Enabling the seamless exchange of health financing data in a growing number of countries
More than five million people are covered by health insurance schemes run on openIMIS, a free and open source software developed with German and Swiss support. Interest in openIMIS is growing as its ability to efficiently manage complex information flows becomes better known. Now, social protection schemes are keen to get onboard.
This article is the first of a two-part series. To learn more about how openIMIS evolved into a Global Good, read the second piece.
In 2017, provincial health officials in South Kivu, in the Democratic Republic of Congo, were grappling with a problem without an obvious solution. To boost utilisation of health services in rural and underserved areas, they wanted to revitalise community-based insurance schemes, known as mutuelles, in health zones across the province. In exchange for a modest monthly contribution, members of households registered with a mutuelleare entitled to primary health care services at any health center or hospital in the network. At a policy level such schemes are favoured by the government as a way to advance progress towards universal health coverage. In practical terms, however, administering them in South Kivu’s challenging geographical and security conditions would not be straightforward. How could standard insurance functions – enrollment and renewals, claims submission, claims processing, and payments – be managed in an efficient way?
A user-friendly software
An answer came in form of openIMIS, a simple, user-friendly health financing software which brings beneficiary, provider and payer data together in a single platform. The Support for the Health Care System in South Kivu project (Projet d’Appui aux Systèmes de Santé au Sud Kivu, or PASS), funded by Swiss Development Cooperation (SDC) and implemented by GIZ International Services with technical support from the Swiss Tropical and Public Health Institute (Swiss TPH), helped to customise and roll out openIMIS for use by mutuellesoperating in eight of the province’s health zones. By 2019, openIMIS was bringing together information about more than 20,000 enrolled beneficiaries with details of the 85 health facilities contracted by the mutuelles and the services covered under the benefit package. Staff at the mutuelles use the web-based user interfaces of openIMIS to check the insurance status of beneficiaries, to submit reimbursement requests and to prepare reports about the operation of the scheme.
The introduction of openIMIS has helped to strengthen the day-to-day operations of the mutuelles, but the journey is not yet over. Connectivity is a challenge in South Kivu and staff of the mutuelles plan to use an offline version of openIMIS on smartphones or tablets to sign up new beneficiaries in the communities where they live. Registration officers will go from village to village to enroll households, collect their contributions and issue insurance cards, linked to unique identification numbers, right on the spot. The global community behind openIMIS understands the reality of implementing insurance schemes in places like South Kivu. It supports the further enhancement of tools, such as apps with offline functionality, to address these challenges.
Linking beneficiary, provider and payer data in a single platform
openIMIS was created to solve problems like those facing the mutuelles. For scheme operators, it offers a standardised, yet easy to adapt way to manage the large volumes of information which need to be exchanged as part of the administration of social health protection schemes. For beneficiaries, it simplifies enrollment procedures, reduces costs and makes it easy to verify one’s coverage status, at the point of care, when seeking services.
Although the details of national health and social protection frameworks differ from place to place, the core functions and business processes are largely the same. Households enroll in schemes and pay contributions. Providers verify the identities and eligibility of scheme beneficiaries and then submit claims to the paying authority for services rendered. Adjudicators review the submitted claims and approve payments. Using information from all these processes, administrators then monitor and analyse the performance of the scheme as a whole.
It is complicated, expensive and time-consuming to manage these processes if they are not digitalised. By bringing together information from multiple stakeholders – beneficiaries, providers, and payers – into a single digital platform, openIMIS makes it possible to manage social health protection schemes at scale, thereby enabling a gradual expansion in coverage to hitherto excluded populations. Because the software is open source, it can be downloaded, customised and used free of charge. And because it is built in accordance with industry standards for interoperability, it can be easily integrated with other information systems, such as DHIS2, which are widely used in countries working towards universal health coverage and universal social protection.
From a locally-designed software to a global good
The fact that openIMIS has been relatively easy to deploy in the challenging operational context of South Kivu is a reflection of its own origins in Tanzania, where it got its start as IMIS (Insurance Management Information System) in 2012. With funding from SDC, the software was designed by Swiss TPH and a local developer as a custom-made solution for managing district-based community health funds.
A year later, after the software had proven its ability to bring complex insurance processes down to community level in Tanzania, Swiss TPH customised it for use in administering four mutual health insurance schemes in Cameroon. Shortly thereafter, the software was customised again for use in Nepal, where a new national health insurance programme was being launched. Swiss TPH provided the initial expertise as part of a larger technical support project implemented by the Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH on behalf of the German Federal Ministry for Economic Cooperation and Development (BMZ).
By 2015 the software had demonstrated its potential for easy adaptation to different types of health financing mechanisms in three disparate contexts. German and Swiss advisors recognised that, if the package was transformed into an open source product, it could be a valuable addition to the growing field of global goods – digital tools that can be used to manage, analyse or share information across different countries and contexts.
The openIMIS Initiative, implemented by GIZ on behalf of BMZ and SDC, was established in 2016 to transform IMIS from a stand-alone digital solution to an integrated and modular open source software, supported by a community of developers and users, and made available to programmes in many more countries. An important milestone was reached when SDC, which holds the copyright for openIMIS, released the application under an open source license, thereby ensuring that the software could be used and adapted free of charge. The source code for openIMIS was published in early 2018 on GitHub, a platform which facilitates collaborative software development by developers around the world.
A vibrant community
Over the past four years, openIMIS has grown into a dedicated community of users, development partners, implementers, software developers and academic institutions who are pursuing the shared goal of improving health financing operations through the seamless exchange of data. ‘The software has evolved from one built for a specific purpose in Tanzania to one generic enough to handle a wide range of applications,’ explains Saurav Bhattarai, an advisor with the GIZ-implemented Sector Initiative Social Protection, which hosts the openIMIS Coordination Desk. ‘The future direction of openIMIS is now decided by the community of users.’
The software is continuously improved and further developed through the experiences of teams implementing openIMIS in a growing number of countries, and through inputs from a network of experts around the world. The fourth version of openIMIS (v 1.4.0) was released in April 2020.
The openIMIS community comprises stakeholders at the local, regional and global levels. At the global level, a steering group comprised of financial contributors and scheme operators sets the overall strategic direction and allocates resources for software development and implementations.
In the countries where openIMIS is deployed, country teams made up of scheme operators, implementing partners and local developers work together to manage the software, to identify bugs and technical issues which need to be resolved at the global level, and to adapt the solution to country-specific needs. If fed back into the core version of openIMIS, these additional features can then be used free of charge by other countries.
openIMIS also currently has two regional hubs: Asian eHealth Information Network (AeHIN) and Jembi Health Systems. Using their existing networks, AeHIN and Jembi are working to build and expand the communities in Asia and Africa, respectively, and to facilitate training and capacity development.
The engine behind openIMIS is the so-called ‘product group,’ which operationalises the strategic direction of the initiative; maintains and supports the core source code of openIMIS at the global level; and supports existing and new implementations of openIMIS through analysis and advice. This group is supported by a co-ordination desk based at the GIZ-implemented Sector Initiative Social Protection in Bonn, which acts as a sort of ‘invisible hand’ to keep the community of practice engaged and vibrant, for example, through regular calls, workshops and community events.
openIMIS in action
The openIMIS Initiative works with organisations around the world to assess the suitability of openIMIS as the digital solution for their health financing schemes. The software is currently being implemented in five countries, underpinning insurance schemes which cover more than five million beneficiaries. It is poised for adoption in several more: Djibouti, Myanmar and Nigeria are among the countries which have requested an initial assessment of their existing IT infrastructure and the potential fit of openIMIS for their health financing systems.
The Government of Tanzania has long supported voluntary, affordable community health funds as a way to expand utilisation of health services by those working in the informal sector. In the late 1990s every district in the country was mandated to set one up; small variations in design have developed over time from one district to another. In recent years, as part of an effort to accelerate the achievement of universal health coverage, the government has introduced changes to the community health fund model to transform it into a fully operational social health insurance scheme. Under the ‘improved’ community health funds (CHF Iliyoboreshwa, or iCHF), the benefit package was broadened, entitlements were made portable across empaneled health facilities nationwide, and management of the scheme was shifted to dedicated local government structures in each region.
‘When the iCHF was being designed, IMIS was taken on board as part of the standardised model that would be rolled out nationwide,’ explains Siddharth Srivastava, a technical expert with Swiss TPH. The President’s Office Regional Administration and Local Government (PORALG), which is responsible for community health funds, was a strong proponent of the solution. ‘PORALG was already hosting the server for the districts using the software and felt a lot of ownership. It was therefore an obvious decision to make the new national model dependent on the same system,’ he adds.
The improved scheme has now been rolled out to almost all 26 regions in mainland Tanzania. As of March 2020, approximately 900,000 Tanzanians were covered, out of 2.7 million individuals who have been registered in the database to date. Nearly 19,000 people work with the software on a regular basis. The majority are enrollment officers deployed at village level, while staff at more than 6,100 dispensaries, health centers and hospitals also rely upon it to submit claims. Thanks to the work of local developers, the software is now able to exchange information with the Tanzanian Government’s e-Payment Gateway. This allows beneficiaries to make mobile payments for their scheme contributions – and for these payments to be reflected in the system when health facilities verify patients’ eligibility for services. This has helped to resolve some long-standing challenges with money collection at the local level.
Nepal is also using openIMIS to administer a large-scale social health insurance scheme. The Health Insurance Board of Nepal has gradually scaled up the country’s national health insurance scheme since its launch in three districts in April 2016. Now, more than 2.7 million Nepalis are enrolled in 56 of the country’s 77 districts.
openIMIS has made the expansion of the scheme possible. Enrollment assistants who go door-to-door to sign up beneficiaries use Android-based apps to register households. More than 285 primary health centers and hospitals use openIMIS to prepare and file claims. These functionalities significantly reduce the volume of paper-based transactions and make the administration of the social health insurance scheme more efficient. The Health Insurance Board appreciates openIMIS for its stability, flexibility, and user-friendliness.
Discussions are well advanced in Nepal about linking openIMIS with the electronic medical record systems (EMRs) used in hospitals. Local software developers which implement EMR systems in private hospitals have signaled their willingness to align their standards with the HL7 FHIR specification used by openIMIS. FHIR, which stands for Fast Healthcare Interoperability Resources, is an internationally accepted standard for health care data exchange. ‘If this happens, it will mean that everyone is part of one system,’ says Purushottam Sapkota, a technical advisor with the GIZ-implemented project ‘Support to the Health Sector Programme’ (S2HSP) in Nepal, which works closely with the Health Insurance Board. ‘This will make claims processing more efficient, as hospital staff will no longer have to manually enter information and claims can be sent directly from the EMR.’
The country team in Nepal participates actively in the openIMIS global community. It contributes local modifications to the master version of openIMIS, submits requests for new features to the global development committee, and has hosted multiple study tours and joint learning events. Nepal was the first country to test the latest release of openIMIS (v 1.4.0) – which boasts a newly designed claims module written using modern technology and a smoother, fresher user interface – and is compiling feedback from users across the country to share with developers at the global level. Nepal was also the driving force behind the global initiative’s decision to invest in making openIMIS and DHIS2 interoperable: the country team identified a need to analyse its insurance data in greater detail than was possible with openIMIS alone. Once the integration is complete, not only will Nepal be able to apply DHIS2’s analytical tools to openIMIS data, but users in other countries will be able to as well.
openIMIS is also the digital tool of choice for a trio of smaller-scale insurance schemes in three African countries. In addition to the mutuelles in South Kivu, described earlier, church-based and district-based insurance schemes in Cameroon and Chad have also turned to the open source tool.
In Cameroon, the Bishops of the Bamenda Church Province launched the Bamenda Ecclesiastical Provincial Health Assistance (BEPHA) scheme on a pilot basis in 2008. BEPHA was designed as a solidarity-based ‘trouble fund’ in which members contribute financially and can draw upon support in times of need. Since its inception, BEPHA has covered the healthcare costs of more than 100,000 people in the North West and South West regions of Cameroon through a network of 159 health facilities. In recent times, instability in the region has affected the operation of the scheme: at present, 16,500 members are able to receive care at 115 health facilities.
BEPHA has been using openIMIS to manage beneficiary enrollment and claims management since 2013, when SDC provided it a free of cost license to customise the source code. According to George Yuh Atohmbom, the Director of Finance and Operations at the BEPHA Coordination Office, the adoption of openIMIS has yielded enormous benefits. It has made it easier to track its members across different insurance products and cycles, greatly simplified the renewal of expired policies, made it possible to track the volume of claims paid by the scheme to different health facilities, and helped to track fraud, including ‘ghost’ beneficiaries. BEPHA staff also appreciate the ease with which they can generate different types of reports using data on enrollment, claims and renewals.
Since 2018 openIMIS has been used on a pilot basis in Chad for the administration of a small-scale insurance scheme in Moyen Chari region. Sixteen health centers and a district hospital are part of the scheme, which is operated by Mutuelle des santé Borsa and supported technically by Swiss TPH as part of the SDC-funded Support Project for the Health Districts in Chad (Programme d’Appui aux Districts Sanitaire au Tchad). Approximately 9,500 people are covered by the scheme. For Mutuelle des santé Borsa, the adoption of openIMIS and the digitalisation of membership data and core operations has made the management of the scheme more professional. Although the initial focus has been on training systems administrators, managers and enrollment officers to make data entry more efficient, in the future the software will also help to improve the quality of monitoring and reporting.
In 2019 the Rwanda Social Security Board (RSSB) invited a team from the openIMIS Initiative to visit Rwanda and assess whether the tool could help the country’s Community Based Health Insurance (CBHI) to digitalise and thereby streamline its claim processing. Over 9 million people are covered by CBHI, which is funded by a mix of member contributions, the Government of Rwanda and external development partners. Close to 800 health facilities – public, private and NGO-run – are part of the scheme, and are reimbursed on a fee-for-service basis.
But the scheme has become a victim of its own success: it is so heavily used that, at one point, a backlog of nearly 80,000 claims had built up. Although these were ultimately cleared, through a special adjudication process supported by the Clinton Health Access Initiative (CHAI), it has become apparent that changes to the management of core business processes are needed to avoid a recurrence of the same problem. Discussions are now underway about how openIMIS could be tailored to meet the needs of the CBHI.
Beyond health insurance
Although openIMIS was originally developed in the context of health insurance, its modular design means that it can easily be customised to meet the needs of other types of financing schemes which involve multiple stakeholders and the exchange of large amounts of data. Operators of social protection schemes which address other types of risk are beginning to recognise that openIMIS’ core functionality makes it applicable to their needs as well.
In Nepal, the Social Security Fund intends to use openIMIS to manage its Employment Injury Insurance scheme for formal sector workers. Launched in 2019, the scheme currently covers more than 130,000 employees, providing them with full coverage of medical expenses following employment-related accidents and salary compensation until the employee returns to work. The scheme lacks a set of standard operating procedures and a management information system that would allow it to systematically process claims; thus far, submitted claims have been processed manually. Recognising that a digitalised system would be much more efficient, the Social Security Fund will work with the GIZ Sector Initiative Social Protection, the S2HSP project, Hochschule Bonn-Rhein-Sieg and the German Social Accident Insurance (DGUV) to customise openIMIS as the management system for the Employment Injury Insurance scheme and to build the capacity of Social Security Fund personnel to manage such a scheme, which is completely new for Nepal.
In Cameroon, openIMIS is being customised to manage a new voucher-based reimbursement mechanism for health facilities. As of January 2020, user fees may no longer be charged for HIV-related services – a change which has necessitated the development of a new set of business processes to enable health facilities, the Ministry of Health and Regional Funds for Health Promotion to track HIV-related service delivery, claim reimbursements and verify their accuracy. ‘For this to work smoothly patient data has to be combined with financial information,’ explains Josselin Guillebert, the focal person for the P4H network in Cameroon and an advisor with the GIZ health programme. ‘After a study tour to Nepal, the Ministry of Health saw that openIMIS could be linked to the DHIS2 patient tracker to provide this functionality.’ With support from UNFPA, the Ministry of Health will customise openIMIS to manage these processes, build the capacity of staff to work with the system, and roll-out out the software on a pilot basis in the Central Region. Once in place, the digital administration of the scheme will help to ensure smooth access for patients to HIV-related services and an efficient, transparent reimbursement process for health facilities.
The emerging gold standard for digital health financing
Over the past four years, investments in the openIMIS software and in the global community have brought the initiative closer to its goal of becoming the gold standard for digital health financing among global goods for digital health. In collaboration with global communities of e-health experts and software developers – such as the OpenHIE community, a global standardisation initiative which supports country-driven, large-scale health information sharing architectures – the openIMIS Initiative is working to ensure that data exchange processes and requirements meet the needs of health care financing communities. Through intensive outreach efforts, including through its regional hubs in Africa and Asia, the Initiative has also helped to position openIMIS as the leading open source solution for digitalisation of health financing schemes. In the coming years, the openIMIS initiative will continue to convince new organisations to use the software and join the growing global community which supports it.
June 2020
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