous waste. Given the nature of the sector, there are often stringent regulations in place for the safe disposal of biomedical and hazardous waste and companies may face strict penalties if these regulations are not adhered to.

    Such wastes include (but are not limited to) infectious, pathological, needles and sharps, chemical, pharmaceutical, genotoxic and radioactive. It is important to extend the due diligence scope to waste-disposal vendors the company engage with to check that they are adequately licensed and practising according to local laws and regulations – particularly in terms of waste segregation, handling, treatment and disposal. Other typical non-hazardous waste streams include electronic waste, paper, food and general waste. A good way to manage waste is to begin tracking all waste categories by volume over a certain period. By gaining a better understanding of waste generation, the company can set targets to reduce waste volumes, purchase and disposal costs, and storage times.

    The company should engage with all stakeholders who may be affected by its waste, through provision of adequate awareness raising and training, PPE and building secure waste-storage areas. The company should also conduct regular monitoring and testing of waste management and disposal methods to ensure that it meets regulation

    Water / wastewater management: Water consumption is significant for healthcare facilities and may pose material risks to the company if facilities are located in water-stressed regions. As per energy management below, it is important to have good data-management systems in place to track water-consumption levels and identify hotspots. Effective water management can lead to reducing, reusing and recycling water in order to improve the company’s water footprint and mitigate against future water-scarcity threats.

    Typical water-efficiency practices may range from simple changes such as fixing leaks and installing low flow-faucets to larger capital expenditure optimisations, such as recirculating treated water from Sewage Treatment Plants.

    For further sector-specific guidance refer to World Bank Group EHS Guidelines for Health Care Facilities.

    For further general guidance on GIIP relating to resource efficiency and pollution prevention, refer to BII E&S Briefing Note: Resource Efficiency, BII E&S Briefing Note: Pollution Prevention, IFC Performance Standard 3: Resource Efficiency and Pollution Prevention, and World Bank Group General EHS Guidelines.

  • Community health, safety and security

    Risks for the business

    ·         Social licence to operate can be put at risk if appropriate Life and Fire Safety measures are not implemented. Failure to do so can also lead to claims from customers.

    ·         Indirect risks to communities can arise from increased numbers of job seekers or criminal elements moving into the area.

    ·         Reputational damage and loss of licence to operate if excessive, intimidating or aggressive use of force by security personnel is used against communities.
    Opportunities for the business ·         Building relationships with local communities can help to improve reputation, widen the customer base and provide a bigger potential labour pool.

     

    Life and Fire Safety: This is vital to the health care sector. All buildings used by the general public should meet the highest standards for Life and Fire Safety (LFS). LFS should be taken into account at the design and construction phase, as retrofitting can be costly. Monitoring and maintenance systems should be implemented during operations. Companies should design and implement emergency response measures and plans to protect the public (e.g. clear signs for evacuation routes and the installation of smoke detectors and sprinklers). See below.

    Emergency preparedness and response: Like LFS, emergency planning and preparedness including fire and life safety is a fundamental requirement of healthcare facilities and companies should pay close attention to this during due diligence to ensure that it is well managed. Neglect in the governance of emergency preparedness and response issues which then contributes to harming patient and public safety can result in criminal liability for board members and senior management.

    It is important that hospitals install proper firefighting systems and conduct regular mock drills related to disaster management and fires, based on clear emergency response plans and procedures. Regular internal audits should also be conducted to check that firefighting equipment is working and stored properly and that no emergency exits are obstructed. Access roads shall be kept clear so that emergency services are able to easily enter the facility without facing delay and obstructions. Companies shall nominate and train a fire and emergency response team at each healthcare facility who would be responsible for coordinating and managing staff during such events and to ensure compliance with national fire safety codes.

    Local community safety: Hospitality operations can cause safety risks for local communities through increased traffic and population. Customer volumes should be taken into account when planning and managing parking and road access and existing traffic patterns and road use should be assessed when planning deliveries.

    Health: Health care operators should ensure that activities minimise and wherever possible prevent negative health impacts for nearby communities and the environment.

    Security: Many health care companies employ security staff to protect patients and visitors and the premises. When using security forces, companies should be guided by the principles of proportionality, good international practice and applicable laws for hiring, rules of conduct, training, equipping and monitoring of security personnel. Particular attention should be paid to any human rights violations from terrorism and sabotage and the potential for social conflict and unrest instigated by security personnel. Such principles include practices consistent with the United Nation’s (UN) Code of Conduct for Law Enforcement Officials and UN Basic Principles on the Use of Force and Firearms by Law Enforcement Officials.

    For further sector-specific guidance refer to World Bank Group EHS Guidelines for Health Care Facilities.

    For further general guidance on GIIP relating to community health, safety and security, refer to IFC Performance Standard 4: Community Health, Safety and Security, UN Code of Conduct for Law Enforcement Officials, UN Basic Principles on the Use of Force and Firearms by Law Enforcement Officials and Voluntary Principles on Security and Human Rights.

  • Patient quality of care

    Many aspects of E&S management are linked to improving clinical aspects of patient quality and care such as waste and infection control, emergency response procedures, facility management and grievance handling procedures. Additional aspects which relate to quality of care are beyond the scope of this briefing note but form key elements of best practice healthcare accreditations that can help a company gain international recognition. See ‘Guidance on certifications and standards’ below for further information.

  • Corporate social responsibility

    Given the close relationship with public stakeholders, healthcare companies may also wish to consider developing corporate and social responsibility (CSR) programmes. Not only will this improve the company’s reputation and social licence to operate, it also helps employees find greater satisfaction in their job and potentially feel increased pride in their workplace. Healthcare providers are in a prime position to provide health-related CSR support. Some ideas include:

    • Investing in telemedicine and e-health centres to service remote and rural communities.
    • Partnering with local NGOs to provide healthcare camps and awareness raising.
    • Mobile healthcare clinics for diagnostics and preventative care.
    • Equipping primary healthcare centres to deliver affordable care.
    • Supporting medical training for the next generation.
    • Investing in medical research.

  • Antimicrobial Resistance
    The healthcare sector has a vital role to play in reducing antimicrobial resistance (AMR). Drug-resistant infections that require more expensive antibiotics will increase diagnostic and treatment costs for healthcare providers. Vulnerable patients, including new-borns and the elderly, could face an increased risk of mortality from drug-resistant bacteria. Hospitals, where the risk of disease spread is high, need to take urgent action to mitigate AMR risks.

    Proactively identifying and managing AMR risks and impacts can put companies ahead of the curve, helping them to reduce operating risks and avoid regulatory penalties or public censure. Investors are in a unique position to set market-leading requirements linked to AMR, and support companies through the implementation and monitoring of those requirements.

    Risks for the business
    • Reputational damage, fines and penalties from AMR-derived incidents, particularly given the increasingly litigious nature of the healthcare sector and the risks posed by inadequate patient quality of care.
    • Reputational damage, fines, and penalties due to environmental pollution from the disposal of antimicrobials.
    • Negative media coverage and civil society campaigning if companies do not take action to reduce AMR.
    • Negative business implications due to the changing legislative landscape regarding antimicrobials prescription and use.
    Opportunities for the business
    • Investing in strategies to enhance diagnostics, antimicrobials waste management practices and hygiene habits will help companies to prevent future operational shocks.
    • Improved brand value and reputation if reducing AMR becomes part of company strategy.
    • Preparedness for regulatory changes regarding the diagnosis and prescription of antimicrobials.
    • Preparedness for greater emphasis from the health insurance sector on AMR reduction.
    • Better equipped with hygiene practices, leading to improved patient safety and health and enhanced operations overall.

    Measures to reduce AMR

    • Include antimicrobial resistance as a core component of communication and educational programmes: Implement educational training aimed at healthcare professionals. Programmes should include information on disease prevention, control of infections, appropriate storage conditions of antimicrobials and the proper disposal of unused or expired products.
    • Develop or contribute to AMR surveillance systems: Use surveillance systems to improve the understanding of resistance trends, monitor the effectiveness of antibiotics, inform appropriate antibiotic and vaccine use. More broadly, companies can also collect and share data on antimicrobial use through sector-wide surveillance schemes. Laboratory capacities and related infrastructures should be strengthened to actively contribute to surveillance on AMR. This could be done through stakeholder engagement and alliances.
    • Guarantee responsible access: Partner with stakeholders on models that support appropriate patient access and a sustainable supply of antibiotics and AMR-relevant vaccines, preventing substandard and falsified medical products reaching patients.
    • Enhance diagnostic tools: Rapid diagnostics are essential to ensuring that the use of antimicrobials achieves the best patient and public health outcomes. Each patient should receive the right antimicrobial, for the right pathogen, at the right time. This means both knowing what pathogen is causing the infection, how best to treat it, and how to do so in the fastest possible timeframe.
    • Promote vaccination: Contribute to slowing the emergence of resistance by promoting universal vaccination for high-burden diseases that contribute to AMR.
    • Ensure effective environmental risk-management strategies: Implement measures to reduce the environmental impact of antimicrobials through setting science-based discharge limits.
    • Improve hygiene and prevent the spread of infection: Improving hygiene and sanitation in the healthcare system is crucial to counteracting increased drug resistance. Healthcare facilities should implement and monitor their practices based on the WHO Multimodal Hand Hygiene Improvement Strategy (MHHIS).

    Further resources WHO: Hand hygiene monitoring and feedback

 3. Business integrity considerations

Fund managers should ascertain and continue to ensure that companies (regardless of sector) comply with the fund’s business integrity requirements. For further information, see Governance and Business Integrity.

  • Business integrity issues specific to the healthcare sector

    Business integrity is relevant to a number of areas within the healthcare sector. These range from health system governance and regulation, to delivery of healthcare services; from research and development, to procurement, storage and distribution.

    Healthcare companies should have clear assessment and mitigation processes in place to manage the risks associated with their particular area of healthcare.

4. Advice for fund managers

See also BII Environmental and Social Checklist and BII Governance and Business Integrity Checklist and ESG in the Investment Cycle.

  • Sector risk overview

    There are a number of ESG issues that may be material to the long-term value of health care companies, as described earlier in this Sector Profile. These risks will vary depending on the specific circumstances and geographies of each company. Fund managers should expect to find that while the ESG risk and impacts can be complex, they can usually be addressed through the application of widely-used, proven techniques and management practices (although this will need to be assessed on a case-by-case basis). External consultants can be engaged to advise on ESG matters, depending on the nature, scale and location of a company’s operations, its track record and the fund manager’s expertise and capacity to conduct appropriate E&S due diligence.

    Fund managers should take note of any investors’ Exclusion Lists (e.g. Schedule 6 of BII’s Code of Responsible Investing) as some of the exclusions typically included relate to activities in the hospitality/entertainment sector (e.g. gambling, gaming or associated activities).

  • Scoping consideration

    In addition to the aspects highlighted above, fund managers should take into account the following during the life of the investment:

    • Associated facilities (e.g. access roads).
    • Contractors whose operations present significant E&S issues which could have an impact on the business (e.g. cleaning staff).
    • Supply chains (e.g. food suppliers or medical suppliers). Even where a company cannot directly address risks because it lacks leverage or commercial influence, it is important that fund managers are aware of the risks. For further guidance refer to BII E&S Briefing Note: Supply Chains.

  • Situations requiring extra attention

    Extra attention, longer timescales, more intensive ESG due diligence and ongoing company engagement may be required in more complex situations. This may involve engaging consultants (see BII Guidance: Working with Consultants) to conduct a gap analysis against the applicable local and international E&S standards (e.g. IFC Performance Standards and World Bank Group EHS Guidelines).

    Examples of activities or situations in the healthcare sector which require extra attention include:

    • New projects/expansions: Greenfield construction, major expansion projects where the scale of operations carries a high risk of major social or environmental impacts, projects involving land acquisition or where the site is in a sensitive location (e.g. close to protected natural habitats). See also the BII Project Design and Construction Guide.
    • Geographies in which the retention of original professional certificates is common practice as this can constitute a form of bonded labour.
    • Geographies with poor Life and Fire Safety Standards / regulations.
    • Transactions and geographies with high business integrity risks.
    • Any other activities or projects involving involuntary economic and/or physical displacement of communities or significant adverse impacts on biodiversity or ecosystem services, Indigenous Peoples, cultural heritage, or local communities: There are no intrinsic features of the healthcare industry that predispose the sector to be associated with such impacts and risks (other than through the primary supply chain), but such issues may arise on occasion and should be managed in accordance with the applicable IFC Performance Standards.

5.Standards, guidelines, and other resources

For authoritative guidance, fund managers should consult the applicable IFC Performance Standards and World Bank Group EHS Guidelines.

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