OpenIMIS was design initially for a precise usage, now that it is a GlobalGood initiative it should changed its data model to be more adaptable.

Example of limitations because of the data model:

1. Services can be limited by HF Price List or by product Service list but it is not possible to set different price for the same service based on the product and location, ex:

   1. Service 1 when covered by the UHC is reimbursed X to State facilities but reimbursed Y to private Facility (e.g. ). but for the insuree with a Advnaced insurance plan the service is reimbursed Z to private Facility

2. Remuneration models, today there is only 2 remuneration models (fee for service and capitation) but only one set of parameters is possible per product meaning that you cannot have 2 different capitation financing on a single product

3. Contribution model is defined on a product level, only one set of parameters is available meaning that all the insuree are using the same pricing models which prevent adapting the contribution to the payment capacities of the insuree (formal sector will address that issue but not for the informal part)

4. There is not possible to define constraints between diagnosis (ICD) and items/services

5. There is not possible to define constraints between services and items (ex. the service include already some items so those items could not be included separately in the claim)

6. There is no way to define limitation on the size of the family to be covered by a policy (thresholds only apply to family members ( not for other adults see https://openimis.atlassian.net/wiki/spaces/OP/pages/1838612485/Policy+Values+Calculations )

Product redesign

Covers points: 1*,2,3,

Open

Mapping between product actions and product entity

Open

Ideal data structure

Realist data structure for openIMIS

In addition the PP&R plan could be added under the HF to enable flexibility in the way of payment,

PP&R plan could include the price list with an additional column for origin (column to remove for Coverage plan Service and item list) and the limits : like price list they will overwrite the default set in insuree coverage plan

HF could have different PP&R plan (link between a product/pool and a calculation )

Insuree coverage plan are today configured in the product with

• item and service list

• limits on care (e.g. number of delivery …)

In the Realist data structure for openIMIS this part stays with the product because without the Insuree coverage plan, contribution plan , nor pool, nor PP&R plan the product will be a simple mapping table.

Provider Payment plan are today configured in the product with:

• price list (not in product, but should be incorporated and location should have the possibility to have more than one price list)

• deductible

Contribution plan are today configured in the product with:

• lumsum

• policy value

• threshold

• …

→ Formal sector already introduced the contribution plan in openIMIS