How openHIMIS could boost the global community’s efforts to realise Universal Health Coverage
Many countries have turned to open source software as a flexible, reliable and low-cost approach to managing their health information systems. Germany and Switzerland have now joined forces to facilitate the creation of an open source solution for social health insurance and to foster the global community needed to support it.
The push towards UHC highlights the need for digital solutions
With the global push for Universal Health Coverage (UHC), countries around the world are introducing or expanding social health protection schemes to increase people’s access to quality, affordable health services. While models for health financing differ from country to country, one challenge is universal: how to manage the complicated work processes and large data volumes involved in the administration of such schemes.
Core processes – enrolling beneficiaries, renewing policies, filing and processing claims, issuing payments – need to be handled digitally if a scheme is to work efficiently at scale. However few low- and lower middle-income countries have the technical capacity to design, procure, set up and maintain their own computerised systems.
In the drive to move beyond paper-based systems, many governments invest in the development of custom-made solutions or purchase commercial software licenses, often with financial assistance from development partners. However there are significant drawbacks to both approaches: custom-made software needs to be continuously adapted – often at great cost – as a country’s social health protection system evolves, and while commercial software can be continuously updated, it rarely meets a country’s needs fully because it isn’t tailor-made. Another common pitfall when investing in new systems is the failure to consider whether the chosen solution will be interoperable with other health-related information systems. The result is a fragmented information landscape and, far too often, a digital ‘dead end’: when a commercial provider goes out of business, a development partner phases out its financial support, or a commercial product is not interoperable with the information system used by other ministries or departments, authorities are left with obsolete systems and have to start over from scratch.
Towards an open source solution for social health insurance
In response to the growing demand amongst low- and lower middle-income countries for reliable and cost-effective digital solutions for their social health insurance systems, German Development Cooperation and the Swiss Agency for Development and Cooperation (SDC) are joining forces to facilitate the creation of an open source health insurance management information system – openHIMIS – and to foster a global community of users and supporters to maintain it and ensure its quality over time. Open source software represents an attractive alternative to commercial products because it can be downloaded and customised to meet countries’ specific needs.
The idea behind open source solutions is simple and elegant: developing software is such an enormous undertaking – both technically and financially – that it makes far more sense to work collaboratively than to go it alone. Because the core requirements for social health insurance systems in most low- and lower middle-income countries are fairly similar, there is no need for each country to develop its own. A well-designed modular software which is regularly updated at a global level, yet fully adaptable for use in local contexts, would be an invaluable support for many countries in their journeys towards UHC.
‘Right now the focus is on health, but a system like openHIMIS will be able to facilitate the collection and management of data needed for all kinds of insurances,’ explains Stefanie Ruff, of BMZ’s Division Health, Population Policy and Social Protection. ‘In the long run, it’s a tool that could be used much more broadly.’ It will also contribute to the harmonisation and standardisation of health and social protection data across countries, she adds, which is important for monitoring progress towards UHC and the Sustainable Development Goals.
Coming together to realise a shared vision
A road map already exists for such an approach: Over the past 15 years, open source solutions such as the District Health Information System (DHIS2) and OpenMRS have emerged as the backbone of routine health information and medical record systems in dozens of countries around the world. These products were brought into being through the sustained efforts of global networks comprising regional and national health authorities, research institutions, technical experts and programmers, and major development partners who converged around a shared vision and assumed joint responsibility for its realisation. Together, members of these networks financed the development of the open source solutions and worked to set up the structures needed to maintain and update the core versions of the software for the growing number of users around the world.
Inspired by this example – and committed to filling a gap in the open source landscape for a financial management tool for the health sector – GDC and SDC established the openHIMIS initiative in 2016. The initiative is being implemented by the Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH on behalf of the German Federal Ministry for Economic Cooperation and Development (BMZ) and the Swiss Agency for Development and Cooperation (DEZA).
Building on a prototype developed for community health funds in Tanzania
OpenHIMIS is being created on the basis of an existing insurance management information software called IMIS, which was developed by the Swiss Tropical and Public Health Institute in 2012 for the management of district-based community health funds in Tanzania. Designed to be used in rural areas with varying levels of infrastructure, IMIS brings insurance processes such as enrolment, patient verification, claims submission and policy renewals closer to the community level through the use of mobile phone and Internet technology.
In Tanzania, IMIS has helped to increase the coverage rate of community health funds in the districts in which it is used, according to Alexander Schulze, the co-head of the Global Programme Health at SDC, which supported the original development of IMIS. ‘IMIS made it possible to enroll people more easily,’ he explained, ‘but it also led to better management, which made it easier to handle a bigger volume of beneficiaries.’
Based on IMIS’s promising results in Tanzania, SDC – the license holder – agreed that IMIS could be used in two other countries. The Swiss Tropical and Public Health Institute supported the development of a customised version of IMIS for use in four large mutual health insurance schemes in Cameroon, and Germany began to support Nepal’s Ministry of Health and Population to customise IMIS for use in the country’s new National Health Insurance program. As of March 2017, the IMIS software was being used to process insurance coverage for members of more than 130,000 households in 983 health facilities in the three countries.
From IMIS to openHIMIS
‘The idea behind openHIMIS is to take a digital solution which already exists and is being used in specific countries and to make it available to many more users,’ explains Alicia Spengler, of the GIZ Sector Initiative on Social Protection Systems, which coordinates the openHIMIS initiative. Once the master version of IMIS is re-written as a modular open source product, local software developers and programmers will be able to download the software and begin adapting it.
‘We are ready for openHIMIS,’ says Saurav Bhattarai of the GIZ-implemented Support to the Health Sector Program in Nepal, which has worked with the Ministry of Health and Population to roll-out IMIS in eight districts of Nepal. The introduction of IMIS has been smoother than expected from a technical point of view, he explains, but there are some aspects, such as the way the calendar is programmed, which have required temporary work-arounds for the system to function smoothly in Nepal. They also have some changes to the enrollment module in mind. ‘We have ideas about what we’d like this software to do in the future,’ explains Bhattarai. ‘This is where the open source community comes in.’
Establishing a global community of practice
The unique feature of open source software is its continuous refinement by an international community of programmers and users who feed back country-specific adaptations into a core version which is maintained and regularly updated by a host institution. As programmers begin experimenting with the software, local capacities are strengthened. ‘The benefit of this approach is that it can catch the dynamics of what is going on in individual countries,’ observes Spengler. ‘It is a much easier to develop new features and to feed them back into the core version when there is not a single “owner” of the code and the knowledge.’
At the global level, the openHIMIS initiative will work to bring together key partners willing to commit the financial resources and technical expertise needed to bring openHIMIS into being and to maintain and update it for its community of users. ‘An undertaking like this requires solid strategic partnerships between a number of complementary institutions who are willing to go for such an endeavour,’ notes SDC’s Alexander Schulze. ‘Funding is needed, political outreach is needed, and linkages into different types of circles are needed. A global initiative like this could be interesting for a lot of countries – high-, middle- and low-income alike.’
OpenHIMIS is part of Germany’s commitment to strengthening health and social protection systems
Germany’s main role in this process is to act as a facilitator. The goal is to bring a new open source community to life by convening the right players, by encouraging them to share their knowledge and experience, and by fostering a long-term commitment to sustaining openHIMIS. As part of this process, the initiative plans to draw upon the expertise of institutions which have been centrally involved in the development of other open source solutions to ensure that lessons from these experiences are fully taken into account.
Strong health systems, including social health protection systems, are essential for the achievement of UHC, and investments in information systems are a key part of this. ‘Germany has initiated the Healthy Systems – Healthy Lives initiative to support the strengthening of health systems in partner countries around the world,’ explains BMZ’s Stefanie Ruff. ‘OpenHIMIS is a crucial element in this systems strengthening approach.’
Karen Birdsall, March 2017
If you would like to know more, contact Alicia Spengler at Alicia.Spengler@giz.de.