Field Trip Reflections & openIMIS Initiative

Date: February 15, 2018

Location: Sea Cliff Hotel, Dar es Salaam

Moderator: Christian

A. Expectation Setting

-Mapping hospital workflows

-Use of data from openIMIS for research 

-Use of data from openIMIS for decision-making and national policy making

-Integration with Health Curriculum

-Integration with SMART policy

-Digitizing claims

-Fit openIMIS with Enterprise Architecture in Tanzania

-Capacity-building on openIMIS

-How openIMIS can come in as a system for medical insurance

-Operationalizing the system (field level)

-Translation of field lessons to national level implementation

-Tanzanian perspective in technology/ digital health

-Learn more about openIMIS, knowledge and resource sharing

-Learn how openIMIS can fit with health financing schemes

-Coordination with other partners

-Linkages with health management systems

-Perspective on sustainability with evolving technologies

-Inclusion of indigents with openIMIS as a tool (Chad)

-Requirements gathering from countries

-Understanding country needs 

-Sharing of lessons learned

-Governance structure of openIMIS

-Strengthening the management of openIMIS implementation 

-Look forward into proposing it as a test tool in a local town in Cameroon

-Advance implementation with BEPHA in Cameroon

B. Field Trip Experiences

Group 1: 

• Members' enrolment: central them, a lot of data entry done and similar data is entered in different systems
• Members' enrolment: concern about keeping data on phone and the security issues related to this (theft etc)
• Client Identification: no patient verification without internet is a challenge
• Client Identification: Definitions of household is loose (up to 6 people).
• Cards don’t have photos which makes it difficult for illiterate people to know which card is there’s
• Capitation: reimbursement system calculated on number of cases but provider still needs to add diagnosis in OpenIMIS. Should we be putting this level of effort on the provider when this data is not required for capitation payment 

Group 2: 

Members' Enrolment

• obersvation - User familiar and efficient using system
• Obersvation - QR codes being used
• observation - lots of paper still around
• No means of confirming family/household size. Need a definition of household and how we implement it (Rwanda eg)
• Is it possible to do enrollment  the household to get the GIS
• Linking with other systems is important
• Diagnosis code should be accompanied by text. This has positives and negatives - issues of data security.
• Data security is also an issue with people using personal phones at the health facilities.
• didn’t get to the reporting functionality which would have been valuable
• is the computer version also bilingual? App is yes don’t know about computer version

C. openIMIS Global Initiative

• Timeline: From IMIS to openIMIS
• Vision & Mission: Link health financing schemes into interoperable digital health systems by using open source software
• Components
  • Open Source
  • Sustainable Community
  • Interoperability
  • Customizable Architecture
• Open Source Sofware is free but needs to consider:
  • Licensing Agreement
  • Free to use as-is
  • Costs for customization and implementation
  • The community of practice (DHIS2, openLMIS, etc)
• Governance Structure
  • Developers Committee
    • Continuity: SwissTPH and SolDevelo
    • Re-architecture: BlueSquare
    • Interoperability: HISP India, etc
  • Implementation Committee
    • Communication: FFW
    • Capacity: SwissTPH and EPOS
    • Community: AeHIN and Jembi
• Clarifications
  • openIMIS as an avenue to create an environment for solving issues
  • Specific country customizations to be done by responsible payer in the system
  • 2 versiosn at least in a year
  • Data ownership is locally managed 2019: small releases, knowledge production, master version

D. openIMIS Regional Hub Africa: Jembi Health Systems

• NGO in Africa
• Started in 2009
• Technical development, business analysis, implementation
• Requirements definition, system architecture and design, development of software, 
• Implementation in countries in Africa
• Managing and evaluation of projects
• International open software communities
• Role with openIMIS:
  • Define requirements and provide technical assistance
  • Technical specifications for interoperability
  • Helping in implementation (matching with donors)

E1. Parallel Session: Developers Committee

• Alignment with digital development
• Alignment with digital investment
• Embedded in sustainable development goals
• From MS IMIS to openIMS
• Components
  • Open Source: openIMIS in an open source environment
  • Local Development: IMIS in TZ, NP, CM (adapt with unique requirements)
  • Modulat Transformation: From a monolithic web structure to a mode modular structure  
  • Slow Transition: Prioritize modules depending on country needs
  • Interoperability: Data exchange among different systems anchored on openHIE framework that would allow fire data to en ESB as an itneroperability layer
  • Vision: Integrated Workflows (Examples: Eligibility, Claiming)
  • openIMIS Outsourcing 2019
    • Continuity: Software maintenance and support (Swiss TPH and SolDevelo)
    • Re-architecture: Modular transformation (BlueSquare)
    • Interoperability: HISP India (openIMIS and DHIS2), SwissTPH and SolDevelo (openMRS and openIMIS for claims management), Possible Health (openIMIS and Bahmni for claims management)
  • Current Activities
    • Routine support and release building
    • Getting the teams on board
    • Concise weekly coordination calls
    • Need-oriented special topic calls
    • Developers workshop (February 2019 in Bonn)
      • Decide on technology options
      • Learn new technologies
      • Harmonize work plans

Q&A Session 1:

1. How insurance will come into the new diagram of openHIE? The new version will include openIMIS.
2. To have a lot of buy-in in Tanzania and other countries, there is a need for local developers for customization and development.  How to ensure that they meaningfully come in (like they are paid on a regular basis)? This is where the regional and country hubs come in. 
3. Are there local developers in Tanzania? These are contracted by another implementing partner. 
4. To be part of openIMIS, what does it require?

E2. Parallel Session: Implementers Community

• UHC is the aim - through health financing sysems
• health financing processes
  • resource collection
    • taxes/payroll
    • Insurance contributions
    • user fees/co-pooling
  • resource pooling
  • purchasing of services (holds the funds for resource pooling, we need data to design a strategic purchase -match with services needed)
    • capitation
    • budget
    • case based payment / fee for service 
    • more fee for service focus the more information we need. Always need data if we want to move away from a general budget
    • how do we use openIMIS
      • registration / enrollment (also collect money)
      • verification of member
      • claim submission
      • Claims review 
      • client feedback
      • reporting _ basic but growing (what are you diagnosing, getting money for etc)
      • OpenIMIS is a flexible tool that can be used for main health financing schemes: NI, tax funded national health system, community-based health fund, vouchers scheme, strategic purchasing arrangements (P4P and RBF)
    • What we do at the implementing committee? Next.  Steps for OpenIMIS - globally
      • position OpenIMIS globally as digital tool for health financing and UHC (so countries don't start from scratch)
      • software development - collecting and defining new user requested features
        • formal sector enrollment 
        • additional reporting and monitoring functionality 
        • dashboards for management and policy decision making
        • interoperability with other systems
      • marketing and communications: new website
      • expanding the network of development and implementing partners (promote sustainability at the local level)
    • Next steps: country-level
      • bringing new countries onboard
      • COuntries: RW, MW, CAM CH
      • country assessments to gather requirements and software functionality requirements
      • expansion of network of developent and implementing partners (support possibilities for country level implementation)
      • implementation steps
        • starter kit (including costing estimates) 
        • costing estimates
      • Demo on software
      •  
        • online video, wiki guide
      • Capacity-building: alliances and strategic partnerships
    • Q&A session 1:
      • from persepctive of operators already using a system would you have to do this twice
        • different insurance providers different systems. Can look at interoperability for single form for data import
        • paralel systems currently running. It’s a policy level decision. 

OpenForum Q&A:

• In Chad, how can this request for change (for co-payment) at the global level can be accommodated or we have it to develop it via local projects? We'll talk about the channels being used later in the afternoon. This shall be discussed among the implementers - it's something we need to find out based on your priorities. Local implementation structure and teams are needed for local development and features. Prioritization of requests is being assessed based on discussions with the technical advisory group. 
• How can we be registered to openIMIS (as a local company)? 
• How can we be capacitated? (Communication between local and global) Self-learning via wiki platform for architecture.. also via github
• For interoperability initiatives, how can we coordinate (so we don't end up doing the same thing)? Communicate with our developers.
• How high is the risk if I cannot fund local developers into the redesigned and modular system? Roadmap for communication among developers to be released by the end of the month.
• is there a timeline for redesign? 2 modules by end of 2019 but size of module not clear. There is a will. Will have roadmap and timeline at end of Feb 2019. Until then we will be sticking with the MS based system for implementation? Yes. It should also allow for seamless transition to modular approach
• Would you know about the licensing agreement (when it will be offered for free)? At the end of feb, they would most probably know about the new architectures
• Can this whole work be done offline? Enquiry part is still online. 
• Recommendation: Big opportunity to involve developers from pioneer countries like Tanzania (re-architecure phases, etc) . Response: Academic outreach with universities
• Recommendation: Need to involve local institutions like academia as early as now. Include in their curricula activities
• Comment: Local private software firms may be willing to participate in the developers' committee. Response: Universities can be entry points for capacity-building. 
• How can we benefit from the global initiative when the complete package is complete? We want to add open source development languages that are not dependent on Microsoft. Ideal scenarios is that the database layer exchangeable that can be run on a Microsoft server and Linode server.
• Comment: Potential for openIMIS to interoperate with other systems or existing systems that are up and running (GOTOHOMIS, etc)? 
• Will there be a claims management demo? Rejection reports

COUNTRY GROUP WORK

Q: Is there a sustainability plan for CBHI?

A: 

Q: In Cameroon and Rwanda, no enrolment features. Recommendation: Cameroon might want to customize it in their country as we are developing a master version. 

A: Government want to use the aspect of this program for the future. We want to check if we can adopt openIMIS. Our problem is we have many bills and we want to extend this program in Cameroon. It's a strategic decision to make.  We want to get ready on the rollout of openIMIS. To get the offline version installed and understand the functions so we can manage it on our level. 

Country System and Requirements: Tanzania

• Unclear policy direction 
• Governance: Sector-wide approach, health financing technical working group, CHF Implementers group, technical committee established on CHF IMIS, installment of payments (a question right now)
• Harmonization: Current rollout, harmonize strategy for enrolment officers, lot of issue on mismatch of money, 
• Feature Requests: Payments have arrived, policies are active, app that runs on any hardware, integration with facility system, client registry might have overlapped with insurance system - integration needs to be aligned re data capture, standardization on NHIF and CHF
• Challenges: SMS cost, hardware needs, lack of phones, capacity building (large number of people), administrative costs, unclear policyQ&A:

Q: Microsoft training - we have done video tutorials, we can create training in each region via video

Q (Rwanda): Standards for claim management or wait for the openIMIS software to be ready?

Comment: There should be closer linkages between working groups on health client registry and openIMIS. 

Technical

• Front (Material-ui, React & Redux, Javascript) in MS active source pages
• Back (Django/Python <> Java)
  • University students come with Java and Python
• Database (SQL server)
• HL7-FHIR as data exchange standard (issue: question on database set-up or use an external one?)
• Airflow for monitoring of batch processes
• Migrating mobile application

Academia

• Assets
  • Social protection and insurance (with courses on health financing)
  • IT programming
  • Research component
• Gaps
  • Limited tools for practical learning
  • Limited real-life scenarios
  • Curriculum outdated
• Action Items
  • Revisit curriculum to include openIMIS
  • Research topics on digital health trends using openIMIS
  • Ad hoc projects on openIMIS for collab between IT and social protection
  • Short courses on health financing (with openIMIS as a tool)
  • IT specialist to support the local openIMIS developers team

COMMUNICATIONS CHANNEL

-Data Confidentiality Onion

• Confidentiality Access
  • Public Communication (website) - representative deign
  • Team Communication (wiki) - transparent discussions
  • Internal Team (forum) - restricted 
  • Peer to peer (eMail) - confidential 
  • GIZ Internal - GIZ internal systems
• Communication Platforms
  • Issue Queue (Jira)
  • Wiki (Confluence)
  • Source Code Repository (Git)
  • Documentation Repository (Git)
  • Etc (Refer to Uwe's list)

-Public Communication

• Corporate Identity
  • Brand Guidelines
  • Templates (Powerpoint, Banner, Icons)
  • Merchandise 
  • Technical Writing
• Website
• Newsletter and Social Media
• Demo Server
• Documentation

-Team Communications

• Wiki for IC
• Wiki for DC
• Events
• Calendars
• Google Groups
• Google Folders

Reflections:

• Encouraged to talk more about openIMIS and adopt it in the country
• Appreciate the clarification of governance structure
• Importance of communications
• Broaden our systems with openIMIS
• Difference between IMIS and openIMIS and the potential of timing in terms of starting implementation
• Sustainability via academia
• Strengthening the local capacity

DAY 2

Reflections:

-How do we approach the next steps (work plan-oriented)

-Requirements from different countries and find out how we can continue the conversation in Rwanda

-How we can collaborate from the requirements to the development (how the process can be easily managed)

-Communication channels are easily completed

-Some are skeptical about openIMIS

-Participants gained confidence on openIMIS

-Interaction between implementers and developers (communication channels)

-Harmonize and streamline processes

-Interaction, timelines, guidelines

-Connect the global, regional, and national levels

-Knowledge exchange and knowledge production

-Regional hubs roles (what are expected from them)

-Use of tools for knowledge sharing among different country contexts 

-How do we make countries contribute to the global good 

Implementing 

*Private Sector

*Dr Mashaushi and Dr Faraja (Academe they dont have health - IFM), similar gaps with Asia

*Good branding

*KPIs - what are expected from CoPs and timelines

-Template for presentations, etc and documentation of country context stories

JEMBI HEALTH SYSTEMS

-African non-profit company

Jembi's core competencies include:

*needs assessment and requirements gathering

*system design and solution architecture

*software design and solution architecture

*software development

*implementation and capacity-building

Jembi's approach to health information systems

-acknowledging the interconnection between policy, practice, and technology

-focusing on building local capacity to use, manage and maintain the health information systems

-honest brokers of technology

-focus on interoperability

-Project Canvas

Country Engagement

AIM: Viable solution for health financing in low-resource setting

*Country Engagement

-represented in relevant African health information systems communities

*Products and Requirements

-country driven requirements are available to support openIMIS feature refinement and the ongoing development of the system

*Technical Product Requirements and Interoperability

-openimis interoperab

*Implementers

*Capitation

*Technical Architecture

Q&A:

Q: How do you conduct projects in countries?

A: TA, work with local capacity in the country and build that, work with ministries of health, work with openMRS in Cameroon, also do some of the dev work, build capacity with local moh to manage systems, 

Q: Interesting to look deeper into, how do you reach out to people, how do you transfer and write messages and communicate to people? 

A: System we designed we look at individual country requirements and make it universal and develop that functionality and follow standards from the blood transfusion society. We looked at how we do that product management or project management. A lot of engagement on the user side.

Q: It's important to have the translation part outlined at the beginning. That kind of highlights sustainability in the country. 

Q: Interested in process steps. Based on the country assessment, how you went about it? In terms of prioritization and creating the global good? How do you list and select them and prioritize? 

A: Slide deck later in the afternoon to check the processes

Q: Besides the blood project, we also have the CRVS project.

Q: What do you need to be onboard? So we can support you in the process?

A: We don't have the health financing knowledge but the more we know about the area. People don't state the point or tell a story that illustrates the point and is able to repeat the point and reiterate. A lot of discussion on how you go about gathering your requirements kind of capacitating in that way. We want to look at health financing and this is how you go about for these requirements. Health financing knowledge so we shape all those discussions. W have a lot of people we can start these discussions with. 

Q: Use your networks. Interesting to know your network (later at lunch)

Q: Local capacity-building it may be where the networking part comes in (which may include private sector). 

A: Anything for us to read. It's a bit complicated.

Q: Have a presentation on how Jembi is operating in Africa and how we leverage this collaboration. We face a lot of questions on success factors. Our colleagues will be interested in about it. If a possible joint session? 

A: We can set up a webinar.

EPOS 

-Group of companies in Germany (1985)

-Mainly active in Africa but also involved in hospital planning and supply

-Michael as a freelance consultant (hospital sector)

-Workflows in hospitals (focus on IT system implementation) and see how they can fit in the workflow

-openIMIS (open source approach is a good thing) and might go in the same direction with DHIS2 (university-based)

-To serve whole countries instead of having siloed pilot solutions

-From cap bldg perspective, we should focus on the political decision-makers, play with it, see the benefits

-Easier to have a menu on issues (as multiple choices) - small things that would make it easier to use

SWISS TPH

-Research and tropical diseases, training and cap bldg, health systems programs (education), insurance medicine courses, research activities happening within the institute, 

-Department is on the implementation side, siddhart based on the technology side

-Implementation side - doing different health sector sides

-Dragos - health technology and telemedicine

WORK PLAN

Promotion

-Webinars

-Marketing

-Resources (demos, videos)

-Social Media

-Donor side

-Government side

Implementation

-Implementation Starter Kit (ongoing)

-Capacity-building (modules, content)

-Support to the implementation side (resources)

-Usability requirements (Flow of issue queue)

-Focus on rearchitecturing within the development teams

Infrastructure

-Generic training manual

-Generic powerpoint presentation

FAQs on data privacy issues and data analytics

-individual cant enrol themselves (which may translate to new requests)

WEBINAR (Channel it to the african hub)

Youtube channel for openIMIS (where you can upload openIMIS video) as go to channel

Newsletter with key themes (openIMIS central mailing list) link mailing list to central list

Alicia metacards

• Swiss TPH and EPOS support regional hubs (workflows)
• Jembi focus on country support (know who to involve)
• Link up among different groups
• Training courses and implementation starter kit (make sure no double work among hubs) - 
• Process flow for requirement gathering
• Messaging and training package and implementer starter kit for Africa 

Opportunity to implement openIMIS in Rwanda

-see how we can operationalize that

-immediate next steps: connect the right people to via Jembi

-we don't push any particular solutions 

-work is promoting open source solutions specifically in Rwanda

-how the integration will take place

-how will the capacity-building take place

-how this local capacity-building can be done

-Assess based on those recommendations and figure out how we can fill the GPAS then talk to CHAI and ask if we can borrow technical resources

-Start from smaller scale pilot implementation (setting up the implementation and seeing it how it works locally)

-Start to secure some mid-term funding (talk to bluesquare who have linkages to Belgium)

-Ask IT team to send specifications about the platform (send screenshots of the database)

-Parallel approaches in capacity-building

-Mix an interview where you see a speaker and see the text - but these videos are difficult (i recommend to do this)

-Webinars, demo videos, and cap-bldg are important (addressing different audiences at different entry points) 

-Comm materials for different target groups

-Training assets as we move along the implementation 

-There needs to be a starting document on training assets and material development even though we have country-specific materials

-Audiences for training materials

• Policy-makers 
• Technical training in Africa (digital square, jembi, digital health course), hackathons
• End-users (videos of country projects)

-Local office of GIZ in Cameroon

• Better understanding of GIZ
• Want to push through with the program (full round) to reach to the population in providing health insurance with BEPHA structure
• Government is reflecting on implementing a national system for health insurance (but expensive) so openIMIS is another alternative the government is looking at
• Interested in accompanying the implementers side when decisions or improvements are made and benefit from the improvements
• Better training of users/ demonstration (in government)
• Needs (use the full rollout of the openIMIS) otherwise we're working on a limited scope
• More comprehensive understanding of the openIMIS
• Political issues 
• Focal point for f, africa

-Tanzania (what we can do for openIMIS Implementation)

• Minister of Health (roll out to 26 regions)
• Working and reaching the communities
• Tanzania (we ant other nations to learn from it)
• Creating stories in Swahili to be transmitted to the global level
• This is our vision based on the symposium from the government point of view
• Need: Have a good communication channel as a country and know the timeframe of requirements (how long will it take to be delivered)
• Need: Local developers who can develop the own requirement that may benefit the global level to help other countries
• Need: Develop local modules (normally have a training of trainers) when a new feature is developed, need to make sure that the trainers are trained
• Need training courses via local academia (field workers can get knowledge from the institution)
• We are happy the initiative is moving forward
• Challenges on the health insurance system (we should walk with other countries)
• Create new innovators that may help the product grow

-