Mukul Asher, V Ramakrishnan
Public-Private Partnerships (PPPs) describe a government infrastructure and or service or private business venture funded and operated through a partnership between one or more governments, one or more private sector companies and civil service organizations. These could be at any level of government and cover the construction, operations, and maintenance phases.
The Covid-19 Pandemic underscored the vital importance of a sound health sector infrastructure and management capable of coping with unexpected demands on healthcare resources. There is a widespread acknowledgement that India managed the Covid-19 Pandemic well. To illustrate, as of 10 November 2022, there were 638. 9 million cases (81,963 per million population) and 6.61 million deaths (848 deaths per million population). In contrast, India’s cases were lower at 39 per cent of the global cases, and deaths at 44 per cent of the global average per million population1.
India’s rapid action to limit the spread and oversee the rapid development, testing and roll-out of locally developed vaccines-among very few countries to develop effective, affordable vaccines- helped arrest the spread and contain the virility. The vaccines have been used globally and won India much goodwill for its generous sharing.
The four primary case studies from Coonoor, Tamil Nadu, were undertaken through personal interviews by Mr V. Ramakrishnan, co-author of this column, between April and August 2022. They illustrate different facets of delivering health services and amenities during the Covid-19 Pandemic, leveraging the PPP construct, despite extensive and frequent lockdowns and disruptions of daily activities.
In all four cases, the importance of local leadership, trust among the stakeholders, and a clear focus on the outcomes designed to improve citizens’ healthcare access and affordability have been vital ingredients. These also illustrate the extent to which local capabilities can be structured in PPP mode to contribute to meeting India’s health care and similar challenges.
Primary Case Studies
Primary Case Study 1: This study involves the purposeful delivery of health support infrastructure.
A small group of well-to-do individuals became sensitive to the suffering of average residents brought on by limited healthcare infrastructure in the Nilgiris, a hilly area nestled in the Western Ghats in India.
They joined hands with an overloaded local government, panchayat authorities, and the police to get massive efforts going in a PPP mode and deliver the outcomes set out to support healthcare in a very limited time. The intent was to assist both long-term residents and migrant labour. The rudimentary and dilapidated care centres were overwhelmed and could not meet the basic needs of the common people in the hills. The awareness that action was needed, and urgently at that, came in the second wave of COVID in the region.
The PPP resulted in renovating decrepit public health services, building new facilities, equipping the old and new care centres, providing transport, delivering supplies to tribals in remote areas, and supporting migrant workers.
The outcome was that the Nilgiris had amongst the lowest mortalities during the Pandemic, despite being in a hilly area. This was a remarkable outcome of the PPP, improving citizens’ welfare.
How were the Outcomes Achieved?
Two key individuals at the local level played a leadership role in this PPP. These were Radhika Shastry, an experienced international manager in the travel industry, now the owner of a gourmet café, and Charles Nathan, a resort owner, a plantation manager and native of the hills, who brought to bear his considerable knowledge of the hills, the terrain and with a sound local network. They reflected on what they could do to help fill healthcare amenities and delivery gaps. They were unknown to each other till the urgency of the common goal brought them and a few other like-minded people to gather.
The individuals mentioned above were aware of PPP in generic terms and believed it could deliver substantial value in the local Indian context. There is no need to depend on the administration and government for all needs.
The outcomes they set were simple and clear. They focused on helping to develop a quality, state-of-the-art health infrastructure to deliver affordable healthcare through the government hospital in Coonoor. Initially, it related to treating COVID and ensuring its sustainability in better times when the crisis has passed.
The PPP was structured with the intent of delivery of health care. All projects were time-bound, and funds were crowdsourced. No government funds were sought. Critically, the local administration helped provide timely requisite clearances and support and arranged for assistance from the electricity and public works departments. In the literature, the importance of speedy clearances and strong support of the local administration for the success of the PPP is often underemphasised.
When donors began to trust the intent (niyat) and integrity of the team, needed funds were forthcoming spontaneously. These funds were routed through a registered NGO, which also made-up fund shortfalls, to ensure accountability, which is key in raising and spending such large sums as were disbursed.
Private individuals combined with local government enthused a vast array of donors- small and big- to contribute. As Corporations and NGOs tended to be both bureaucratic and self-seeking, diverse funding sources helped expedite the progress of the PPP.
The organisation structure was informal, and often the leaders met with teams on-site rather than in offices. They created a small and focused organisation structure, a combination of formal evolution, informal discussions and an adaptive mindset that helped them deliver projects on time, on budget, and meet the exacting quality standards required in medical equipment.
The informal structure aided in quick decision-making. No SPV (Special Purpose Vehicles), typical of PPPs, no reporting as all reviews on the ground and targeted time-bound agendas in meetings set the tone.
Feedback was sought from locals, community heads, government, operational staff, and contractors on an ongoing basis, creating a feedback loop. This enabled quick and effective review and correction.
Not only was the local population, the community elders and shopkeepers supportive, but many also initiated local projects on their own, on a smaller scale of their own accord. They witnessed the outcomes and got inspired. This may be termed the demonstration effect arising from this PPP case study, which helps channel the energies of the stakeholders in a more constructive, positive manner.
The local group of well-knit, committed individuals undertook detailed research, the selection, and negotiations for and the installation of the equipment, commissioning the medical equipment, training the operators and maintenance staff, fund sourcing, reporting, documentation, communication, and media management. The projects, equipment, and funding were based on research and on, connecting with the donors and doing all the paperwork required.
Local, level competencies are often not fully utilised, but this PPP helped overcome this aspect. This also illustrates the need to develop a diverse set of competencies at the local level.
In less than a year, this PPP helped deliver four critical sub-projects at a local level in a short time. First, the PPP helped populate the care centres with oxygen concentrators, which were then in short supply. Second, learning from the media that funding for oxygen generators and ambulances from donors was available, they contacted and obtained funds to install a large oxygen plant for the decrepit government hospital and six autorickshaw ambulances to transport sick and medical staff in the hilly district. The ambulance initiative received national coverage for its innovative approach for a three-wheeled vehicle capable of navigating narrow roads and hilly terrain.
Third, the PPP helped trigger a complete revamp of several facilities in the hospital- the casualty ward, a new pediatric centre and the modernisation of a dilapidated ICU. Fourth, the projects required repairing and modernising heritage buildings (some close to a century old).
The group helped set up a series of facilities through a PPP, which neither they nor the government could have set up individually. The learnings from this primary case study are- to stay focused, set challenging timelines, look ahead, and avoid knee-jerk responses.
All facilities created are now in daily use for the benefit of the local population at all income levels who otherwise had a two-hour drive to the plains to get the treatment.
Due to this local PPP, healthcare has become affordable for many people. Locals who tended to avoid government hospitals now prefer them in large numbers. A major benefit has been that those high-income individuals who would drive up to 100kms for basic and secondary care now get treated in government hospitals. Being well-to-do in local community affairs constructively helps build social capital. Further, what doctors viewed as punishment posting is now a sought-after location for many.
POST SCRIPT: The group has now crowd-sourced funds to set up a mortuary in a private hospital linked to a leading medical college in the state to serve the area.
Primary Case Study 2
This PPP at the local level focused on organising to deliver daily needs and basic infrastructure during the Covid-19 Pandemic.
The main towns in the Nilgiris- Ooty and Coonoor- are about three hours from a major urban centre in the foothills. The government’s public health system was the residents’ main source of health care. While decent in normal times, transport services came to a complete halt during the Pandemic. In this hill town, much of the goods and services had to be obtained from the plains- a massive task in a lockdown.
One of the consequences was that food security, especially for locals in remote areas and for migrant labour, became inadequate. Moreover, simple requirements for quarantine, such as bedsheets, pillows, and blankets, were in short supply.
Local leadership for this PPP was provided by the Sancheti family, an old and established family of traders settled in the hills for over three generations. They are also involved in manufacturing, garment sector activities, construction, and real estate. Philanthropy has been a long-cherished ethos of the family. Their spokesperson was aware of the potential of PPP in the infrastructure sector though he had not been involved in one. This PPP indicates a huge need for and big potential for developing infrastructure and delivering health and related outcomes using the PPP model at the local level.
With Covid related lockdowns paralysing the movement of essential goods, people, healthcare workers and labour, the family decided to extend the scope of their social work that hitherto was focused on girl child support. They reoriented their administrative structures and processes to locate worthy projects, raise funds from family, friends and well-wishers and support the execution of projects conceptualised and overseen by like-minded individuals, NGOs, and their internal organisations.
The family’s reflection on the suffering gave an impetus to push hard on timelines and deliveries, be it food, blankets, bus tickets, clearances, payments of rent, and such. The local administration helped identify the beneficiaries and rendered the required support through administrative and police forces, with clearances and approvals coming expeditiously when requested.
The lack of bureaucracy within the PPP was a significant advantage. This advantage was further amplified as the local administration provided support without caveats or interference. The practice of facilitating the provision of basic resources and leaving the implementation to people on the ground worked well.
The singular outcome they concentrated on was to expand accessibility- as much support and as much assistance as required to as many people who needed it. Despite many requests made at the last minute, this was the outcome they related to and delivered.
All projects were operationalised on time, helping the beneficiaries. The PPP team delivered on what they undertook to do and won the respect of the officials, local communities, and beneficiaries. Encouraging feedback from government officials, community elders, NGOs, and individuals was spontaneously forthcoming without seeking it.
Specific Projects: This PPP supported several projects, consistent with the focus on delivery and reaching a maximum number of people. However, the tactics to pursue these were flexible depending on the need at a particular time. The Projects included revamping the derelict Public Health Centre (PHC) with an isolation ward for testing suspected covid patients; sourcing a steady supply of masks and PE kits; and purchasing and equipping a large ambulance to ferry the sick and a small ambulance to transport medical and health care workers to remote tribal areas.
In consultation with the local administration, the PPP organised food packets daily in cooperation with the PDS (Public Distribution System); provided packed meals to healthcare workers, migrant labour, and their families; and paid rent for the outstation labourers. In the later phase, the PPP funded and organised the repatriation of the labour from the hills to the plains and onward to their homes. The PPP also partly funded a kidney dialysis centre through the local Rotary Club, as the facilities in the district were limited, and the movement of sick patients was virtually impossible.
The need to speedily organise and support on multiple fronts was recognised early by the PPP leadership. The family used their resources initially and then started collecting funds from within, from their social circle, friends, and relatives. Every small donation was welcomed and acknowledged. Donors trusted the Sancheti family.
Collecting funds and distributing them quickly was the guiding principle. This suggests that the public is willing to spend for a cause if the integrity of those in leadership positions in the PPP and local administration is not in doubt. The learning is that it was possible to be self-reliant and sufficient and not rely only on the government for financial resources.
The PPP brought together diverse skill sets and covered joint working with NGOs collecting and distributing food and aid, with local administration, public distribution system for rations, panchayat and municipalities, the health authorities, and the police. This suggests that community trust and local resilience were vital ingredients in the positive outcomes achieved by this PPP.
This case study suggests that private individuals with quality support from local administration can do much good in short order in critical health sub-sectors at the local level, as illustrated by this case study. The broader research question is, would these arrangements, with suitable changes, deliver the same outcome in a non-crisis period?
Primary Case Study 3
This case study of primary PPP concerns waste management and dredging/cleaning of the Coonoor river. Coonoor is a quaint town in the Nilgiri Mountains in South India. Its salubrious climate attracts large tourist inflows during the cool summer months. Tourists bring along massive quantities of waste dumped randomly; this greatly harms the pristine environment and wildlife-rich forests.
The township of around fifty thousand inhabitants is divided into several sub-districts for administrative purposes. The waste collection was haphazard, and the dumping was not taken seriously. The river had not been desilted in decades, and plastic and construction waste choked and dammed the water flow; many houses on the banks flooded during the monsoons. The plastic choked the gutters, the drains, the forests, the roadsides, and the river- all critical to drain water during and after heavy monsoon rains.
There was a lot of talk about plastics clogging the verdant grasslands and shola forests-unique to the Nilgiris- for quite some time. The local governments, municipalities and panchayats did little to tackle this urgent environmental issue. They needed the tourists but could not control, collect or dispose of the vast waste. This would reach 8-10 times the normal waste generated in the tourist season.
Conservation measures were initiated in Coonoor before 1950. It, therefore, has a long tradition of realising the importance of environmental issues. The realisation, however, does not necessarily lead to outcome-oriented public policies. This is where the significance of this PPP lies as it sets the goal of outcome in sanitary management and cleaning of the Coonoor river.
The two individuals leading the PPP were Samantha Iyanna, a travel professional born and raised in the hills, and Dr P.J. Vasanthan, a senior doctor in the government service, specialising in treating chest and respiratory diseases and settled in Coonoor. Their goal was to find a solution to the problem of flooding culverts and the Coonoor river. Given the heavy rains, the choked water channels and gutters posed a serious health risk.
The leadership of the PPP decided that they needed to act to clean up the plastic that was overwhelming the population, flora and fauna.
How Was the PPP Structured?
The PPP leadership approached the local administration for permission to clear the plastic waste. At the suggestion of the District Collector, they undertook the manual collection of plastic and physically cleaned the rubble and silt choking the drains.
They planned and cleared a major tourist attraction as a pilot. The results were encouraging, so they expanded the scope to cover the town. Around 500-600 tons of waste was removed and moved, without mechanised equipment, through and by local volunteers working on weekends for months on end.
Disposing of the rubble and silt posed a huge problem. The only dumping ground was a municipal waste dump renowned for its filth and overpowering stench. Undaunted, the PPP leadership sought and got permission from the municipality to convert an eye sore of a dump yard into a waste management centre. The landfilled with rotting vegetation, offal, and waste was made over along with crumbling buildings of the municipality by an NGO the two leaders of the PPP cofounded called Clean Coonoor. The town provided electricity and water as well as waste collection from in and around the town.
Transportation was an issue but had to be done, as was running the sorting and baling centre. The clearances for well-protected staff to collect waste were given in short order, and during the lockdowns, waste was collected, sorted, and shipped out. This primary PPP case study suggests that the willingness of the administration to support well-intentioned citizens to deliver socially relevant and high-impact low, visibility projects is critical.
The outcome the NGO has set for itself was 100% collection of waste and ZERO waste residual of the town and its expanding periphery. This is an ambitious goal. The NGO has progressed to collect around 50-60% of the waste, around 3.5 tons, against an estimated generation of 6 tons per day. Now plans are being laid to increase the collection of dry and wet waste.
Through its NGO vehicle, the PPP also wants to set up a wet waste centre to convert it into compost. The intent is to ensure the operational cost break-even point as soon as feasible. The move is to scale up the operation, for which a switch to an active waste collection system is essential. This has been initiated recently, and the NGO is reaching out to the residents to hand over waste to the collection vehicles under deployment.
Clean Coonoor NGO had to provide the oversight, management and supervision of the facility refurbished and equipped with balers and other equipment through generous and environmentally and socially conscious private donors. The sale of sorted plastics covers approximately 30% of the operating costs; donors and the government-mandated CSR (Corporate Social Responsibility) funds contributed for the rest. The concept of cost-recovery has therefore been incorporated by the NGO in the PPP.
The NGO employed and trained local women and men to physically sort the waste and bale it for transport to factories that extract oil from it. They composted a beautiful garden from the wet waste consisting primarily of local flora. The operational costs are borne by various donors who make up the monthly shortfall. Subsequently, the PPP leadership also persuaded a donor to fund the dredging of the Coonoor river that runs through the spine of the town.
This primary case study suggests that a group of committed citizens can significantly improve waste management and river repair. The PPP was undertaken without formal permissions, initial grants, and a formal contract agreement. The community felt relief, just relief, that somebody is undertaking dirty, dangerous, smelly waste management and river repair work. The Covid-19 Pandemic acted as a nudge for people to be more disciplined in waste disposal. It is hoped this will continue after the pandemic is over.
This local, informal PPP has delivered very satisfying results quickly. With the PPP-led arrangements in place, the heavy rains showed their value as Coonoor was flood free after many years.
This primary PPP case study also suggests that it is desirable to clearly define who at the local, state, and national levels is accountable for what and who is responsible for delivering what. Informal structures are a good starting point, but as administrators retire and rotate, a more organised and clear-cut division of labour is essential. The public must be sensitised to well-structured campaigns on an ongoing basis, bringing out the importance of communication in improving waste management and river repair.
Primary PPP Case Study 4
This case study focuses on the benefits of a structured PPP for infrastructure development during the covid-19 Pandemic. It also suggests that even local-level PPP can have international dimensions. It thus differs from other primary case studies, which have been domestic-oriented. The objective was to improve the free healthcare framework dramatically and quickly.
The Rotary Foundation, an arm of the Rotary Club of Nilgiris, led by its Chairman, Lt. Gen. Girish, worked to alleviate those suffering from renal failure requiring dialysis after organising oxygen concentrators, PPE kits and masks initially. The Foundation recognised the immense hardship and suffering for patients on dialysis who could ill afford to travel either by public transport, which was locked down or by taxi to the nearest centre 150 km away thrice a week, as permissions for private vehicular traffic was hard to come by during the Pandemic.
Gen. Girish has had substantial exposure to PPP, having led NGOs post-retirement. The projects he led, managed, and administered were funded by international NGOs such as Bloomberg. Philanthropies in conjunction with the Ministry of Urban Development, GOI (Government of India), with the World Bank-certified organisations in Africa for development activities, and with DFID (Department of International Development) of United Kingdom, now replaced by Foreign Commonwealth and Development Office (FCDO), to identify and certify trainers to absorb proven technologies in Agriculture and transfer them to Africa. His experience over several years has given him a sound understanding of the structured nature of formal PPPs, the need for an SPV to manage the project, accountability for fund deployment and timely execution.
How the PPP Operated: Gen. Girish approached the health department and sought permission to set up a dialysis centre. The initial hesitancy led to silent support from other concerned authorities, such as the PWD (Public works Department) and the Forest Department. Required permissions to remodel and refurbish an existing shed came very expeditiously. Through the Rotary Club network, Gen Girish reached out to corporates to fund a dialysis centre attached to the blood bank of the Government General Hospital – Lawley Hospital in Coonoor.
An old building was renovated, and a spanking new state-of-the-art dialysis centre to the best-in-class international standards was set up within nine months. A 30-bed dialysis centre was set up and staffed to serve the needs of the local patients. Requisite staff were trained in using ultra-modern equipment; maintenance teams were tutored to maintain the highest level of hygiene. Within a month of its inauguration, the centre started working on a two-shift basis and, as of August 2022, treated around 50 patients weekly.
At the centre, all treatment is free for the patients, though economic costs are real and positive. The funding was largely by the corporations with whom the Foundation had a formal reporting structure for both progress of the project and the benefits delivered, as required by regulations on CSR spending in India. The Union Government permitted the use of CSR funds. and allowing diversion at short notice to support Covid-related infrastructure development was among the key support from the government sector. It encouraged corporates to divert sanctioned funding to address immediate priorities.
Because of the demonstrated positive results, several endowments by individuals were forthcoming spontaneously. This helped expand the scope to upgrade an ICU and modernise the outpatient department, which required the renovation of a heritage building despite populating it with processes a modern OPD (Outpatient Department) demands.
The Pandemic galvanised doctors and governments to expeditiously provide all needed clearances and permissions. The local CMO (Chief Medical Officer) identified the beneficiaries and staffing provided by the hospital. The centre is now managed by the hospital. The project was overseen by a team of Rotarians led by the General himself. They will continue to oversee the management of the centre for five years.
In setting up the dialysis centre, a combination of informal engagements with the district authorities and a formally structured outreach to corporations for CSR contributions were necessary. The belief is that there is substantial value in the PPP concept. It requires that outcomes be clear, scope and intent specified, well planned, and executed with integrity. Being adept at communicating the needs of corporates and given his stature, the General broke down barriers which enabled speedy and timely execution.
The SPV, in this instance, was the Rotary Foundation which organised the fundraising, project management and fund disbursement. The experience of this PPP suggests that government agencies can, in conversations with NGOs, citizens and corporations, set up an SPV with an able administrator, not necessarily a bureaucrat, to set clear and time-bound outcomes at the local level.
POST SCRIPT: The Rotary Foundation has initiated converting a disused and run-down hostel into a palliative care centre- the first in the hills- attached to the Lawley Hospital.
The key insights from the authors’ four case studies involving primary healthcare research are that focusing on outcomes is vital for a successful PPP. This outcome must deliver sustained value to meet the current and emerging needs of the beneficiaries. Time is of the essence in projects serving basic quality of living needs.
It is suggested that the above primary case studies open a constructive new avenue to operationalise PPPs involving local context and stakeholders in improving citizens’ quality of life in selected sub-sectors of health and other social subsectors. The authors urge much more focused research efforts across many regions in the country on local decentralized, informal PPPs in the health and social sectors.
It is stressed that the case studies of the PPP in this chapter complement large national, regional, and international PPPs in energy, space, defence, high-technology manufacturing, and others that the country needs. So, efforts to acquire greater competency in undertaking such PPPs must continue.
But local, decentralized, and informal PPPs outlined in the four case studies can broaden public participation in improving citizen welfare and generating social trust.
This article was first published in MyIndMakers as The Covid-19 Pandemic and the Local Outcome-Driven PPPs: Case Studies from Tamil Nadu, India.
About the Author
Prof Mukul Asher, Former Professor, Lee Kuan Yew School of Public Policy. National University of Singapore
V. Ramakrishnan, Managing Director, Organisation Development, Singapore