AI in Health Insurance (Learning exchange with Amref)

In the realm of health insurance, the evolution from traditional Business Intelligence (BI) to Artificial Intelligence (AI) marks a transformative leap. AI can be incredibly useful in health insurance due to its ability to process large amounts of data quickly and detect patterns that humans might miss, which is of critical importance especially in claims in adjudication and fraud control. Automated processing of claims by extracting information from medical records and medical guidelines or policy rules help with real time decision support and anomaly detection for identifying fraud. Further, due to pattern recognition and machine learning, AI could be used in predictive analytics, natural language processing (NLP) and workflow optimization due to the ability to prioritize high risk claims. Some health insurance agencies have already started to benefit from implementation of AI to streamline claims processing, improve accuracy in adjudication, and enhance fraud detection capabilities, ultimately leading to cost savings, improved efficiency, and better protection against fraudulent activities. However, there are emerging learnings to be considered in implementation regarding data governance, standardization & quality, regulatory compliance, continuous learning, data privacy, security and ethical concerns.

Since January 2025, GIZ and Amref Health Africa, in partnership with the Asian Development Bank (ADB), have delivered a practical AI learning program to equip professionals and policymakers with the tools to harness AI for strengthening health financing. Grounded in the proven "Learning Exchanges" framework, the program merges theoretical expertise with actionable solutions, co-developed by specialists and participants from 13 countries.

Through a blend of hybrid workshops and online sessions, 26 representatives from Africa, Asia, and beyond collaborated to design modular learning content – spanning AI fundamentals, ethical considerations, and technical implementation hurdles. Participants hailed from Nepal, Cambodia, Nigeria, Ghana, Kenya, Tanzania, Zanzibar, Cameroon, Pakistan, Uzbekistan, the Philippines, Bangladesh, and Indonesia, with contributions from two lead AI trainers and six guest experts from health authorities and research institutions in India, Singapore, Switzerland, and the UK. Their diverse perspectives enriched discussions, ensuring a comprehensive and globally relevant approach.

An integral part of the program is openIMIS, a Digital Public Good offering open-source solutions for health and social protection programs, including social health insurance and AI Claims Adjudication. The latter served as a key case study, enabling participants to examine practical implementation strategies – from system integration and fraud detection to workflow optimization. By incorporating real-world experiences from their respective health systems, participants ensured the program’s practical relevance and adaptability across diverse contexts.

A cornerstone achievement of the initiative is the "AI in Health Insurance" e-learning course, set to launch as a Digital Public Good in January 2026. Designed for practitioners and policymakers in health ministries, insurance agencies, and international organizations, the course features adaptable content – covering data management, fraud prevention, governance, and ethics – rooted in the actual challenges faced by participating countries.

To amplify these insights globally, ADB, Amref, and GIZ hosted a UHC Day webinar on December 10, 2025, showcasing the program’s key findings and exploring pathways for integrating AI into national health financing systems. With over 110 participants from policy, practice, and research, the webinar fostered a dynamic exchange on the future of AI in health financing.

This initiative underscores how collaboration, hands-on education, and digital innovation can propel progress toward universal health coverage. The free e-learning course and Learning Exchanges outcomes – including lessons from openIMIS – will soon be accessible to all, marking a pivotal step toward equitable, efficient, and AI-powered health financing.

Access to e-Learning course AI in Health Insurance:

• Weblink to e-Learning course on Jibu platform by Amref Health Africa

Further reading:

• Unlocking the potential of AI for social health insurance (Aug 2025)

• openIMIS AI Claims Adjudication

• UHC webinar on AI in Health Financing (Dec 2025)

• Collection of country case studies for 13 countries represented in the Learning Exchanges (from mid Feb 2026)

• Information on thee-Learning course AI in Health InsurancePreview

• Partners, trainers & guest speakersPreview

• Learning Exchange - Cohort IPreview

• Learning Exchange: Cohort IIPreview

• Other AI resourcesPreview