case study presentation:

Turkey Hospital PPP Project

ESCAP Second Thematic Workshop of the Infrastructure
Financing and Public-Private Partnership Network of Asia
and the Pacific

March 2021
ICBC at a Glance
Integrity Leads to Prosperity

Turkey Hospital PPP Project

Structure and Mechanism

2
ICBC at a Glance Integrity Leads to Prosperity

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ICBC at a Glance Integrity Leads to Prosperity

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ICBC at a Glance Integrity Leads to Prosperity

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Hospital PPP Project in Turkey Structure and Mechanism

Good practices in the preparation of PPPs

The Ministry of Finance or central budgetary authority assesses, accounts for, and signs off on the long-term fiscal implications
of a project both before launching procurement and signing a contract.
There is a system in place to track the fiscal impact of PPPs such as inclusion of PPP projects in the budget, accounting for and
reporting on them.
The project is selected, assessed, and prioritized together with all other public investment projects in accordance with national
public investment plans and strategies.
The project is adequately justified based on the following types of assessments:
The results of the above-mentioned assessments are included in the tender documents.
The results of conducted assessments are published online.
The tender documents are published online.
The procuring authority prepares a draft PPP contract and includes it in the request for proposals and/or tender documents.
The procuring authority has developed standardized PPP contracts and/or transaction documents to facilitate the procurement
process and to guarantee consistency.

source: <Benchmarking Public-Private Partnerships Procurement 2020>

Hospital PPP Project in Turkey Structure and Mechanism

1. Overview of the Turkish PPP Healthcare Programme

As a result of rapid increasing demand for healthcare services, Turkey’s Health Transformation Programme(HTP) was
introduced by the government in 2003 to enhance the accessibility, efficiency, and quality of healthcare facilities.

The HTP aimed at increasing the administrative and financial autonomy of hospitals.

Facing constraints on public resources and fiscal space, while recognizing the importance of investment in
infrastructure to help their economies grow, governments are increasingly turning to the private sector as an alternative
additional source of funding to meet the funding gap.

• Creating a new modern and efficient public health infrastructure.

• Increasing number of beds.
• Upgrading current beds to qualified beds.
• Bringing together small hospitals under one campus to consolidate and save on operation expenses.
• Increased service quality and efficiency.
• Expansion and improvement of medical education and training.
Hospital PPP Project in Turkey Structure and Mechanism

2. ICBC's paticipation in hospital PPP projects in Turkey

There are 18 hospital projects implemented on PPP basis in Turkey, with more than 27,000 beds. Some of them are ongoing and
some of them are already in operation.
ICBC paticipated in several hospital PPP projects in Turkey , two Projects in operation are as follows:
Bursa Hospital PPP
 1,355 beds integrated healthcare campus located in Bursa.
 Project cost is EUR 487 mio.
 the hospital is operational as of 16 July 2019.

Elazığ Hospital PPP

 1,038 beds integrated healthcare campus located in Elazığ.
 Project cost is EUR 360 mio.
 Elaz ı ğ Integrated Health Campus is operational as of 1 August
2018.
Hospital PPP Project in Turkey Structure and Mechanism

3. Structure of the Hospital PPP project in Turkey

MoH Direct
Agreement
Project
Agreement
Shareholders’ Loan
Agreement
Sponsors Project Company
Facility
Lenders
Direct
EPC O&M Agreement
Contract Contract

EPC Contractor O&M Contractor

Direct
Agreement

The Structure of the Hospital PPP project in Turkey is standared and typical.
Hospital PPP Project in Turkey Structure and Mechanism

3. Structure of the Hospital PPP project in Turkey

Average Concession Period: 28 Years

3 Years 25 Years

Investment Operation
Period Period

Highlights of the Project Agreement

 The SPV is required to provide at least 20% Equity.

 Investment period starts with Site Delivery.
 SPV is responsible for the construction or renovation of the health facilities on a
Build and Lease Basis, and provide the services in health facilities other than
medical service.
 Market testing protects SPV to level service prices with market conditions.
Hospital PPP Project in Turkey Structure and Mechanism

4. Payment Mechanism of the Hospital PPP project in Turkey

The Project revenues that are denominated in Turkish lira (“TRY”) will comprise Availability Payments, Service
Payments and Commercial Revenues.

+ Commercial Revenues

Availability Payments Service payments Commercial Revenues

is paid mainly for the CAPEX of the
project, to cover the debt servie and
equity.
is paid to cover the OPEX of the project. the payments is related to commercial
consist of a) Non-Volume Services and b) Volume activities in the project.
Services. Volume Services further divided into Medical
support services and Service support services.
(MoH guarantee certain volumes for volume based
services )
Hospital PPP Project in Turkey Structure and Mechanism

4. Payment Mechanism of the Hospital PPP project in Turkey

4.1. Availability Payments: Payable in advance by the Administration to the Project Company at the beginning
of each quarter in consideration of usage of the health facilities during the relevant period.

 Payable quarterly in advance and denominated in TRY.

 Collected independent of hospital occupancy rates (Fixed Income), and the deduction is caped at 10%.
 Guaranteed by MoH.
 Adjusted quarterly by inflation and devaluation (Protection).
 The correction factor (CF) provides mitigation should currency devaluation be more than inflation such that
the EUR value of the AP cannot be lower in any period than the preceding period.
Hospital PPP Project in Turkey Structure and Mechanism

4. Payment Mechanism of the Hospital PPP project in Turkey

4.2. Service Payments: are the maximum net amount payable to the Project Company in consideration of the provision of
the services by the Project Company excluding VAT and any other taxes and duties that are payable. Service payments
shall be made by the Administration to the Project Company on a monthly basis.

 Payments will be paid by monthly by the MoH to the SPV in TRY.

 19 support services (P1+P2) will be provided by the SPV; 12 non-volume services and 7 volume services.
 The deduction is caped at 20%.
 MoH guarantees a minimum 70% of the potential volume based services.
 Payments will be adjusted by inflation annually; each period at the average of Turkish CPI and Turkish PPI (except
medical support services).
 Medical support services (which are all volume based) are not adjusted by inflation. The unit price of these services are
increased periodically in line with nationally agreed unit prices for medical services by MoH.
 Market Test will be conducted for each service every 5 years in order to ensure and maintain the competitiveness of the
price. If market test is lost, MoH guarantees mark-up for overhead costs of SPV.
 Capital intensive and specialized services such as imaging, lab, etc. will be outsourced (via sub service agreement).
Hospital PPP Project in Turkey Structure and Mechanism

4. Payment Mechanism of the Hospital PPP project in Turkey

4.2. Service Payments

Services Category Market Testing
P1 - MANDATORY SERVICES
Estate non-volume
Extraordinary Maintenance non-volume ×
Utilities non-volume
Other Medical Equipment Support non-volume
Furniture non-volume
Grounds & Garden (Landscaping) non-volume
P2 - OPTIONAL SUPPORT SERVICES
Pest Control non-volume
Car Parking non-volume
Cleaning non-volume
HIMS (IT) non-volume
Security non-volume
Patient Guiding/Portering/Reception/HelpDesk non-volume
Linen (Laundry) volume - support
Catering volume - support
Waste Management volume - support
Laboratories volume - medical support
Imaging volume - medical support
Sterilization and Disinfection volume - medical support
Rehabilitation volume - medical support
Hospital PPP Project in Turkey Structure and Mechanism

5. Termination Mechanism of the Hospital PPP project in Turkey

No. cause of Termination Compemsation on Termination

1 Project Company Default Equity Expenses + Senior Debt Termination Amount + cost due to early termination

Equity Expenses + Senior Debt Termination Amount + cost due to early termination +
2 Administration Default
loss of profit calculted according to the Financial Model

Equity Expenses + Senior Debt Termination Amount + cost due to early termination +
3 Force Majeure
loss of profit calculted according to the Financial Model

The Senior Debt is 100% covered in any scenarios.

The Senior Debt Termination Amount will be paid directly to the lenders, without any objection.
Hospital PPP Project in Turkey Structure and Mechanism

6. Key Attractions of Turkish PPP Program

Key Attractions of Turkish PPP Program

Payment adjustment against Inflation and FX Capped Variation Orders (1% and up to 20%)

Capped Deductions (20% of Service, 10% of Availability) Protection against Change in Law

No Double Counting for Deductions and Penalties Insurance Risk taken by MoH if insurance not available

Market Testing for Services (every 5 years) VAT Exemption for CAPEX

Lenders sign Direct Agreements with the MoH ICC International Arbitration for Dispute Resolution

Compensation at Termination for Loan & Equity

Hospital PPP Project in Turkey Structure and Mechanism

6. Key Attractions of Turkish PPP for lenders

PPP projects in Turkey allow free use of government-owned land and

expropriation.

Certain PPP projects provide minimum revenue guarantees.

Lenders’ step-in rights allow the lenders to select, with the consent of the
procuring authority, a new concessionaire to perform an ongoing PPP
project in cases when the initial private partner is at risk of default.

The government will pay the ermination on compensation, and the debt
will be fully covered in any circumstances.
Hospital PPP Project in Turkey Structure and Mechanism

7. PPP Legal Scores of Turkey by World Bank

Turkey got 75 in the score of PPP contract Management, which is above the average of ECA countries and Upper Middle Income
countries.
Hospital PPP Project in Turkey Structure and Mechanism

8. The COVID-19 Effect on Hospital PPP project in Turkey

COVID-19 is expected to have an impact on the full spectrum of the Project lifecycles of Hospital
PPP Projects in the short-, medium-, and long-term.

Due to pandemic, inpatient occupancy ratio and daily admitted patient number has decreased.

Some of the Hospital PPP Projects are designated as the“pandemic hospital” for the COVID-19
infected citizens in the Cities of Turkey. These hospitals are included in detailed COVID-19
Pandemic Management Plan of Turkey and the plan includes an action table for COVID-19
management in the hospitals, the actions have been defined for all these issues and the relevant
actions are being continuously taken.
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Contact:

Mr. Zhang Jianjun Mr. Ahmet Can YAKAR

Tel: (8610)66104638 Tel: +90 (212) 2762561
Email: zhangjianjun@icbc.com.cn Email: ahmetcan.yakar@icbcyatirim.com.tr
Global Finance Dept., ICBC Head Office Project Finance Dept., ICBC Turkey
Beijing, China Istanbul, Turkey