Training hospitals in costing in the midst of a pandemic
In Pakistan a GIZ project reinvents its approach to capacity development – with considerable success!
Despite the huge challenges posed by it, the pandemic has also shown that human beings are adaptable and will find innovative ways of working in the ‘new normal’: Staff of a social health protection project in Pakistan used virtual solutions to implement a complex health costing exercise. Their own and their partners’ determination has led to impressive results.
‘There was a point where we thought the whole health system would simply collapse,’ says Gul Rukh Mehboob, a technical adviser in GIZ’s Social Protection-Social Health Protection (SP-SHP) project in Pakistan, reflecting on how COVID-19 has impacted on the project’s work in the last year. To begin with, it looked as though a carefully planned costing training programme with hospitals would also collapse, but as the initial pandemic panic subsided, the team adapted to the new ways of working – with some great results.
Introducing costing of treatment packages
Pakistan recently decided to extend its social health protection programme with the aim of moving towards Universal Health Coverage, based on a comprehensive social health insurance scheme. The SP-SHP project, implemented by the Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) on behalf of the Federal Ministry for Economic Cooperation and Development (BMZ) is providing technical support to Pakistan’s government to implement this ambitious programme.
Introducing such a large social health protection programme is a complicated business. To reimburse hospitals adequately, insurance companies need to know the actual costs they incur as they treat specific diseases. The project decided to train several public and private hospitals in the provinces of Khyber Pakhtunkhwa, Federal and Punjab in costing various commonly occurring illnesses of four selected specialities. The idea was that they could use the resulting figures for their negotiations with the insurance company, instead of relying on assumed or estimated costs like in the past.
‘Costing is a constant headache for us,’ says Usman Maqsood, Chief Executive Officer in charge of finance and administration at MMC General Hospital, a 250-bedprivate teaching hospital in Peshawar. ‘Generally, hospitals do department-specific costings, not disease-specific costings, so this new model was very different and very difficult as well.’
At the reception of Maqsood Medical Complex 
Doctor and patient at Maqsood Medical Complex
Moving training workshops online
The project originally planned to run two face-to-face workshops for hospital administrators and medical staff in each of the two provinces. But then the pandemic hit. With bans on travel and other restrictions in place, actual workshops with groups of people in the same room became impossible and comprehensive web-based training sessions were scheduled instead. However, as the crisis escalated, hospitals and staff were stretched to the limit and the plans were changed once more: The GIZ project decided to conduct individual training sessions online whenever staff could be made available, and to follow up with phone calls to support hospital staff in applying the costing model.
Convincing overstretched medical personnel that costing matters
Persuading overstretched hospital staff in the midst of a pandemic that cost-based pricing of their services was crucial for successful negotiations with insurance companies was a challenge. ‘Asking doctors to do a costing exercise it a bit like asking an economist to perform surgery – it’s almost impossible to do that,’ says Ms Mehboob. But she persisted.
Usman Maqsood’s initial reaction was initially ‘a bit sceptical about whether it could work. The hospitals were very busy at that time and it was difficult to coordinate work schedules and online training.’
Ms Mehboob had to rely on her powers of persuasion to convince the hospitals to take part in the training: ‘The only thing I could say was, I know you’re in a very challenging situation. But we don’t know when this pandemic is going to end – it might take years! So we have to do this costing training virtually – whatever it takes.’
Multiple training sessions 24/7
And it took quite a lot. The project had to conduct the training sessions many, many times – some with several people, some with just one person. ‘I told the participants that my timetable is open. If you’re free at midnight, if you’re free on Saturday, Sunday, Monday, it doesn’t matter – whatever time suits you I am available’ explains Ms Mehboob. According to Muhammad Waqas, Senior Financial Manager for Dr Akbar Niazi Teaching Hospital, ‘The GIZ coordinator explained everything to me – at least twice, because I didn’t want to miss anything! We had two or three sessions virtually.’
At Peshawar’s MMC hospital, Usman Maqsood remembers how the virtual training was often disrupted because participants got infected:
‘There was a time when all of our finance department was in isolation because one of them contracted COVID, and when they came back one of our HR department became COVID positive, so we had to send the rest of them home as well. Then when they came back, one of our doctors tested positive and her department was sent home… So instead of 15 days, it took around 45 days for us to work out our costs for specific diseases.’
What really made a difference was the project’s proactive follow-up: It encouraged the hospital teams to contact the team with any questions they had and followed up with phone calls as the costing model was applied. According to Usman this was particularly useful given that the exercise was so detailed: ‘For example, we worked out how much it costs for an orderly to take a patient to a ward, the cost of electricity and generator fuel – all the small things that add to the cost of treating a disease. ‘
Major benefits for the hospitals
The SP-SHP project team is proud of what it has achieved. When the training exercise was over, doctors and administrators told them that they could now clearly see the benefits, not only for claiming reimbursements from the insurance company, but also for the ongoing financial management of the hospital.
According to Usman Maqsood, ‘It has given us more confidence in our discussions with the insurance company because now we know what they are looking for. We can use the costing model and the figures it generates as a reference in our costing discussions with them. That is a major, major benefit for our hospital.’
Senior Financial Manager Muhammad Waqas says he has already used the costing model to define COVID- 19-related costs for his hospital. ‘I used the techniques from the GIZ training for this and it really helped me to define fair charges for both the hospital and the patient.’
These are the kinds of outcomes the project had been hoping for. The team is delighted to see that the hospitals have begun to do the costing work for themselves. ‘Up to now hospitals were constantly looking for support and relying on consultants to do this work for them’ says Ms Mehboob. ‘Now they can do it themselves. The training has really boosted their confidence.’