Introduction

Public-Private Partnerships (PPPs) describe a government infrastructure and or service or private business venture that is funded and operated through a partnership between one or more governments, one or more private sector companies and one or more civil service organizations. These could be at any level of government and cover the construction phase as well as the operations and maintenance phase.

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, globally, 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 percent of the global cases, and deaths 44 percent of the global average of 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 and trust among the stakeholders, as well as 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 case 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 for 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 the Outcomes were Achieved?

There were two key individuals at the local level who 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 the gaps in healthcare amenities and delivery. They were unknown to each other till the urgency of the common goal brought them and a few other like-minded people to gather.

Both the individuals mentioned above were aware of PPP in generic terms and believed it could deliver substantial value in the Indian local 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 subsequently 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 also contribute.  As Corporations and NGOs tended to be both bureaucratic and self-seeking, diverse funding sources were helpful in expediting 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 above all, 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. There were 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 of the medical equipment, training the operators and maintenance staff, fund sourcing, reporting, documentation, communication, and media management. The projects, equipment, and funding was based on research and on connecting with the donors and doing all the paperwork required.

Often local level competencies are 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 the repair and modernisation of 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 of their own accord 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 a vast number of people. Locals who tended to avoid government hospitals are now preferring them in large numbers. A major benefit has been those high-income individuals who would drive close to a 100kms for basic and secondary care now get treated in government hospitals. The benefit of well-to do in local community affairs constructively helps build social capital. Further what was viewed as punishment posting by doctors 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 hour drive from a major urban centre in the foothills. The government’s public health system was the main source of health care for the residents. Transport services, while decent in normal times, 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, and 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 actually 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. This was the outcome they related to and delivered, despite many requests made at the last minute.

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. The tactics to pursue these however were flexible depending on the need at a particular point in 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 organise and support on multiple fronts speedily was recognised early by the PPP leadership. The family used their own 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 of the 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 who were 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 that are 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 very little to tackle this urgent environmental issue. They needed the tourists but were unable to control, collect or dispose of the vast quantities of waste. In tourist season, this would reach 8-10 times the normal waste generated.

Conservation measures were initiated in Coonoor before 1950.  It, therefore, has a long tradition of realising the importance of environmental issues. Realisation however does not necessarily lead to outcome-oriented public policies. This is where the significance of this PPP lies as it set 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 the treatment of 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, the flora and fauna.

How the PPP Was 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. In all, 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 the collection of waste 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 of waste, against an estimated generation of 6 tons per day. Now plans are being laid to increase the collection of both dry and wet waste.

The PPP through its NGO vehicle 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 even 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. From the wet waste, they composted, a beautiful garden consisting primarily of local flora. The operational costs are being borne by various donors who make up the shortfall on a monthly basis. 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 make a significant difference in better 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 and smelly work of waste management and river repair. 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 in a short time. With the PPP-led arrangements in place, the heavy rains showed their value of their as Coonoor was flood free after many years.

This primary PPP case study also suggests that it is desirable to have a clear definition of 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 kms 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 gave way 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. Gen Girish, through the Rotary Club network, reached out to corporates for funding 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 the use of 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, treats 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 as well as 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 provide all needed clearances and permissions expeditiously. The beneficiaries were identified by the local CMO (Chief Medical Officer) 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 a period of 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 to corporates and given his stature, the General was able to break 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 outcomes 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.

Concluding Remarks

The key insights from the four case studies involving primary research on healthcare by the authors 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 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 local stakeholders in improving citizens’ quality of life not only in selected sub-sectors of health but also in other social subsectors. The authors urge much more focused research efforts across many regions in the country on local decentralized, informal PPPs not just in the health sectors but also in other social sectors.

It is stressed that the case studies of the PPP in this chapter are a complement to large national, and regional, and international PPPs in energy, space, defence, high-technology manufacturing, and others that the country needs. So, efforts to acquire much 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 in generating social trust.

 

References 

1.       https://www.worldometers.info/coronavirus/ -Accessed on 11 November 2022