The journey towards a sustainable open source solution for health financing
Over the past four years the openIMIS Initiative has facilitated the development of a free and open source software for administering social health protection schemes. Supported by a vibrant community of developers and users, openIMIS is now a recognised global good. How did it get there? And what lessons have been learned along the way?
This article is the second of a two-part series. To learn more about how openIMIS works and where it is being used, please read the companion piece ‘openIMIS: Health and social protection’s digital backbone’.
It was about five years ago that offhand comments gradually gave way to serious conversations: why not transform this piece of software into a free and open source product that can be used anywhere? The software in question was IMIS, the Insurance Management Information System, which at the time was being used to manage social health insurance schemes in Tanzania, Cameroon and Nepal. With the adoption of the Sustainable Development Goals, countries around the world were ramping up efforts to achieve Universal Health Coverage. Surely, the thinking went, many could benefit from a customisable digital tool which could efficiently handle the exchange of data related to insurance processes and could communicate seamlessly with other health information systems? In the growing open source landscape for digital health, anchored by widely-used tools such as DHIS2 and OpenMRS, there were no solutions specifically designed for health financing. The idea, the need and the opening were all there. In early 2016, the openIMIS Initiative was born.
No more reinventing the wheel
The openIMIS Initiative was established as a collaboration between the Swiss Agency for Development and Cooperation (SDC), which supported the initial development of the software by the Swiss Tropical and Public Health Institute (Swiss TPH) in Tanzania in 2012, and the German Federal Ministry for Economic Cooperation and Development (BMZ), which financed the adaptation and introduction of the software for use in Nepal starting in 2014. ‘It was never the goal at the outset to create a global good, but we saw over time that there was interest in the software. And we realised that, if we joined forces to promote it internationally, other countries might make use of it to support their health financing processes,’ explains Olivier Praz, a Senior Policy Advisor with SDC’s Global Programme Health. ‘If openIMIS became a global good, it could be an effective tool for advancing universal health coverage.’
In the global health space, the term ‘global good’ is used to describe digital tools which can be adapted to help address key health systems challenges across different countries and contexts. The premise is that, despite differences in strategy and policy frameworks, core health system processes such as disease surveillance, clinical services, supply chain management, human resource management, financing, and health service monitoring are largely the same everywhere. For far too long development partners and programme implementers continuously reinvented the wheel by creating multiple, overlapping and narrowly focused solutions which were not interoperable and which locked health systems in to reliance on a particular vendor. Longer-term aligned investments in ‘shareable’ digital solutions – in line with the Principles for Digital Development and the Digital Investment Principles – are a better bet, because they reduce duplication and enhance efficiency.
Flexible, interoperable solutions
For a ministry of health, a health insurance board or a health service provider there are many advantages to using an existing global goods software. The solutions are flexible, and can be easily scaled and adapted to local needs. They are continuously updated in line with industry standards, which means that users benefit from a top-quality product and expert support, available through a community of practice, without being locked in to a single software provider. Moreover, many global goods use common standards for information exchange, which makes it is possible for different digital systems to communicate easily with one another. Software for managing logistics and supply chains, for example, can draw upon service-related data generated by immunisation or HIV programmes to ensure that inventories of essential medicines and supplies kept are up to date. Finally, the overall investment in software customisation – in terms of both time and money – is less than developing a new solution from scratch.
‘It’s a huge benefit to have access to a flexible product that’s already on the market,’ says Marielle Goursat, a technical advisor on social health protection with the International Labour Organization (ILO). Under the auspices of the Luxembourg-funded project ‘Support to the Extension of Social Health Protection in South-East Asia,’ the ILO has commissioned a feasibility study into the possible use of openIMIS in administering social security benefits for formal sector workers in Myanmar. ‘The amount of time that is required to design and develop an information system from scratch is enormous. Saving this time is incredibly precious.’
Many contribute, everyone benefits
Beyond the technical and programmatic benefits of global goods, there is another major advantage: the very process of developing and maintaining a global good is open and collaborative. Knowledge about the tool is diversified and not concentrated in the hands of a single software company. Many different people and institutions contribute ideas and innovations, and everyone who is part of the community benefits as a result. The best ideas are integrated into the core version of the software and made available to users everywhere through the periodic release of updated versions. In this way the tool is continuously improved through feedback from users and practitioners, who by working with the product become part of a process much bigger than themselves.
In essence, the journey to global goods status involves a leap of faith: that the underlying idea is so good, and the need for it so clear, that it will be picked up and taken forward with the help of a diverse set of actors, eventually attaining the critical mass needed to ensure its sustainability.
Bringing the right players together
This dynamic process of co-creation has to be facilitated. In the case of openIMIS it has been guided by a Product Group, comprising a Developers Committee and an Implementers Committee and supported by a Coordination Desk located at the Sector Initiative Social Protection at the Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH in Bonn. Working on behalf of SDC and BMZ, the role of this group has been to bring the right players together, to guide the technical transformation of the original software into an open source product, and to promote the tool among potential implementers.
‘Developing a global good is too complex and expensive for a small group of partners to undertake alone. It’s crucial to leverage others’ strengths,’ explains Saurav Bhattarai, a GIZ advisor with the Coordination Desk. ‘From the outset the strategy has been to identify stakeholders at the global, regional and country levels who have an interest in openIMIS and who can work together to develop the tool further.’
Advisors at the Coordination Desk have actively promoted openIMIS at events and conferences around the world, including the DHIS2 Annual Conference, the Global Digital Health Forum and meetings organised by the Asian eHealth Information Network (AEHIN) and Health Informatics in Africa (HELINA). This has been a key factor in raising awareness of the tool and in attracting interest from potential partners.
A key resource: Digital Square
The openIMIS Initiative found an important ally in Digital Square, an initiative based in Washington, D.C. which works to coordinate investments in digital health global goods and to foster an environment in which these can flourish by bringing together funders, developers and users of such systems. Digital Square recognised that there was a gap in the global goods landscape which openIMIS, as a solution focused on health financing, could potentially fill. It began advising the Initiative on a range of issues, including the technical roadmap for developing openIMIS further as a modular system based on open source technologies and standards such as HL7 FHIR. It also helped the openIMIS team to think through options for a governance structure and the steps it could take to build a global community.
Starting in 2018, the openIMIS Initiative began to expand the pool of software developers working on openIMIS through an open call for applications facilitated by Digital Square, as well as through tenders for specific work packages which the Initiative issued directly. By early 2020, six different teams of developers – each working on a specific aspect of openIMIS, from ensuring continuity of the legacy system to transforming to a modular architecture and building interoperability with other products – were linked through the Developer’s Committee. Though an active Wiki, regular calls and developers workshops, members of the group – who are spread across more than 10 countries on four continents – update one another on progress, flag up technical challenges and find joint solutions to problems in real time. This process of co-creation facilitates transparency, creativity, trust and a sense that everyone is pulling together in the same direction.
One part of a bigger puzzle
Another important collaboration has been with OpenHIE, a global standardisation initiative which supports country-driven, large-scale health information sharing architectures. Members of OpenHIE’s community of practice work to enable interoperability between different health information systems, based on the use of common standards which allow systems and devices to exchange and interpret shared data.
Although openIMIS can operate on its own, it has even greater potential as part of a bigger puzzle, explains Uwe Wahser, who coordinates the openIMIS Developers Committee. ‘Our focus is on health financing, but we want the whole digital health ecosystem to profit. Through OpenHIE we work closely with others to make sure that our products talk to each other for the greater good.’ Because openIMIS is based on shared standards, patient-level data collected in the system can be used by ministries of health, for example, to better understand patterns of healthcare service delivery and for commodities forecasting.
As part of the re-architecture of the software that is currently underway, openIMIS is adopting the FHIR (Fast Healthcare Interoperability Resources) specifications, an internationally accepted standard for health care data exchange published by HL7 and which is favored by members of the OpenHIE community of practice. openIMIS also contributes to the broader FHIR community, feeding back experiences from openIMIS into FHIR and advocating the use of FHIR standards among other global goods.
‘The engagement with OpenHIE has given openIMIS a visibility that wasn’t there before,’ says Carl Leitner of Digital Square. ‘Previously, OpenHIE wasn’t looking at the interoperability needs around health financing or considering health financing use cases. Now finance and insurance services are a key component of the OpenHIE architecture, providing strategic guidance to countries as they plan national digital health architecture and roadmaps.’
Growing the community of users
For openIMIS to fulfill its objective of expanding social health protection to hitherto excluded populations, it needs to be used – by as many institutions in as many places as possible. SDC, which holds the copyright for openIMIS, has released the application under an open source license, thereby ensuring that the software can be used and adapted free of charge. The source code for openIMIS was published in early 2018 on GitHub and public code repositories have been set up to manage code contributions. Alongside the technical investments in the software, the openIMIS Initiative has been working to raise awareness of the solution, to promote it among relevant institutions and development partners, and to help scheme operators in different countries assess the potential fit for their health financing schemes.
Regular calls among members of the Implementers Committee bring together implementers and scheme operators with openIMIS’s regional hubs (currently Jembi Health Systems in Africa and AeHIN in Asia) and representatives of other interested institutions. Since late 2019, members of the Social Health Protection team at the ILO in Geneva have joined the discussions and are engaged in exploring the potential application of openIMIS for both health insurance and social protection schemes in various countries.
For governments or scheme operators interested in learning more about openIMIS, or in joining the community, a wide range of community tools is available. These include an online demo installation for experimenting with the software’s functionalities; the Wiki, which is an open platform for engagement between members of the community; a help desk; and a generic implementation toolkit and training materials which are free to download and use. In keeping with its status as a global good, openIMIS’s knowledge products are also open source. Any modifications to these materials, which are issued under a Creative Commons License, should be contributed back to the community so that learnings from one scheme operator can get picked up by another.
Learning from others, with eyes to the future
By early 2020, approximately five million people in five countries – Cameroon, Chad, Democratic Republic of Congo, Nepal and Tanzania – benefitted from health financing schemes administered using openIMIS. These numbers are poised to climb as the software is implemented in more countries: teams in Djibouti, The Gambia, Myanmar and Rwanda, among others, have either begun customising openIMIS or have undertaken feasibility studies into its applicability. A number of these potential use cases are for social protection schemes – such as employment injury insurance for formal sector employees and cash transfer schemes – which go beyond health insurance. This is a promising sign that, as hoped, openIMIS’s modular design makes it an attractive solution for a wide range of financing services.
The openIMIS Initiative has been conscious to learn from the experiences of other global good communities. It has engaged actively and openly with other open source projects and with pivotal actors such as Digital Square. It committed early on to the adoption of common standards which would embed openIMIS more tightly into the open source landscape. As openIMIS continues its journey from an ‘emergent’ global good to a ‘mature’ one, opportunities abound to connect the health financing solution with other domains – and eventually to attract investment from other development partners and institutions. ‘There is huge value and utility in the data managed by openIMIS. Health insurance claims contain information on service delivery and utilisation of medical commodities that can be used for data triangulation to improve the overall quality of data in national health systems,’ says Carl Leitner, of Digital Square. ‘When these data are connected to purchasing and planning units in ministries of health, they can be used to better understand demand for key medical commodities, such as antiretroviral therapy, across different health program areas.’
A new three-year programme of support from SDC and BMZ is about to begin, providing the Initiative with the space and resources it needs to promote the solution at the local, regional and global levels and to grow it even further. Thus far, the leap of faith in the idea of openIMIS has paid off, thanks to the extraordinary personal engagement of software developers, implementers and users who have ensured that the openIMIS community remains vibrant. In the coming years this community is poised to grow even further, pushing openIMIS towards the critical mass of users that will be needed for longer-term sustainability.
- This article is the second of a two-part series. To learn more about how openIMIS works and where it is being used, please read the companion piece ‘openIMIS: Health and social protection’s digital backbone’