openIMIS supports beneficiary and claims management of a variety of different protection schemes (or instruments) in health and beyond. The nature of a scheme defines which functionalities and data structures in openIMIS are needed. As a prerequisite for building these in an efficient way, a well structured classification of protection schemes is needed.
HL7 defines Coverage as data structure that describes the protection of a beneficiary in the context of health services: http://hl7.org/fhir/R4/coverage.html . openIMIS is mapping this structure directly into data base tables: FHIR R4 - Coverage . There are two elements that can be used to classify the coverage of an individual:
coverage type: contains one code of a list of predefined codes: http://hl7.org/fhir/R4/valueset-coverage-type.html . It is recommended that this list comes from a generic, standardized list of classifications. Note that these are currently at a maturity level of 0.
coverage class: can contain a collection of additional attributes that can further classify a coverage.
Social Protection
Non-contributory
Social assistance
Social transfers
Cash transfers
Vouchers
In-kind transfers
Public works programmes
Cash for work
Food for work
Fee Waivers
basic health
education
Subsidies
Fuel
Food
Social care
Contributory
Insurance
Unemployment
Maternity
Disability
Work accident
Old age pension
Survivors’ benefits
Policies
Active labor market policies
Work sharing
Training
Job-search services
from https://ww1.issa.int/system/files/documents/2021-05/2-Guidelines ICT-2020.pdf, p.188
Schemes
Long-term benefits
Pensions
Disability
Hybrid benefits
Family
Health insurance
Short term benefits for income replacement
Sickness
Unemployment
Maternity
Medical care
Sickness benefit
Unemployment benefit
Old-age benefit
Employment injury benefit
Family benefit
Maternity benefit
Invalidity benefit
Survivors' benefit
See also: https://www.social-protection.org/gimi/Standards.action
Beneficiaries’ view: Refers to all facts that should be known to potential beneficiaries, such as who can become a beneficiary, at what time and for how long, what are benefits, and when they are provided and under what conditions.
Payers’ view: Refers to all facts that should be known to potential payers for social insurance programs as for example what contributions should be paid, when they are paid, what happens if contributions are not paid properly.
Providers’ view: Describes which providers (or types of providers) will provide benefits in-kind, what benefits in-kind are provided, how benefits are claimed, and how claims are paid or settled.
Business processes view: Describes all processes associated with the administration of the programme, such as the process of enrolling a beneficiary, approving benefits, evaluating and clearing claims for benefits in-kind and paying benefits in cash, as well as the change management and grievance processes. In addition, the identification of beneficiaries comes under business processes.
Financial resources view: Describes all sources of funding for the programme and includes specifying the level of pooling, rules of possible redistribution and subsidisation.
Human resources view: Includes a description of all roles of the internal and external human resources participating in the administration of the programme.
Institutional view: Describes which institutions will oversee the administration of the programme and which institutions will participate in delivering the supporting data needed for the administration of the social protection programme.
from: Deep Dive: openIMIS beyond Health (technical) :
Risk: e.g. illness, long life, pregnancy, accident, death, economic loss, injury, disability, unemployment, uneducated
Type of Benefit: e.g one time payment, recurrent payment, free service, consumables, transmittable rights
Target Group: e.g. formal sector, informal sector, youth, mothers, under fives, poor, specific targets (HIV et al), health care workers
Type of Contribution: e.g. one time payment, recurrent payment, one time subsidy, recurrent subsidy
Oxford Policy Management
Oxford Policy Management (2018-03), https://www.opml.co.uk/files/Publications/a0408-shock-responsive-social-protection-systems/srsp-literature-review.pdf?noredirect=1
Oxford Policy Management (2018-01), “Shock-Responsive Social Protection Systems Research“,https://www.opml.co.uk/files/Publications/a0408-shock-responsive-social-protection-systems/srsp-synthesis-report.pdf, page 6 (figure 2)
ISSA:
ICT Guidelines: https://ww1.issa.int/guidelines/ict/pdf
HL7 FHIR: