IDENTIFICATION (1)

PLACE NAME __________
NAME OF HOUSEHOLD HEAD __________
CLUSTER NUMBER __ __ __ __
HOUSEHOLD NUMBER __ __ __ __
HOUSEHOLD SELECTED FOR MAN'S SURVEY (1=YES, 2=NO) ____

(1) This section should be adapted for country-specific survey design.

INTERVIEWER VISITS

FIRST VISIT:
DATE ______
INTERVIEWER'S NAME ________
RESULT* ________

SECOND VISIT:
DATE ______
INTERVIEWER'S NAME ________
RESULT* ________

THIRD VISIT:
DATE ______
INTERVIEWER'S NAME ________
RESULT* ________

NEXT VISIT:
DATE ______
TIME ______

FINAL VISIT:
DAY __ __
MONTH __ __
YEAR __ __ __ __
INT. NO. __ __ __ __
RESULT* __

TOTAL NUMBER OF VISITS: __

*RESULT CODES:

TOTAL PERSONS IN HOUSEHOLD __ __
TOTAL ELIGIBLE WOMEN __ __
TOTAL ELIGIBLE MEN __ __
LINE NUMBER OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE __ __

LANGUAGE OF QUESTIONNAIRE** 01
LANGUAGE OF INTERVIEW** __ __
NATIVE LANGUAGE OF RESPONDENT** __ __
TRANSLATOR USED (YES = 1, NO = 2)
LANGUAGE OF QUESTIONNAIRE** ENGLISH

**LANGUAGE CODES

SUPERVISOR
NAME ______
NUMBER __ __ __ __

FIELD EDITOR
NAME ______
NUMBER __ __ __ __

OFFICE EDITOR
NUMBER __ __

KEYED BY
NUMBER __ __

COLUMNS TO ADD TO HOUSEHOLD SCHEDULE:

INPATIENT

21. In the last six months, was (NAME) admitted overnight to stay at a health facility?

22. CIRCLE LINE NUMBER OF HOUSEHOLD MEMBER ELIGIBLE FOR IN-PATIENT MODULE.

OUTPATIENT

23. In the last four weeks, did (NAME) receive care from a health provider, a pharmacy, or a traditional healer without staying overnight at a health facility?

24. The last time (NAME) received care, was any money paid?

25. CIRCLE LINE NUMBER OF HOUSEHOLD MEMBER ELIGIBLE FOR OUTPATIENT MODULE.

INPATIENT HEALTH EXPENDITURES

201. CHECK COLUMN 22 IN HOUSEHOLD SCHEDULE:

202. CHECK COLUMN 22 IN HOUSEHOLD SCHEDULE: ENTER THE LINE NUMBER AND NAME OF EACH HOUSEHOLD MEMBER WHO WAS AN INPATIENT. THEN ASK: Now I would like to ask some questions about the household members who stayed overnight in a health facility in the last six months. (IF THERE ARE MORE THAN 3 INPATIENTS, USE ADDITIONAL QUESTIONNAIRE).

203. LINE NUMBER FROM COLUMN 22 IN HOUSEHOLD SCHEDULE

204. NAME FROM COLUMN 2 IN HOUSEHOLD SCHEDULE

205. Where did (NAME) most recently stay overnight for health care? (1)

206. What was the main reason for (NAME) to seek care this most recent time?

207. How much money was spent on treatment and services (NAME) received during the most recent overnight stay? We want to know about all the costs for the stay, including any charges for laboratory tests, drugs, or other items.

208. Did (NAME) stay overnight at a health facility another time in the last six months?

209. Where did (NAME) stay the next-to-last time he/she stayed overnight for health care? (1)

210. What was the main reason for (NAME) to seek care this next-to-last time?

211. How much money was spent on treatment and services (NAME) received during the next-to-last overnight stay? We want to know about all the costs for the stay, including any charges for laboratory tests, drugs, or other items.

212. Besides the two stays you have told me about, did (NAME) stay overnight in a health facility another time in the last six months?

213. Where did (NAME) stay the second-to-last time he/she stayed overnight for health care? (1)

214. What was the main reason for (NAME) to seek care this second-to-last time?

215. How much money was spent on treatment and services (NAME) received during the second-to-last overnight stay? We want to know about all the costs for the stay, including any charges for laboratory tests, drugs, or other items.

216. Besides the three stays you have told me about, did (NAME) stay overnight in a health facility another time in the last six months?

217. In total, how many times did (NAME) stay overnight in a health facility in the last six months?

218. Is (NAME) covered by any health insurance?

219. What is (NAME)'s main type of health insurance? (2)

220. GO BACK TO 205 IN NEXT COLUMN; OR, IF NO MORE INPATIENTS, GO TO 301

SELECTION FOR OUTPATIENT HEALTH EXPENDITURES (PAPER OPTION) (3)

301. CHECK COLUMN 25:

LOOK AT THE LAST DIGIT OF THE HOUSEHOLD QUESTIONNAIRE SERIAL NUMBER ON THE COVER PAGE. THIS IS THE ROW NUMBER YOU SHOULD GO TO. CHECK THE TOTAL NUMBER OF ELIGIBLE OUTPATIENTS (COLUMN 25) IN THE HOUSEHOLD SCHEDULE. THIS IS THE COLUMN NUMBER YOU SHOULD GO TO. FOLLOW THE SELECTED ROW AND COLUMN TO THE CELL WHERE THEY MEET AND CIRCLE THE NUMBER IN THE CELL. THIS IS THE NUMBER OF THE PERSON SELECTED FOR THE OUTPATIENT QUESTIONS FROM THE LIST OF ELIGIBLE OUTPATIENTS IN COLUMN 25 OF THE HOUSEHOLD SCHEDULE. WRITE THE NAME AND LINE NUMBER OF THE SELECTED OUTPATIENT IN Q302.

EXAMPLE: THE HOUSEHOLD QUESTIONNAIRE SERIAL NUMBER IS '716' AND THE HOUSEHOLD SCHEDULE COLUMN 25 SHOWS THAT THERE ARE THREE ELIGIBLE OUTPATIENTS IN THE HOUSEHOLD (LINE NUMBERS 02, 04, AND 05). SINCE THE LAST DIGIT OF THE HOUSEHOLD SERIAL NUMBER IS '6' GO TO ROW '6' AND SINCE THERE ARE THREE ELIGIBLE OUTPATIENTS IN THE HOUSEHOLD, GO TO COLUMN '3'. FOLLOW THE ROW AND COLUMN AND FIND THE NUMBER IN THE CELL WHERE THEY MEET ('2') AND CIRCLE THE NUMBER. NOW GO TO THE HOUSEHOLD SCHEDULE AND FIND THE SECOND OUTPATIENT WHO IS ELIGIBLE FOR THE OUTPATIENT QUESTIONS (LINE NUMBER '04' IN THIS EXAMPLE). WRITE THE NAME AND LINE NUMBER OF THE SELECTED OUTPATIENT IN Q302.

302.

OUTPATIENT HEALTH EXPENDITURES

303. Now I would like to ask some questions about health care that (NAME IN 302) received in the last four weeks, without having to stay overnight. Where did (NAME) get care most recently without staying overnight? (1)

304. How much money was spent on treatment and services (NAME) received from (NAME OF PROVIDER IN 303)? Please include the consulting fee and any expenses for other items including drugs and tests.

305. What was the main reason for (NAME) to seek care this most recent time?

306. Did (NAME) get care another time in the last four weeks from a health provider, a pharmacy, or a traditional healer, without staying overnight?

307. How many other times did (NAME) get care in the last four weeks?

308. How many times was money spent?

309. Is (NAME) covered by any health insurance?

310. What is (NAME)'s main type of health insurance? (2)

311. Sometimes people buy vitamins, medicines, and herbal remedies without consulting with a health provider, pharmacy, or traditional healer. They may also buy other health-related items such as band-aids/plasters, thermometers, or other medical devices, and so on without a consultation. In the last four weeks, how much money was spent on these types of health-related items for members of your household?

HEALTH EXPENDITURES: FOOTNOTES

(1) Coding categories to be developed locally; however the broad categories must be maintained. Additions to the codes under the private medical sector heading may include religious affiliated sources and NGO sources.

(2) If a health service prepayment or other types of plans are available in the country, add those types of plans to the question.

(3) If the survey will be conducted using paper questionnaires, retain "SELECTION FOR OUTPATIENT HEALTH EXPENDITURES". If the survey will be conducted using CAPI, delete the "SELECTION FOR OUTPATIENT HEALTH EXPENDITURES", because the selection will be done automatically.