openIMIS for Health Insurance

The Challenge: Efficiently managing beneficiary, provider and payer data

Efficiently managing beneficiary, provider and payer data Many countries are working to extend social health protection as part of the drive to achieve Universal Health Coverage (SDG 3). As health financing schemes are expanded to include people working in the informal sector and other hitherto excluded groups, there is an acute need for digital solutions to efficiently manage the growing information flows.

Many scheme operators continue to invest significant time and resources in the establishment of digital information systems designed to meet their specific needs.

Stand-alone digital solutions introduce problems of their own, however: expensive licensing fees, the risk of vendor ‘lock-in’, and an inability to exchange data with other information systems. Data ‘siloes’ are a significant obstacle to the seamless exchange of information that is needed to make health insurance schemes work at scale and to make progress towards Sustainable Development Goal targets.

openIMIS was originally developed to facilitate the administration of social health insurance schemes for people in the informal sector in low and lower-middle income countries. It has subsequently been modified for use in administering health insurance schemes focused on the formal sector as well. openIMIS supports the following core insurance processes:

• Beneficiary Management

• Collecting and managing contributions

• Issuing membership ID cards to beneficiaries

• Verifying scheme membership

• Health service claims generation and submission

• Medical review of selected claims

• Processing and payment of claims

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

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