The “Introducing openIMIS – an open source solution for Universal Health Coverage” webinar took place on 5 July 2018, and aimed to discuss the interactions between healthcare systems and information and communication technologies (ICTs), by introducing openIMIS, the first and only open source software that links beneficiary, provider and payer data. The webinar was organised by the German Development Cooperation (GIZ).
The event was moderated by Ralf Radermacher (Head of Sector Initiative Social Protection, GIZ), who was joined by presenters Alexander Schulze (Co-Head Division Global Programme Health, Federal Department of Foreign Affairs, Swiss Agency for Development and Cooperation), Siddharth Srivastava (Health Financing Specialist, Health Economics and Financing Group, Swiss Tropical and Public Health Institute), and Dr. Madan Upadhya (Executive Director, Health Insurance Board Nepal).
openIMIS – An open source solution for Universal Health Coverage and Universal Social Protection
Alexander Schulze opened the webinar situating openIMIS in a wider frame, by describing its usage in achieving Universal Health Coverage (UHC) and, indirectly, Universal Social Protection. The software was developed to cater to the around 400 million people worldwide without access to a complete set of essential health services. It also addresses the equally pressing matter of around 100 million people who are pushed into extreme poverty when attempting to access these services, having to pay out of pocket due to the absence of an appropriate social health protection mechanism.
openIMIS and the SDGs
openIMIS, originally released in 2012, operates within the framework of the 2030 Agenda for Sustainable Development, specifically referencing Sustainable Development Goal (SDG) 1.3, which calls for social protection systems for all, and SDG 3.8, which endorses universal health coverage.
According to Schulze, Universal Health Coverage should be treated not only as a SDG 3 target, but also as a systemic approach to healthcare. UHC can be summarised into four different aspects, as demonstrated below:
More specifically, openIMIS’s intentions are to contribute to strengthening social protection initiatives in the context of universal health coverage that ensure equitable access to health – once again reaffirming the software’s principles in employing a systematic approach to healthcare systems.
Establishing a management system
The process of establishing a social protection system for healthcare for all entails very complex business processes linking beneficiary, provider and payer data, such as is the case for most social insurance policies. The focus of openIMIS lies in improving and strengthening the operational core of scheme management, aiming to contribute to the efficiency of these and to nurture the skills of those who run them. This results in an improved capacity of managing and expanding schemes to hitherto excluded populations.
The software’s mission and proposal is composed by four elements, as seen below:
System Description & Open Source Resources
Concentrating on the technical details and on the functionalities of openIMIS, Siddharth Srivastava continued the webinar presenting how communication within the software works. Although it is a centralised system, meaning that it is placed on a central server, the transactions on the system can be done through different means:
- The system functions both on an online and offline basis. The online applications are based on a user who, with the appropriate login information, can undertake transactions. There are also certain features that can be accessed offline, such as the entry of enrollments, entry of claims, etc;
- openIMIS is a mobile-friendly application, in fact, some of the key processes are supported by mobile phones that can send transactions to the central server when connected to the internet.
Constructing health schemes:
- The insurer, who has its own structure and staff, and can negotiate which healthcare services are interesting for the institution to acquire.
- The service provision sites, i.e. the healthcare facilities, that offer certain services that can be itemised, allowing for the creation of an inventory that features the price for these services or items which are being offered by these facilities.
The interaction between these two actors occurs mainly when the insurer negotiates with the health facilities and subsequently decides what kind of services and items they would be interested in. Finally, the products will arrive at the insured beneficiaries, whose information (family size, eligibility for discounts, etc.) is also stored on the system.
2. Product configuration
The second step in constructing a scheme is the product configuration, which brings together all the different pieces that compose healthcare insurance, enlisting information from both the insurer, the service providers and the insured. As seen bellow, the software allows for the input of different sorts of information, from data of the beneficiaries to the extent of the insurance:
3. Standard enrolment process:
- An agent, who is responsible for enrolling possible beneficiaries to a scheme in a village, will try to convince a family to partake in a certain health insurance scheme.
- If the family agrees and the contribution is collected, the next step is to fill up an enrollment form, that features a procuration, which then serves as an insurance card.
- Phones are then used to scan a bar code on the form, which provides an ID number for that specific individual.
- The enrollment form then goes back to the insurance provider, along with the contribution collected.
- All the collected information is put into the system.
- Finally, the available services are activated, allowing users to access all programmes for which they eligible.
The abovementioned process is now becoming more automatised, given that a new generation of applications is updating the process of filling in a form, conducting this process directly on the phone application, and instantly connecting beneficiaries to their desired social protection scheme.
Once the individual has a card, they can visit a healthcare facility to verify their registration with a mobile phone:
The claims submission process is done in different ways – health facilities can do it through mobile phones, online clients, offline clients and paper forms. Once all the claims come in, then the system claims some of the internal processing of these claims and is then split up into different stages:
Implementation experiences from Nepal
Bringing forward a practical example of an experience with openIMIS, Dr. Madan Kumar Upadhyaya began his presentation with a brief overview of Social Health Hnsurance (SHI) in Nepal. In 2014, a National Health Insurance Policy was developed in the country, formalising a contribution-based SHI scheme with subsidies for the ultra-poor, poor and marginalised. This family-based scheme’s design is as follows:
- A contribution of Rs. 2500 (USD 25) for a family of up-to five.
- A benefit ceiling of Rs. 50,000 (USD 500) for all five members.
- Services available through empaneled facilities (public and private).
The scheme, envisioned to be a cashless system, has been designed to pool funds nationally in a single payer modality, and is fully managed by the Government of Nepal’s Health Insurance Board (HIB). It was initially implemented in 2016 in three districts, rapidly expanding to more than 30 districts in 2017/18.
In 2017, the National Health Insurance Act established that Social Health Insurance would be mandatory for all Nepali citizens, and has currently enrolled 870,000 active members.
Customisation of openIMIS for Nepal
The work of designing a social health protection system in Nepal using openIMIS (then IMIS) started in 2013. Customisation of the software to cater to the realities of the country began in mid-2013, and the final Nepal specific version of openIMIS was completed in 2014.
The process of customising the software to Nepal resulted in new features being added to the original openIMIS product:
• Cyclic enrolment: In an effort to reduce administrative burden, enrolment was made to be only possible four times a year.
• Defining a First Service Point: In an effort to promote the primary health care system and to reduce crowds at larger facilities, a First Service Point is defined during enrolment for each insuree. Every insuree has to visit their defined first service point for utilising any service.
• GPS location of Enrolment Assistants: openIMIS collects GPS location information of each enrolment done by door to door agents.
• Inclusion of the Nepali lunar calendar
• Custom Reports
Implementation: Technical setup
As suggested by the openIMIS software, the Nepali experience also counts on a single server setup, being hosted in the Government of Nepal’s Datacenter in Kathmandu. All information related to the social health insurance in Nepal is stored on this server, and regular backup of this software is kept both on and off site (also within Nepal).
In summary, openIMIS has supported the management of core insurance processes, such as:
• Enrolment: Door-to-door enrolment (mix of paper and digital registrations).
• Verification at health facilities (before service delivery)
• Claims Submission at health facilities (after service delivery)
• Claims Review at HIB, Kathmandu
• Data Analytics
openIMIS in Nepal currently caters to 870,000 actively insured members, has processed 607,286 claims, and has paid a total sum of USD 5,182,000 to healthcare facilities. The modifications that allowed for the creation of a Nepali version of the software are starting to be shared with other countries that have gone through similar experiences, through the openIMIS community.