By Rahul S Reddy Kadarpeta, Jane Nyambura, Leonora Mbithi
Over the past decade, several African countries have made significant strides in expanding health insurance coverage, driven by government initiatives and community-based programmes. Rwanda, for instance, has achieved an impressive coverage rate of nearly 90%, while countries like Nigeria, Kenya, Tanzania, and Ethiopia have extended health insurance to between 40% and 50% of their populations. This progress has played a crucial role in improving access to affordable healthcare services across the continent. As insurers work to meet growing demand, they continue to face challenges that affect customer experience, such as long delays in processing claims and an increase in fraudulent claims. Many of these problems arise because insurers still rely on paper-based processes or have not fully adopted digital technologies, making health insurance less efficient and inaccessible. This blog explores how digital innovation—evolving towards artificial intelligence (AI)—is revolutionising health insurance. By drawing on global and African examples, we examine how these solutions are enhancing claims processing, fraud detection, and customer service, unlocking new opportunities to strengthen healthcare access across Africa.
In Tanzania, the National Health Insurance Fund (NHIF) faced significant challenges with delayed payments to accredited healthcare providers, which led to frequent complaints from both healthcare facilities and insured beneficiaries. One of the primary reasons for these delays was the reliance on offline claims submission systems or, in some cases, manual processing methods. To address this issue, NHIF introduced an online claims submission system in July 2019 by integrating it with the Hospital Management Information System. This transition aimed to overcome inefficiencies caused by offline or paper-based claims processing. With the new system, claims are now submitted instantly on the same day that services are provided, eliminating the need to wait for the full claim to be compiled before processing begins. As a result, the efficiency of claims processing has improved significantly. Currently, 187 healthcare facilities utilise the online submission system, leading to a drastic reduction in claims processing time—from an average of 55 days in 2017–18 to just 14 days in 2021–22.
In Nigeria, Electronic Health Insurance Management System (eHIMS) was implemented to modernise health insurance operations since 2020, in three states (Ondo, Ogun and Adamawa). This streamlines health insurance processes by automating key functions such as digital enrolment of beneficiaries through both mobile applications and web portals, as well as the registration and management of healthcare facilities. The system facilitates electronic claims submission and processing, providing real-time reporting for improved transparency and efficiency. It enhances oversight and accountability by incorporating multi-step approval processes to ensure integrity in decision-making. It maintains up-to-date service and medication lists, along with associated pricing, including those requiring prior authorisation. Additionally, it integrates with third-party payment gateways, enabling electronic premium payments for applicable insurance plans.
In South Kivu, a rural province in the Democratic Republic of Congo (DRC), faced issues in managing community-based health insurance schemes, known as "mutuelles." Traditional paper-based systems often led to inefficiencies, such as delays in claims processing, difficulties in verifying insurance coverage, and a lack of accurate data for decision-making. To address these challenges, 9 mutuelles introduced OpenIMIS, a digital health insurance management system, in 2017. This platform enables healthcare providers to electronically verify a patient’s insurance coverage, process claims more efficiently and generate real-time reports on service utilisation and financial flows. Digitising these processes, has significantly reduced administrative burdens on both insurers and healthcare facilities, allowing them to focus on improving service delivery. OpenIMIS is now working towards integrating AI into the claims processing modules to enable rapid analytics and fraud control mechanisms.
In Ghana’s National Health Insurance Authority, e-claims processing started in 2013 on a pilot basis, and the providers uploaded claims through a Web Front End model or through Health Management Information System that integrated for e-claims processing at the central unit. Using the paper-based system over 50% of claims were not reimbursed within the stipulated 28-day period, which reduced significantly. Further electronic claims (e-claims) had a rejection rate of 7.26%, compared to just 1.26% for paper claims. This suggested that digital systems are better at identifying errors or fraudulent claims, helping to improve the accuracy and integrity of health insurance processes. The NHIA is actively integrating AI and machine learning to modernise traditional insurance operations. Their Biometric Membership Authentication System (BMAS) verifies memberships at credentialed provider sites, aiming to curb financial leaks in enrolment and claims management.
Some global digital solutions that could further inspire achieving efficiencies par excellence in the African context are - In Singapore, Prudential allows patients to simply upload photos of their hospital bills online, for processing claims. This secures near instant approval, reducing approval times from several days to just minutes, significantly improving customer satisfaction while cutting administrative costs. In China, Ping An has developed an AI-powered healthcare ecosystem that seamlessly connects insurers, hospitals, and doctors. This system processes over a million medical consultations daily by integrating AI into claims management and patient care, demonstrated reducing waiting times while enhancing healthcare delivery. In the United Kingdom, Vitality Health is using AI, Big Data, and the Internet of Things (IoT) to create an incentive-based programme that tracks and rewards healthy behaviours. This proactive approach has led to a significant reduction in hospital claims among actively engaged members, highlighting how digital innovation can encourage better health outcomes while lowering insurance costs.
The shift to digital systems has had a major impact, and adding AI could take things even further—especially for health systems in Africa. However, setting up these technologies isn’t without challenges, as issues like standardisation, security, privacy, and data management need to be addressed. A good example of overcoming these challenges is Indonesia’s BPJS-K, the world’s largest single-payer health insurance system. Since 2019, BPJS-K has used AI to speed up claims processing, analyse health records, and track service delivery in real time for its 270 million members. This system is built on a strong data framework, using Fast Healthcare Interoperability Resources (FHIR) and Open EHR, with strict security measures and compliance with national data protection laws. The learnings from Indonesia’s experience are critical to ensure ethical use of technologies. As AI advances, it’s important to focus on solutions that are adaptable to different contexts while ensuring strong data security and governance. Transparency, patient privacy, and ethical oversight should be top priorities. This means making AI decisions clear and understandable, protecting patient data, and keeping human experts involved in critical decisions. Singapore sets a great example with its AI Strategy, which emphasises responsible AI use. The goal isn’t to replace human expertise but to enhance it, making AI a powerful tool for improving health insurance.
As more countries embrace digital transformation, knowledge-sharing and cross-country collaboration will be key. By learning from each other, nations can tackle common challenges around data management, implementation, and ethical concerns—helping to speed up the adoption of effective AI-driven solutions in health insurance.
Photo by Freepik
About the Authors:
Rahul S Reddy Kadarpeta serves as the Executive Director at Amref Health Africa. Jane Nyambura is a Programme Officer, while Leonora Mbithi works as the Country Engagement Officer, both also at Amref Health Africa.