Cameroon has adopted the digital public good openIMIS to bring together different health financing schemes in one digital UHC platform. This is improving scheme efficiency, transparency and governance, and extending access to health services for those in need.

‘UHC presents us with an important opportunity to invest in the digitalisation of Cameroon’s health information and management systems because you cannot achieve UHC without this’, says Emmanuel Batoum, Head of IT at the Ministry of Health.

In January 2023, the Government of Cameroon formally adopted openIMIS as the digital management tool for Phase 1 of its UHC Scheme. Through openIMIS and its interoperability with other software applications, selected health financing schemes are being brought together so as to provide free or highly subsidised access to services for pregnant women and their newborns, children under five, and those affected by HIV, tuberculosis and kidney failure.

Today, openIMIS is enabling the integration of common processes across these schemes, most notably invoicing and payments, as well as monitoring and control. The unified data are contributing to more robust governance in the health sector and strengthening evidence-based decision making.

This is the second in a series of articles examining Cameroon’s journey towards Universal Health Coverage. The first article can be found here: Thinking and working politically to realise universal health coverage: insights from Cameroonian-German cooperation.

An unexpected request from the Ministry of Health

It was during the December 2022 festive holidays that the team at Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH received an unexpected invitation from the Ministry of Health in Cameroon asking whether openIMIS could be adapted to manage Phase 1 of its new UHC Scheme.

The Cameroonian-German bilateral health programme, however, had a different focus at the time and Julius Murke, GIZ Digital Health Advisor in Cameroon, remembers both the excitement and the trepidation generated by such a request:

We recognised that this was a great opportunity to scale up openIMIS to support the Government’s UHC Scheme. But we were unsure whether we could respond quickly enough given this was a request for major support to implement a major health system reform.

A decade of preparation

The request did not come out of the blue. In fact, it followed more than a decade of technical and financial support by the Swiss, French and German governments and other partners, to adapt and pilot the openIMIS software for different health services and schemes in Cameroon.

In 2013, Cameroon was only the second country to implement an earlier version of the software – called simply IMIS. The Swiss Tropical and Public Health Institute (Swiss TPH), developed the original, custom-made digital solution for managing community health funds in Tanzania in 2012. With financial assistance from MISEREOR, Swiss TPH then adapted IMIS to support the management of a micro health insurance scheme of the Bamenda Ecclesiastical Provincial Health Assistance (BEPHA) in Cameroon’s North West and South West regions.

The openIMIS Initiative was created in 2016, implemented by GIZ on behalf of Germany’s Federal Ministry for Economic Cooperation and Development (BMZ) and the Swiss Agency for Cooperation and Development (SDC). Over the years, this initiative has transformed IMIS from a stand-alone digital solution to an integrated and modular open source software, supported by a community of developers, implementers and users.

In 2021, the Government of Cameroon selected openIMIS as the management software for their HIV user fee removal scheme. Two events in particular laid the ground for this important decision and provided convincing evidence that openIMIS could be used to digitalise the management of different health financing schemes: a feasibility study in 2019 looked at the potential to adapt openIMIS for the management of Cameroon’s maternal and newborn health voucher scheme (Chèques Santé); and a study tour to Nepal provided an opportunity for senior Ministry of Health officials to see openIMIS working in a context with some similarities to that of Cameroon. The officials were particularly interested to see that openIMIS could be linked with the district health information system DHIS2.

On the back of these developments, a core team of openIMIS developers (see below) began to work on the adaptation of openIMIS to digitalise the management of the Chèques Santé’ in five of Cameroon’s ten regions.

UHC is a catalyst for digital development

The December 2022 request from the Ministry of Health was the incentive needed for development partners to start planning how to bring the existing health financing schemes together, using digital technology. The fact that several of these schemes were already using adaptions of openIMIS meant that much of the know-how and skills required, as well as networks with local software engineers, were already in place.

Digital experts from the Ministry of Health, GIZ and Swiss TPH, local digital development firm Y-Note and the Cameroonian consultant George Atohmbom Yuh formed a core openIMIS development team. They began to work on adapting and linking the different schemes that could be integrated from a financial management perspective – that is, the same processes for identifying a person in need of the service, monitoring the provision of the service, and making and verifying payments.

The unifying idea was – and remains – that Cameroonian citizens everywhere should be able to access a basket of essential health services through one, seamless interaction with the health sector, without incurring financial hardship. Progress since early 2023 has been fast, and many new and innovative developments have taken place (Figure 1). What did this look like in practice?

Fig 1. openIMIS Timeline for Cameroon 2023-2024

An agile approach: build, learn, customise

Working in an agile fashion was particularly important for rapid, early progress on the openIMIS UHC platform. The openIMIS development team employed user-centred design techniques to define system requirements. Adaptation of the software began just two days after defining the requirements, leading to the rapid development of a Minimum Viable Product – that is, a product with just enough features to get the system up and running.

Changes were then made incrementally, and new features were added to the software platform over time based on actual implementation experience in a series of iterative ‘build, learn, customise’ cycles. A decision was also made early on to avoid complexity and to keep the IT as simple as possible.

Maxime Ngoe, Director General of Y-Note, speaks for everyone involved when he says, ‘in Cameroon, we didn’t think this could happen in such a short timeframe’. He continues, ‘in 2022, there was no national plan for openIMIS and then at the start of 2023, the Ministry of Health decided to deploy openIMIS nationally. But we had prepared the ground for this – the proof of concept was there’.

Building with scalability in mind

The team combined this agile ‘what can we do today?’ approach with a longer-term vision for Cameroon’s digital health. The openIMIS UHC platform brings together previously separate health financing schemes that need to be monitored as one UHC initiative, while still being managed separately. Guaranteeing the secure and smooth exchange of data between them is therefore critical.

Interoperability layers and standards were selected and introduced early on. The system is already based on HL7-FHIR (Fast Healthcare Interoperability Resources), which provides a standards framework capable of handling the wide variability in healthcare processes across the selected schemes. In the future, openHIM will support data governance and secure communications between openIMIS and the different software programmes with which it exchanges data.

Josselin Guillebert, Director of the Cameroonian-German Health Programme, explains,

Even though we were under huge time pressure, we made sure to do some important things right from the start that would support the longer-term development of an interoperable system-wide architecture for UHC.

Strong, country-led partnerships that can drive scale

Building country-led partnerships between government partners and national digital-solution providers was a further priority from the start, buttressed by strong relationships of trust that had developed over the years. The earlier openIMIS implementations provided proof of concept that the software could be used successfully to digitalise and strengthen the management processes of health financing schemes at different levels of the health system.

They also provided opportunities for informing a growing group of people about the openIMIS software. As knowledge and understanding increased, advocates emerged in the Ministry of Health who were later instrumental to the decision to adopt openIMIS for the UHC Scheme in 2023.

Building knowledge and capacities

Bilateral programme funds were directed early on to the training of counterparts in the Ministry of Health on how to administer and use openIMIS. Private sector technology innovators play a critical role in the scale-up of digital solutions, and local software engineering firms – for example Y-Note – were contracted to undertake the development, working with the Ministry. Furthermore, the close involvement of national firms has had the effect of stimulating the market for computer engineering skills in Cameroon.

Rapid development of the Minimum Viable Product enabled hands-on training on the openIMIS platform early in the development process. By mid-June 2024, working with Henock Mfouapon, Head of Quality and Accreditation at the Ministry of Health, GIZ had facilitated openIMIS training for 364 health facility teams implementing the Chèques Santé scheme, and for more than 500 health facilities in total. The target is to train all Chèques Santé health facilities by the end of the year, which number around 700 and to extend openIMIS to health facilities that are not implementing Chèque Santé.

openIMIS ‘coaches’ have also been identified in all five of the Chèques Santé regions and were trained in June 2024. Their role will be to provide follow-up coaching and mentoring for users of the openIMIS software. At the time of writing, more than 1,200 users had been registered on the platform.

Working adaptively: the art of development cooperation

Operational adaptations were made to enable the rapid development of the openIMIS platform, and to give real decision-making power to the Ministry of Health to steer openIMIS development. For example, while registration of beneficiaries is a functionality of openIMIS and could have been managed within the openIMIS UHC platform, the approach in Cameroon was to build a separate beneficiary registry based on the CamerHealth application. The development team then adapted the openIMIS system and built interoperability between openIMIS and CamerHealth (Figure 2).

In order to strengthen evidence-based decision-making, the GIZ team also introduced the business intelligence system Metabase. Through a series of tailored dashboards, stakeholders at different health system levels – from the central level through regional and district health offices to health facility teams – have the data at their fingertips for planning, budgeting and course correction.

Demonstrating considerable innovation, openIMIS in Cameroon operates in such a way that the individual schemes which make up the national UHC Scheme can be monitored and controlled separately, while the business processes can be managed more efficiently as one UHC Scheme.

This is particularly important for monitoring and verification. As Henock Mfouapon says

A lot of public money is being channeled to UHC and we need a safe system for reimbursing the health facilities, which carries few risks.

Cameroon’s earlier performance-based financing scheme required verifiers to travel long distances to health facilities every month to verify results against the facility registers. openIMIS, on the other hand, automates the verification process which also helps lower the fiduciary risks for the funding agencies, and this is always welcome.

An important player in the openIMIS community

openIMIS is not only a software, it is also an international community of developers, implementers and development partners, working continuously on the improvement and expansion of the platform. Not only do open source communities enable learning, innovation and scale-up, they also contribute to greater sustainability of digital public goods, such as openIMIS, by facilitating contributions by community members.

As an early adopter of the software, Cameroon has both benefited from being part of the openIMIS community and made invaluable contributions to it. Maxime Ngoe says that, having received support through the openIMIS community, they now do the same for openIMIS newcomers in other countries. He further explains,

If I compare openIMIS with other open source products, openIMIS has a stronger community that is inclusive, open-minded and welcoming. This is a bit unique among open source initiatives.

In 2023, Cameroon hosted the openIMIS Stakeholder Community Meeting in Yaoundé where some 50 people from 17 countries came together including representatives of the Asian eHealth Information Network AeHIN) and Kenya Health Informatics Association to learn about progress in the UHC scheme in Cameroon, to network, learn from each other, and to discuss latest openIMIS developments.

Next steps

Plans for the rest of 2024 and beyond include the transfer of some of the key software management roles and responsibilities to Government partners, in line with their growing capacities. These include handing over the training and coaching of health facility teams on openIMIS to the Regional and District health authorities and giving more responsibility for fixing bugs in the software to central and regional-level counterparts.

In order to implement the national digital health strategy and progress towards a national digital healthcare ecosystem, the Ministry of Health needs more funding. GIZ and the US Government-funded CDC successfully lobbied for and established a technical working group of external development partners on health information systems. Through this group, the two partners are now calling for additional development partners to support the Government in its efforts to digitalise the processes underpinning UHC, as well as to develop the digital public infrastructure required to underpin these developments.

Beyond the health sector

The adoption of openIMIS to manage the UHC Scheme is also having an impact beyond the health sector. The Ministry of Social Affairs is interested in using openIMIS, which would enhance its cooperation with the Ministry of Health, particularly for identification and payments systems. Achieving universal coverage of health services calls for a digital public infrastructure to enable national systems for the identification of beneficiaries, safe and smooth data exchange, grievance redressal mechanisms and payments systems, among other things. openIMIS is already making important contributions to the development of such an infrastructure in Cameroon, and an upcoming article will look more closely at openIMIS and its contributions to DPI. Watch this space.

Corinne Grainger
July 2024