Background - Joint Learning Network for UHC

The most relevant collection of generic user requirements for an IMIS in low and middle income countries was created by the Joint Learning Network for UHC (JLN) in the years 2010 to 2012. The JLN requirements provide an excellent basis because they summarize the requirements from a range of countries, representing different regions, cultures and socio-economic situations (Ghana, India, Indonesia, Kenya, Malaysia, Mali, Nigeria, the Philippines, Thailand, and Vietnam). It is based on the CRDM. (PATH 2012)

Central result of the JLN experience is a universal matrix of processes within a clearly defined process framework, that were identified as “common” amongst most insurance management systems in low and middle income countries:

The requirements analysis focuses on the following five core processes groups:

• Beneficiary Management includes all beneficiary interactions, including the interactions with the Insurance agency and providers.

• Provider Management focuses on interactions between the payer (insurance agency) and the care providers.

• Premium Management covers the beneficiary interaction (premium collection) and administrative procedures at the insurance agency.

• Claims Management ranges from claims transmission to acceptance/rejection.

• Accounting covers ledger systems and payment mechanisms. This functionality is typically handled by a third party software.

The remaining processes are not being discussed in all detail in the JLN requirements documents and range from care management, which relates to care or coverage specific schemes (e.g. catastrophic or chronic disease) to functions such as fraud management.

The resulting documents from the JLN project were released under a Creative Commons License for further re-use under certain conditions. The openIMIS Initiative will build upon these ressources. However, there are also some limitations to using results from this approach for the openIMIS TRM:

• The requirements were compiled in 2011, some recent trends may not have been fully considered.

• The approach aims to help countries build their own requirements based on these general requirements.

Following this logic, the requirements can only serve as a first step towards the determination of openIMIS requirements.