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The institutional context
Social health insurance was introduced by the Government of Nepal in April 2016, with an initial roll-out to three of the country’s 77 districts. The scheme is family based, with a family of up to 5 members contributing Rs. 3500 (EUR 30) for a benefit package worth Rs. 100,000 (EUR 800) per family, per year. It focuses primarily on those working in the informal sector. In 2017, the Health Insurance Board (HIB) of Nepal was formed following the enactment of the Nepal Health Insurance Act, which mandates that every Nepali citizen be covered by a social health insurance scheme. Since its initial roll-out in three districts, the scheme has been gradually expanded and is now available in 76 out of 77 districts of Nepal.
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How the scheme uses openIMIS
IMIS, adapted from the Tanzania and Cameroon implementations, was used from the very beginning to manage all core business processes of the insurance scheme, from beneficiary management to claims adjudication. The Health Insurance Board has been using openIMIS since the master version became available in 2018.
openIMIS has been instrumental in helping Nepal implement social health insurance. Complicated processes, particularly around enrolment and claims processing, have been made easier. The availability of Android-based apps for enrolment has meant that enrolment assistants can go door to door to bring households into the scheme. A web-based claims entry and adjudication module significantly diminishes paper-based transactions and reduces paperwork for health facilities. This has enabled the Health Insurance Board to achieve a rapid rate of expansion.
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Interoperability
The primary focus of interoperability with openIMIS in Nepal has been around the electronic submission of claims via Electronic Medical Record Systems. There are a few service providers that use EMRs in their hospitals and work is currently underway to design standard approaches to allow them to submit claims electronically. An integration of openIMIS and Bahmni (used in 4 health facilities in Nepal) has been implemented, and is used by Bayalpata Hospital to submit their claims automatically to openIMIS. Other hospitals and EMR systems are also adapting their APIs to FHIR R4 to enable digital claiming to openIMIS.
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