Social Health Insurance

Many countries are working to extend social health protection as part of the drive to achieve Universal Health Coverage. Health insurance schemes can protect people from the financial consequences of paying out-of-pocket for needed health services and reduce the risk of impoverishment due to ill health.

openIMIS offers a range of functional modules which can be combined into tailored solutions for the delivery of specific social protection schemes. The health insurance solution powered by openIMIS allows scheme operators to manage beneficiaries, contracts, products, contributions, providers, claims and accounting in a single software. A key strength of openIMIS is its capacity to support the digital creation, submission and review of claims, including AI-supported review. It also connects seamlessly with other open source products, such as DHIS2 and openMRS, using FHIR standards.

Supported processes

openIMIS supports the following processes for health insurance:

• Employer/employee management

• Collecting and managing contributions

• Benefit package design/configuration

• Issuing membership ID cards to beneficiaries

• Verifying scheme membership

• Health service claims generation and submission

• Claims review and management

• Processing and payment of claims

Benefits

For beneficiaries, openIMIS simplifies enrolment procedures, reduces the number of ‘touch points’ (therefore saving both time and money), and makes it easy to verify one’s coverage status at point of care. For health facilities, it streamlines the processes associated with a health financing scheme and makes it easy for them to receive reimbursements. For scheme operators it reduces operational costs and allows for better monitoring and analysis of the scheme’s overall performance. For decision makers, data from openIMIS can enhance policy making and planning related to health service delivery

Example workflow

Current implementations

Cameroon

Chad

Democratic Republic of Congo

Mauritania

Nepal

Niger

Tanzania (Mainland)

Tanzania (Zanzibar)

Further information

Visit the wiki page or download the factsheet for this solution: