Defining common business processes for formal sector insurance schemes

We have seen a growing demand among social protection and health insurance organisations to use openIMIS for different programmes,” says Julia Niklewski, Digital Health Adviser at openIMIS. “And although openIMIS offers basic functionality for formal sector schemes,” she continues, “the software still needs to be customised for each new use case.

The customisation of openIMIS for formal sector health financing and social protection schemes was the focus of a Requirements Gathering Workshop that was part of a week-long study tour to Nepal, from 20 - 24 January 2025. Through a series of meetings and field visits during the first half of the week, delegates from Ethiopia, Senegal and Zambia were able to witness working examples of openIMIS implementation at different levels of Nepal’s health system. During the second half of the week, the delegates sat down with their Nepali hosts and development partners to identify and agree on the common business processes that provide the basis for future customisations of openIMIS. 

The event was organised by the Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH, the International Labour Organization (ILO) and Expertise France, with additional support from the Digital Convergence Initiative (DCI) and the European Commission (EC).

Harnessing the experiences of different countries

On the first afternoon of the workshop, the three teams from Ethiopia, Senegal and Zambia presented an overview of the social protection and social health protection schemes being implemented in their countries, together with a detailed description of the business processes involved in delivering the services.

Each country team identified one business process which could be improved in efficacy and efficiency through the integration of openIMIS, and then conducted a ‘gap analysis’ comparing how the process currently works with how it should ideally work. The selected processes covered registration management (Zambia), contribution management (Senegal) and claims management (Ethiopia). The teams then went on to discuss how the integration of openIMIS could address the identified performance gaps, as well as what would be required in order to implement potential openIMIS solutions.

Identifying common business processes

While openIMIS offers standard functionality for beneficiary and employer management in formal sector insurance schemes, each new use case is unique and must be tailored both to the requirements of the programme and to the context in which it is operating. There are, however, business processes that respond to most of the needs of these programmes, thereby providing a strong basis from which to adapt and extend the software.

The second day of the Nepal workshop provided an opportunity for delegates not only to discuss each other’s formal sector business processes, but to identify and agree on the commonalities between them. To kick off discussions, Luis Frota, Programme Manager Innovation and Digital Transformation at ILO, presented international experiences and good practices on Social Security Administrative processes.

For each of the three business processes selected on Day 1, the country teams defined the detailed process and the functional requirements – dividing the latter into ‘must have’ and ‘nice to have’ requirements – and produced a set of flow charts. In a highly collaborative exercise, all of the workshop participants had an opportunity to comment on and contribute to each of the workflows.
 

Supporting social protection principles

Towards the end of the final morning of the workshop, Mathilde Mailfert, Health Financing and Social Health Protection Technical Officer at ILO, conducted an exercise for delegates to consider how management information systems can help to realise the strategic principles of social health protection. These include universality of protection, legal coverage, access and equity, solidarity in financing, participation and social dialogue, social justice, and transparency and accountability.
 

Among the many examples presented, Ms Mailfert explained that digital management information systems can strengthen data security and confidentiality, particularly in relation to health data interoperability, can generate data on beneficiaries that facilitates analysis of equity gaps, and increase transparency through the tracking of selected performance indicators.

The first important step on a longer journey

Thanks to the huge efforts of the Nepali hosts and the team of facilitators, and the commitment and hard work of the delegates, the study tour achieved its objectives with flying colours; at the end of the week, the Ethiopian, Senegalese and Zambian delegations left Nepal – a country with many of the same constraints as their own – with new knowledge of openIMIS and its operation and requirements, a road map for integrating openIMIS into their core social health insurance business processes, and an invitation to the openIMIS community which stands ready to provide ongoing support as they meet new challenges along the way.

Rosalie Ngom Colie, General Manager of ICAMO in Senegal, attending the workshop as part of a team implementing a compulsory health insurance information project, reflected on the week; 

On this study tour we discovered all the opportunities which openIMIS brings. Our findings have exceeded our expectations.

For more information, please check our documentation in the openIMIS wiki.

Other recommended reading in this context: Building bridges between social protection and health sectors (SDC / Health Network blog, March 2025)