National Identification Number for Healthcare Facilities of India Paper

1Mishra A, Sahay S. BMJ Innov 2020;0:1–6. doi:10.1136/bmjinnov-2018-000327
1
eHealth Department, Ministry
of Health Family Welfare,
Delhi, India
2
Department of Informatics,
University of Oslo, Oslo, Norway
Correspondence to
Dr Amit Mishra, India Ministry
of Health and Family Welfare,
New Delhi 110011, India; dr.
amitmishra@gmail.com
Received 4 October 2018
Revised 30 August 2019
Accepted 1 October 2020
ORIGINAL RESEARCH
Building a master health facility list:
innovative Indian experience
Amit Mishra ‍ ‍,1
Sundeep Sahay2
To cite: Mishra A, Sahay S.
BMJ Innov Epub ahead of
print: [please include Day
Month Year]. doi:10.1136/
bmjinnov-2018-000327
HEALTH APPS AND MHEALTH
© Author(s) (or their
employer(s)) 2020. No
commercial re-use. See rights
and permissions. Published by
BMJ.
ABSTRACT
Adoption of information technology in
healthcare has in recent years improved the
process of information collection, analysis and
use in the Indian public health system. However,
it has also led to multiplicity of information
systems. Currently, a good amount of data is
being generated by various health management
information systems (HMISs); however, usability
of these data sets is limited owing to lack of
technical and institutional ability to share data
with other systems. The lack of an effective
standard list of health facilities is one of the
major impediments to building interoperability
among these multiple systems. To overcome
this challenge, the Indian Ministry of Health
and Family Welfare has initiated a programme
to build a master facility list (MFL) known
as National Identification Number to Health
Facilities. Facility data from two leading national
public health information systems, which were
routinely reporting health data since 2008, were
selected for this purpose. Common facilities
were placed on an online portal for verification
by state-level and district-level officers. Currently,
this portal holds more than 200 000 verified
public health facilities. Use of facility data from
existing systems has helped to quickly populate
the MFL in India. However, design limitations of
the existing systems were also translated to the
facility portal. Some lay challenges to sustain
and evolve this portal in the future include (1)
integration of other HMISs holding facility data
with the MFL, (2) public notification of standards
for MFL, (3) comprehensive data quality audit of
existing MFL facility data and (4) establishment
of robust governance mechanisms. We discuss
how the benefits from this exercise in technical
innovation can be materialised more effectively
in practice.
INTRODUCTION
Health management information systems
(HMISs) are gaining importance day
by day in low-income countries and
are becoming a good companion of
programme managers for strengthening
evidence-based health services and infra-
structure planning and management.1
Rapid adoption of information tech-
nology in recent years has further accel-
erated the adoption of HMISs in national
health programmes.2
These systems have
enhanced processes of collection, anal-
ysis and reporting of health information
in national health systems. However,
these systems have also absorbed design
ambiguities of paper-based reporting
systems, leading to poor quality and
utility of data.3–5
Due to suboptimal
quality of HMIS data, a large number of
low-income countries are relying on data
supplied from national health surveys
instead of the routine national HMIS.
Various efforts towards strengthening of
HMISs have had suboptimal outcomes6
due to approaches that focus on single
isolated systems rather than system-
wide approaches such as standard-based
integration.7
This narrow view has also
adversely influenced the sustainability
and scalability of HMIS in low-income
countries.
In India, the process of HMIS develop-
ment began with the health sector reform
programme in the 1990s, where various
states invested in the development of
electronic HMIS, primarily with a focus
on particular diseases.8
Though a good
number of states opted to participate in
the health sector reform programme, the
uptake of HMIS among these was limited
to only few.
Systematic HMIS reform process began
in 2005 with the advent of National
Rural Health Mission (NRHM), the
flagship programme of the Ministry of
Health and Family Welfare (MoHFW).9
The HMIS reforms included rationali-
sation of reporting formats and guide-
lines, development of data dictionary,
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2 Mishra A, Sahay S. BMJ Innov 2020;0:1–6. doi:10.1136/bmjinnov-2018-000327
implementation of a comprehensive capacity building
programme and a centralised web portal for reporting
district-level data on a monthly basis.10
By 2010, these
efforts helped to establish a discipline of monthly
electronic reporting from all public health facilities in
the country.11
However, the number of information
systems also multiplied owing to the ever-changing
programme data requirements and lack of flexibility
of the central system to accommodate these changes.
By this time, plenty of data were being captured across
various information systems but with limited use as
these systems were not able to exchange data.12
Other
than technical interoperability issues, one of the major
gaps was the lack of a common health facility list main-
tained in these systems, also known as master facility
list (MFL). Each public health information system
(HIS) maintained their individual lists of health facil-
ities, which often were different from lists of other
programmes, contributing to challenges in the sharing
of data.
This paper examines the Indian efforts towards
building an MFL and outline roadmap for its
sustainability.
MFL: WHAT AND WHY
The definition of a health facility includes a descrip-
tion of various attributes of a health facility such as its
name, location, infrastructure, health services provi-
sioned, and number and type of human resources
deployed.13
MFL is one such compilation of facil-
ities functioning within a geography, say, a state or
country, and the information system which collects,
stores, distributes and manages facility data is known
as a health facility registry.14
WHO draft guidelines15
lay out the roadmap for development of MFL and its
governance mechanisms. It defines MFL as (15, p1):
‘complete listing of health facilities in a country (both
public and private) and is comprised of a set of admin-
istrative information and information that identifies
each facility (signature domain)’. MFL equips countries
with two major advantages: first, it helps in aggregation
of healthcare data from various information systems
to generate population-based indicators at all admin-
istrative levels16
and, second, it facilitates in exchange
of patient healthcare information across information
systems.14
Exchange of patient data across two infor-
mation systems depends on the availability of patient
identifier (who), encounter identifier and details (what
and when) and facility identifier (where).17
Unavail-
ability of any of these leads to lack of interoperability.
When such patient-level data exchange is required
across various hospitals in a country, the complexity
multiplies since each system will have their own ways
to identify patients, providers and health facilities. To
overcome this challenge, many low-income countries
have started building national registries for health
facilities, patients (clients) and individual healthcare
providers. A health facility registry is one such registry
which produces a unique list of health facilities in a
country known as MFL. Globally, when countries are
establishing national e-health architectures, the need
for a MFL is more evident since it is the one of the
main components of health information exchanges
(HIEs) and unavailability of this could severely impact
functioning of HIEs.
In the Indian context, there was no reliable single
source available for health facility-related informa-
tion. Various information systems and data sources
presently in use have maintained facility data in some
form.18
Major sources of facility-related information
are routine reporting systems and the periodic rural
health statistics19
publication of the MoHFW. In addi-
tion, insurance regulatory and development authority
maintains the records of the networked private hospi-
tals of insurance companies in an online portal named
as ROHINI.20
However, each of these sources have
their own data quality issues and none are considered
complete.18 21
APPROACH TO BUILDING DATABASE
To create a standard facility database, the MoHFW
initiated a programme called the National Identifi-
cation Number to Health Facilities (NIN Portal) for
allocation of unique identification numbers to health
facilities in India.
To populate the MFL, two leading HISs functioning
under MoHFW’s NRHM were selected. The selection
was based on continuous usage of the system for more
than 5 years and their country-wide coverage. The
facilities registered in both these systems, along with
their attributes, were officially obtained from respec-
tive departments in electronic format. These were
then mapped with each other to identify a common
set of facilities which could be verified and allocated
unique identification numbers. Since the number and
type of attributes collected for a facility by both these
systems were different, a two-step mapping process
was adopted. In the first step, the facility name,
along with two additional attributes (facility type and
district), were mapped using a fuzzy logic method in
Microsoft Excel 2010 not only for the degree of simi-
larities in their names but also for relative degree of
similarities in their attributes like district and facility
type to identify common facilities using a matching
algorithm. In the second step, remaining unmapped
facilities were further compared with other additional
attributes (ie, address) to identify unique facilities
in both the masters. The output of this process was
colour-coded Microsoft Excel files, where completely
mapped facilities were green coloured; unmapped
facilities were yellow coloured; and duplicates were
red colour-coded. These facilities were then placed in
an online portal for verification and update by district-
level officers on 21 attributes covering the signature
domain and facility functionality information. A
random numbering system was used to allocate the
bycopyright.

10-digit unique identification number (national identi-
fication number) for all verified facilities based on the
Luhn algorithm, where each identification number is
verified against its check digit, which is appended with
each partial identification number to generate a full
identification number.
RESULTS
The facility mapping exercise was conducted for a
period of 4 months between May and August 2016.
Overall, 59% of the facilities of both legacy systems
were mapped with each other; 30% of facilities could
not be mapped due to differences in the nomenclature;
and 11% of facilities were either duplicates or invalid
entries in both systems. The unmapped facilities were
shared with the states for manual verification, and
verified facilities were entered into the NIN Portal by
district-level programme officers.
After 2 years of its launch, the NIN Portal holds
records of verified 200 000 public health facilities
covering all states and union territories. Much of the
facility data contained in the NIN Portal are of the
state-owned public health facilities. Though there is
provision for the addition of facilities from all sets of
health service providers, the process for addition of
private facilities in the NIN Portal is yet to start.
ANALYSIS OF THE RESULTS
The MFL list was populated using facility data from
legacy systems, which were primarily designed for
programme data reporting; hence, much of the issues
from the legacy systems were also inherited by the MFL.
The first among these is the inconsistent use of facility
nomenclature across both legacy systems, including use
of discrete rules for writing facility names, inconsistent
use of prefix–suffix, special characters and random use
of colloquial alternative facility names. In addition,
there were no objective criteria in place for the iden-
tification of facility types. A large number of health
facilities which were supported under the NRHM,
had a standard facility definition, and allocation of
facility type to these was relatively easy, for example,
subcentre, primary health centre, community health
centre and district hospital. However, for remaining
health facilities, there was no definite criteria through
which a facility type could be ascertained, for example,
referral hospital, postpartum unit, maternal and child
welfare centre and maternity homes. Overlapping and
ambiguous facility types, along with incomplete infor-
mation about facility infrastructure such as facility
beds, further complicated ascertainment of the type of
facility.
The second major issue encountered was the unavail-
ability of facility hierarchies in the legacy systems. In
the Indian Public Health System, each health facility
reports to a higher-level facility for administrative
purposes, which might also act as referral unit for
lower facilities. Administratively, this facility hierarchy
is an important phenomenon since it helps in aggrega-
tion of facility performance data to identify services
coverage in a population and also facilitates patient
referral and follow-ups between these facilities. Both
legacy systems had no mechanism to ascertain facility
hierarchies at the subdistrict level, which prohibited
development of the organisation tree in the MFL and
made it less useful as a facility master in public HIS.
Third, the use of local norms for identification of
administrative hierarchies in legacy systems affected the
design of facility masters and made it difficult to map
one facility list with another. In India, health is a state
subject, and states have the liberty to organise health
services delivery as per the local needs. To manage
health services better in underperforming areas, states
have redesigned the healthcare administrative system
and have come up with new geographical entities
known as health blocks. These health blocks function
in parallel to revenue blocks and are not coterminous.
Three states on similar lines have also created health
districts by carving out some blocks from the revenue
districts. Both legacy systems, from which facility data
were sourced, followed different administrative hier-
archies, where one system followed revenue hierarchy
and the other system followed health hierarchy. Lack
of standardisation at this level and use of local admin-
istrative hierarchy affected mapping and identification
of the unique facilities in both systems.
The fourth and last among these was the incom-
plete coverage of health facilities in both legacy
systems. Since both legacy systems were created for
reporting from public health facilities, private sector
data reporting was not under the scope of these
systems. In addition, facilities falling under central
government health schemes, centrally sponsored
health programmes and health facilities being run by
other government departments were excluded in both
facility masters. A large number of urban public health
facilities and medical colleges functioning under local
governments and municipal corporations were also
missing in these facility masters.
REFLECTING ON THE INNOVATION PROCESS AND
THE ROADMAP AHEAD
The literature on digital innovation for public health in
low-income countries argues that22
technical innova-
tions on their own are incomplete, unless accompanied
also with associated institutional and social innova-
tions. While the development of the NIN Portal can be
seen as a technical innovation in terms of addressing a
pressing local problem and adopting a quick and clever
method to do the initial population of the database,
arguably the institutional and social innovations are
not yet in place. As discussed in the earlier section,
the health facilities still do not reflect the reporting
hierarchies which impedes the institutional adoption
of the portal. The institutional innovation is thus not
complete. A similar issue was identified in Cambodia,
bycopyright.

where administrative and operational districts had
overlapping boundaries, making it difficult to build
administrative hierarchy in MFL.23
In the NIN Portal,
the facilities are not universally covered, as the list
does not include private facilities, labs and various
other facility types, as also noted in MFL development
experiences of Kenya24
and Haiti.16
Given the inability
of the NIN Portal to cover the whole population, the
social innovation is also not in place. The future road
map should also need to cover how to make the tech-
nical, institutional and social innovations take place in
conjunction.
The NIN Portal has started functioning recently, and
the information on it can be accessed online (https://
www.nin.nhp.gov.in/). Use of health facility data from
legacy systems’ has enabled India to quickly populate
the MFL; however, data quality and completeness
remain major challenges. In addition, the design issues
of legacy systems have limited the usability of the
MFL. Currently, the NIN Portal is an isolated system
and does not disseminate facility data. To overcome
these challenges and to sustain MFL, the NIN Portal
requires addressing the following major concerns. One
of the important considerations is that the register is
dynamic and the healthcare facilities keep on evolving
in terms of their design, number and types of human
resources deployed and health services provisioned. In
this context, a flexible approach in design, develop-
ment and implementation of health facility registry is
necessary to allow it to grow over time. In addition,
the portal should accommodate local norms related to
the administrative hierarchy used to enhance its utility.
There is also a greater need for strong data quality
monitoring programme to match facility data in the
NIN Portal with real-world situation through triangu-
lation, external verification of sampled facilities and
routine internal data quality checks through dedu-
plication logics. Providing public access to the NIN
Portal and enabling a feedback mechanism on quality
of facility data by users could further help bridge data
quality gaps.
In order to make the NIN Portal as a single source of
truth, the continuous enumeration of health facilities in
the NIN Portal is important. This could be achieved by
integration of all legacy information systems holding
facility data with the NIN Portal to regularly monitor
and update facility records. There are large numbers of
private health facilities functioning in India and their
participation in the NIN Portal is an important deter-
minant for creation of an effective MFL. This needs
supportive legal and policy measures such as enrolment
of all private facilities participating in service provision
through public private partnership in NIN Portal.
There is also an urgent need to notify standards for
health facility registry, which includes nomenclature
standards and data rules for writing facility names,
facility type, facility hierarchy and type of facilities to
be included. In addition, rationalisation of processes
for enrolment, verification and update of health facil-
ities records across multiple regulatory authorities
could further enable sharing of facility data across
multiple systems. The Clinical Establishments (Regis-
tration and Regulation) Act, 201025
can be leveraged
in states where it has been notified and in other states
the health directorates could play this pivotal role.
A robust governance mechanism where all concerned
stakeholders are engaged and their concerns are
addressed would facilitate rapid adoption of the NIN
Portal. In this regard, a national level committee
under MoHFW with representation from all major
stakeholders could be set up to govern the MFL. The
committee can issue guidance on facility standards,
rules, protocols and integration mechanisms.
MFL and facility registry are relatively new concepts,
and there is limited awareness about these among
health programme managers in India. It is the need of
the hour to popularise use of the NIN Portal within
and outside the government to boost its usage and to
achieve success. The following potential uses of the
NIN Portal could facilitate its adoption:
1. Use of NIN for identification of public and private health
facilities under recently launched Pradhan Mantri Jan
Arogya Yojana26
for the purpose of electronic claims dis-
bursement will facilitate quick adoption.
2. Access to the NIN Portal by national and local disaster
response forces could help them in locating the nearest
functional healthcare facility from the site of disaster to
organise early response.
3. Ambulance networks could use MFL to identify and lo-
cate the nearest facility where an emergency case could
be treated as per the type of emergency. This will reduce
re-referrals and save lives.
4. Public access to the NIN database could help people to
identify and locate a relevant healthcare facility such as
dialysis centres and blood banks.
5. All institutes which possess medical diagnostic X-ray
equipment are required to obtain licences for operation
from the Atomic Energy Regulatory Board.27
Similarly,
facilities with ultrasonography services are required to be
registered with regulator under the Preconception and
Prenatal Diagnostic Techniques Act, 2002,28
and all fa-
cilities generating biomedical waste need authorisation
from regulators under Bio-Medical Waste (Management
and Handling) Rules, 2016.29
NIN Portal can greatly
facilitate in registration, licensing, inspection and moni-
toring of these facilities falling under respective acts and
regulations.
This study is a reflection on the early efforts to build an
MFL from existing facility masters of two nationwide
public HISs. The study takes into account the practices
used in states for identification of public health facili-
ties. However, the study does not include all possible
sources of the facility data in the country and also does
not touch on the process of identification of private
sector health facilities. This may be studied separately.
The study, however, identifies major policy issues which
need urgent attention. The first among these is the adop-
tion of uniform policy for identification and notification
bycopyright.

of health facilities by different regulatory agencies and
departments, which will prevent duplication of efforts
and streamline sharing of facility information with the
NIN Portal. In addition, policy related to standards for
health facility may be notified to maintain uniformity
in electronic record keeping and enable interoperability
among participating information systems. MoHFW may
also bring in additional policy measures, such as incen-
tive payments for those HIS, which comply with the
NIN Portal and participate in improving it.
CONCLUSION
The NIN Portal has facilitated the unique identifica-
tion of health facilities and has great potential value
for planning and management of health services in
country like India where public funding to health
services is severely low. The innovative approach
adopted to leverage facility data from legacy systems
has helped to quickly populate the MFL; however, a
larger ecosystem needs to be developed to sustain this
innovation. This includes the creation of supportive
policies for engagement of private sector providers to
share their facility data into the NIN Portal, open appli-
cation programming interfaces and policies for dissem-
ination of facility data through NIN, use of common
set of standards for identification and notification of
health facilities and a strong governance structure to
oversee the implementation of this initiative. Agility in
design and evolution approach of the NIN Portal will
help to sustain and evolve this initiative while gener-
ating practical benefits for the country.
Acknowledgements The authors thank various users of the
National Identification Number to Health Facilities who have
provided valuable insights regarding its functioning and outlined
recommendations for its improvement.
Contributors AM, the first author, conceptualised and developed
the initial draft of the manuscript. SS, the coauthor, provided
theoretical background and contributed towards editing and final
revision.
Funding Both authors state that they have not received any
financial grants for this work, and this work is intended towards
enhancing knowledge about strengthening health information
systems in low-income countries.
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; externally peer
reviewed.
Data availability statement All data relevant to the study are
included in the article.
Author note Institutional affiliation for the first author - AM is
now Ministry of Public Health, Doha, Qatar
ORCID iD
Amit Mishra http://orcid.org/0000-0001-7512-6706
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