Questionnaire for collecting information on Health Services …cbmpmaharashtra.org/documents/tools/Village level Health... · 2018. 8. 23. · Information on Health Services at village

Community based Monitoring and Planning of Health

Services under the National Rural Health Mission

Questionnaire for collecting information on Health

Services available at the Village level

Questionnaire for collecting information on Health

Services available at the Village level

under CBM

Da yhV tlail ela Hge

This tool was originally developed in Marathi as part of the Community Based Monitoring and Planning process, supported by NHM Maharashtra. The English translation of this tool has been done with support from Community

of Practitioners on Accountability and Social Action in Health (COPASAH)

SATHI

Questionnaire for collecting information

on Health Services available at the Village level

Community based Monitoring and Planning of Health Services

under National Rural Health Mission

SATHI, Pune

This tool was originally developed in Marathi as part of the Community Based

Monitoring and Planning process, supported by NHM Maharashtra. The English

translation of this tool has been done with support from Community of Practitioners

on Accountability and Social Action in Health (COPASAH)

Questionnare for collecting Information on HealthServices available at the village level.

?Name of the district - ?Name of the taluka -

?Name of the Primary Health Centre -

?Name of the Village -

?Name of the Organisation -

?Date -

?Name of Person filling the Information -

?Phone No. of Person filling the Information -

n If the condition of health services at village level is good, the report card should be filled in Green

Colour.

n If the condition of health sevices available at the village is somewhat satisfactory, the report

card should be filled in Yellow Colour.

n If the condition of health services available at the village level is serious, the report card

should be filled in Red Colour.

Based on the Information obtained from the Group Discussion, the condition of thehealth services available at the village level should be entered in the village healthreport card as follows

3V

Information on Health Services at village level

Note: Before filling the village level questionnaire, following information shouldbe collected.

?Population of village-

?Distance between village & subcentre- kms.

?Distance between village & Primary Health Centre - kms.

?Distance between village & Rural Hospital - kms.

?Availability of health care providers in the village-

1) Is there a Multi Purpose Worker (MPW) for the village? - Yes No

2) Is there an Auxillary Nurse Midwife (ANM)? - Yes No

3) Is there an Anganwadi in the village? - Yes No

4) Is there an Accreditave Social Health Activist (ASHA) Yes No

worker?-

How many ASHA workers are there for the village? -

4V

Questions for Group Discussion with Group ofcommunities from major caste (Open group)

Groupdiscussionunder CBM

Note:

1) The group discussion with open group should be combined for men

and women.

2) The place of the group discussion should be convenient to women.

5V

~~ ~~ ~~ ~~ ~~ ~~ ~~V~~ ~~ ~~ ~~ ~~ ~~ ~~6

Fill in colouras per thesituation

OrIf there is no patient of fever, points should be given infollowing manner -

Good situation7 to 8 circles

Serious situationLess than 4 circles

Somewhat satisfactorysituation 4 to 6 circles

1) Remedial measures undertaken at village level for communicablediseases

No. Question Response (mark correct option)

Has blood sample from thefinger been taken for everypatient of fever, in the last3 months?

1

For every patient–

For some patients-

For none of the patients-

Has a report ofcontaminated water beenreceived by the GramPanchayat in the last 6months?

2 Not even once-

Once-

Twice-

No fever patient-

Did the MPW makehome visits to getinformation oncommunicable diseasesin the last 3 months?

4

How many times didthe MPW viist thevillage in the last 3months?

Total number of circles

5

Regularly-

Sometimes-

Never-

Once-

Not visited-

How many times ismedicine added for thepurification of drinkingwater?

3 Everyday in all sources-

Once in 2 days-

With a gap of 3 ormore days-

Twice-

(Use the village health calendar for reference.)


Serious situationless than 5 circles


Questions to be asked in group discussion with open group

~~ ~~ ~~ ~~ ~~ ~~ ~~V~~ ~~ ~~ ~~ ~~ ~~ ~~


7

If there is no patient of malaria ...

2. Medicine and treatment available in the village



1.

2.

In the last 3 months, hasblood sample been takenfrom the finger of feverpatients and tablets beenadministered immediately?

All patients have beenadministered-

Some patients havebeen administered-

Nobody has beenadministered-

A)

B) All patients havereceived-

Nobody has received-

3.

4.

Every patientreceived-

Some patientsreceived-

Nobody received-

Did the Nurse / MPWprovide medicines forfever, dysentery,cough etc. in thevillage?

2 times-

How many times didthe Nurse visit thevillage in the last 3months?

5-6 times-

3-4 times-

No patients of malaria -

No. of patientsdiagnosed withmalaria-

Of the diagnosedpatients, howmany receivedChloroquin tabletsfor 3-4 days?

Half the patients havereceived-

Or








How many patients havebeen diagnosed withmalaria in last 3 months?

5.

~~ ~~ ~~ ~~ ~~ ~~ ~~V~~ ~~ ~~ ~~ ~~ ~~ ~~8

Fill in colouras per thesituationIf the ASHA does not have medicines then...

Or







3. Situation of ASHA’s work



1.

2.

Has the ASHA health workerbeen selected for our village?

No-

Yes-

No medicines availablewith ASHA at all-

Only to some people-

3.

4.

Yes, regularly-

Yes, sometimes-

No-

Does the ASHAparticipate in theHealth programmesheld in the village?

2 times-

Does the ASHA take thepregnant women to theHealth Centre for delivery?Or, does she advice themto go to the health centre?

Yes-

No-

Yes, for every meeting-

For some meetings-

Does the ASHAprovide medicineand tablets toall patients whocome to her?

Yes to all-


Is the ASHA present forthe Village HealthCommittee’s meeting?

5.

Note : If the answer to thisquestion is ‘No’, then Section 4 onpage No. 9 should be asked

Never present-

~~ ~~ ~~ ~~ ~~ ~~ ~~V~~ ~~ ~~ ~~ ~~ ~~ ~~


9

If maternal death has taken place, detailed information should be taken-

If infant death has taken place, setailed information should be taken-

Name - Male / female - Age- Name of wadi / pada

Information about the incident -

Note- The information about deaths above, should be checkedin the PHC register during the visit to PHC

4. Maternal deaths / Infant deaths

Maternal death– during thelast 6 months, have anywomen died during

delivery or 6 weeks afterdelivery in the village?

Infant death – In the last 6months, has an infant diedwithin a year of birth, inthe village?(if a baby dies within ayear of its birth,it should be consideredas infant death?)

2.

1.

No. Question Response (mark correct options)

Maternal deaths havetaken place-

Infant death hastaken place-


No maternal deaths-

No infant death-

No deathsGood situation

4 circles

Deaths have taken placeSerious situation0 to 2 circles

Name Age Name of the wadi / pada

Information about the incident


* If the child had not been named, note whether it was a girl or a boy.

Information about maternal & infant deaths in the last 6 months, should be taken from the Nurse (information from the open& marginalised group should be filled in this chart itself)

V10

A) Maternal deaths

B) Infant deaths

No. Name Age Women’s delivery no./How many deliveries

women had before this?

Where did thedelivery take

place?

Date ofdelivery

Date of

death What was the reason for the

dealth?

Questions for group discussionof the marginalised group.

Groupdiscussionunder CBM

Note:

1) Group discussion should be held by involving men and womenfrom marginalised groups in the village.

2) The place for the group discussion, should be convenient towomen.

~~ ~~ ~~ ~~ ~~ ~~ ~~V~~ ~~ ~~ ~~ ~~ ~~ ~~12


5. Information about the Village Health, Nutrition, WaterSupply and Cleanliness Committee’s functioning




Questions for group discussion with marginalised group

In the last 6 months,how many meetings ofthe Village Health andCleanliness Committeehave taken place ?

Were the accounts for thefunds received by the

committee in the last year,presented in the Gram

sabha?

Has the Village Health & CleanlinessCommittee conducted healthprogrammes in the village in the last 3months?

1

Yes-

No-

3 or more meetings-

One or two meetings-

No meeting in four months-

Were the committeemembers present in thelast 3 health days?

Yes-

No-

How many health dayswereconductedin the last3 months?

Health day 1

Health day 2

Health day 3-

Health day 2-

Health day 1-


2

3

4

5

Yes-

No-

Health day 3


(e.g. Village cleanliness drive, healthawareness dirve, planning of drainage,cleaning of water tank, travel expensefor patient in emergency etc. )

Fill in colour asper thesituation

~~ ~~ ~~ ~~ ~~ ~~ ~~V~~ ~~ ~~ ~~ ~~ ~~ ~~


13

6. Information about referrals


Note– Referral means availability of vehicle for sending seriously ill patients to thehospital for further treatment.

Has a boardabout referralservices been putup in the village?

Is information relatedto referral serviceswritten on the board?E.g. Vehicle no., nameand phone number ofdriver etc

1

2

Yes-

No-

Grampanchayat

Yes-

No-

3 Phone gotconnected-Try dialing the

given phonenumber Phone could not get

connected-

No. Questions Response (mark correct option)

In the last three months, hasmoney been spent from the tenthousand rupees fund, foremergency patientws to be takento the hospital? (e.g – seriously illpatient, or for delivery) No-

Yes-

Incident did not take place-

Is the benefit of thereferral servicesavailable to people,when required, from allparts of the community/ pada?

5

No-

Yes-


4







If the response to question No. 4, is incident didnot take place, then...

Vehicle No.

MH-00-2565

Name of Driver-

Ph.-

Vehicle No.

MH-00-2565

Name of Driver-

Dinesh Bhalerao

Ph.-9422235256

Accounts / Income – expense chart for funds received by the Village Samiti in the last one year

V14

No. Date CreditedAmount/incomeamount

Date Expenseamount

Details ofexpense Was the expense madeafter taking permissionfrom the committee?

If the details are notavailable, state the

reasons for the same.

Details of programmes conducted by the committee during the last year

No. Date Name of programme Venue & time of the programme Details of the programme

V15

~~ ~~ ~~ ~~ ~~ ~~ ~~V~~ ~~ ~~ ~~ ~~ ~~ ~~16


OrIf there is no patient of fever, points should be given infollowing manner -




7. Remedial measures undertaken at village level for communicablediseases


Has blood sample from thefinger been taken for everypatient of fever, in the last3 months?

1

For every patient–

For some patients-

For none of the patients-

Has a report ofcontaminated water beenreceived by the GramPanchayat in the last 6months?

2 Not even once-

Once-

Twice-

No fever patient-

Did the MPW makehome visits to getinformation oncommunicable diseasesin the last 3 months?

4

How many times didthe MPW viist thevillage in the last 3months?


5

Regularly-

Sometimes-

Never-

Once-

Not visited-

How many times ismedicine added for thepurification of drinkingwater?

3 Everyday in all sources-

Once in 2 days-

With a gap of 3 ormore days-

Twice-

(Use the village health calendar for reference.)





~~ ~~ ~~ ~~ ~~ ~~ ~~V~~ ~~ ~~ ~~ ~~ ~~ ~~


17

If there is no patient of malaria ...

8. Medicine and treatment available in the village



1.

2.

In the last 3 months, hasblood sample been takenfrom the finger of feverpatients and tablets beenadministered immediately?

All patients have beenadministered-

Some patients havebeen administered-

Nobody has beenadministered-

A)

B) All patients havereceived-

Nobody has received-

3.

4.

Every patientreceived-

Some patientsreceived-

Nobody received-

Did the Nurse / MPWprovide medicines forfever, dysentery,cough etc. in thevillage?

2 times-

How many times didthe Nurse visit thevillage in the last 3months?

5-6 times-

3-4 times-

No patients of malaria -

No. of patientsdiagnosed withmalaria-

Of the diagnosedpatients, howmany receivedChloroquin tabletsfor 3-4 days?

Half the patients havereceived-

Or








How many patients havebeen diagnosed withmalaria in last 3 months?

5.

~~ ~~ ~~ ~~ ~~ ~~ ~~V~~ ~~ ~~ ~~ ~~ ~~ ~~18

Fill in colouras per thesituationIf the ASHA does not have medicines then...

Or







9. Situation of ASHA’s work



1.

2.

Has the ASHA health workerbeen selected for our village?

No-

Yes-

No medicines availablewith ASHA at all-

Only to some people-

3.

4.

Yes, regularly-

Yes, sometimes-

No-

Does the ASHAparticipate in theHealth programmesheld in the village?

2 times-

Does the ASHA take thepregnant women to theHealth Centre for delivery?Or, does she advice themto go to the health centre?

Yes-

No-

Yes, for every meeting-

For some meetings-

Does the ASHAprovide medicineand tablets toall patients whocome to her?

Yes to all-


Is the ASHA present forthe Village HealthCommittee’s meeting?

5.

Note : If the answer to thisquestion is ‘No’, then Section 4 onpage No. 9 should be asked

Never present-

~~ ~~ ~~ ~~ ~~ ~~ ~~V~~ ~~ ~~ ~~ ~~ ~~ ~~


19

If maternal death has taken place, detailed information should be taken-

If infant death has taken place, setailed information should be taken-

Name - Male / female - Age- Name of wadi / pada

Information about the incident -

Note- The information about deaths above, should be checkedin the PHC register during the visit to PHC

10. Maternal deaths / Infant deaths

Maternal death– during thelast 6 months, have anywomen died duringdelivery or 6 weeks after

delivery in the village?

Infant death – In the last 6months, has an infant diedwithin a year of birth, inthe village?(if a baby dies within ayear of its birth,it should be consideredas infant death?)

2.

1.

No. Question Response (mark correct options)

Maternal deaths havetaken place-

Infant death hastaken place-


No maternal deaths-

No infant death-

No deathsGood situation

4 circles

Deaths have taken placeSerious situation0 to 2 circles

Name Age Name of the wadi / pada

Information about the incident


~~ ~~ ~~ ~~ ~~ ~~ ~~V~~ ~~ ~~ ~~ ~~ ~~ ~~20


Have babies born in thelast 3 months been

administered the BCGvaccine on their arm?

(the vaccine on the arm isexpected to be administered

within one month)

Only some babies havebeen administered-

No baby has beenadministered-

All babies have beenadministered-

Check the mark on theleft arm of all babiesborn in the last 3months, and writedown the names ofbabies who have themark?

Mark not found on armof some babies-

Mark found on the armof all babies-

Mark not found on arm ofany baby-

Have children above6 months age beenadministered a doseof Vitamin ‘A’?

Yes, some babies-

Not administered-

Yes, all babies-

Where is theimmunization/ vaccinationdone?

Anganwadi /subcentre-

Somebody’sResidence-

No baby born in last 3 months-

If no baby is born in the last 3 months, then(don’t ask question 2 & 3)

Good situation4 circles


Somewhat satisfactorysituation 3circles




11. Child health - immunization / vaccination




A)

B)

1.

2.

3.

4.

~~ ~~ ~~ ~~ ~~ ~~ ~~V~~ ~~ ~~ ~~ ~~ ~~ ~~


21

-

A. Services available at the health centre

Note – If even a single patienthas not gone to the publichospital, then don’t ask section12 A & B




If less people are going to the public health centre, reasonfor it should be written -

12. Experiences in the Public Health Centres


How many people in the groupdiscussion, had fallen ill inthe last 6 months? How manyof the them went to thepublic health centre?

In the last three months, wasextra money apart from thecase paper fees, demandedat the public health centre?

In the last 3 months, hasthe public health centregiven the patientprescription to getmedicines from outside?

1

Extra money notdemanded-

Extra moneydemanded-

3 or more meetings-

Less than half

Not even one-

In the last 3 months, hasthe patient been sent to

another health centre,without vehicle or provision

of expense for thevehicle?

Vehicle arranged, didnot ask for money-

Vehicle arranged, askedfor money or did notarrange vehicle

In the last 3 months haspatient been sent back fromthe public health centrewithout check-up / treatment?


2

3

4

5

Yes-

No-


Yes-

No-

~~ ~~ ~~ ~~ ~~ ~~ ~~V~~ ~~ ~~ ~~ ~~ ~~ ~~22


On visitingthe health

centre, howwas the

behaviour ofthe other

workersbesides the

doctor?

It was ok-

It was bad-

It was good-

Are yousatisfiedwith theservicesreceivedfrom thehealthcentre inthe last 3months?

Satisfied-

Somewhat satisfied-

Not satisfied-

When youvisitedpublichealthcentre, howwas thebehaviourand way oftalking ofthe doctor?

It was good-

It was ok-

It was bad-




B. Behaviour of health centre staff




1.

2.

3.

12. Experiences in the Public Health Centres

~~ ~~ ~~ ~~ ~~ ~~ ~~V~~ ~~ ~~ ~~ ~~ ~~ ~~


23

Difficulties / problems faced by ASHA-

Yes-

No-

Give points based onhow many trainingshave taken place-

ASHAtraining

structureof ourbody

Yes, full amount-

Yes-

Yes-

No-

No-

Yes, regularly-

Yes, sometimes-

No-

Let’s have

dialogue with

the PHC doctor!

Note: Interview all the ASHAs who have been appointed in thevillage. For this take independent xerox copies of this page.




13. Condition of the ASHA programme

Interview with ASHA


1.

2.

HavetrainingsforASHAtakenplace?

3.

4.

Has ASHA receivedfull payment for theservices provided byher during the lastsix months?

Has there been adiscussion about theproblems faced bythe ASHA, in themeetings for theArogya Samiti inthe last six months?

Are Medicineswhich arefinished, refilledregularly?


Has the ASHA been givena medicine box and eighttypes of tablets /medicines?

5.

Training 1

Training 2

Training 3

Training 4

Training 5

Yes, but not full amount-

No-

Interviews with pregnant women and

delivered women from the marginalized group

lllll Interview with pregnant women-

Two women who are currently 7 to 9 months pregnant should be interviewed.

Or

If there is no pregnant woman in the village, then...

Take interview of women who have delivered in last 6 months.

lllll Interview with delivered women-

Interview of two women who have delivered in the last 6 months.

lllll Interview of women who are entitled for Janani Suraksha Yojana -

Interview of two women who have delivered in last 6 months.

Before taking the interviews, fill the form about informationon pregnant women from the Nurse. Of these, select two

women for the interview.

Anganwadi

Take information from the Nurse about women from the marginalized groups,who have delivered and availed of the Janani Suraksha Yojana in the last six months.

V25

No. Name Age Women’sdelivery no./ How manydeliveriestook place

before this?

Where did thedelivery take

place?

On what date didthe delivery take

place?

Did they receive thesanctioned moneyunder the JSY?

How much ofmoney has been

received?

~~ ~~ ~~ ~~ ~~ ~~ ~~V~~ ~~ ~~ ~~ ~~ ~~ ~~26


Name of woman- Age- How many deliveries before this?-

14. Maternal health

A. Services available in pregnancy

Take interviews of two women from the marginalized group,who are 7 to 9 months pregnant,


When did youreceive theregistrationcard for thepregnancy?

How many timeswas your weighttaken duringpregnancy?

How many timeswas your bloodpressurechecked duringpregnancy?

Was your blood(heamoglobin)checked duringpregnancy?

Healthcentre In first 3 months-

Not received-

3-4 times-

2 times-

Once / not even once-

After 4 months-

3-4 times-

2 times-

Once-

Yes-

No-

1

2

3

4

Interview No.-1

who have delivered in the last 6 months.or

~~ ~~ ~~ ~~ ~~ ~~ ~~V~~ ~~ ~~ ~~ ~~ ~~ ~~


27





How many timesduring pregnancy,an examinationwas done overyour stomach?

While giving irontablets did thenurse give theentire informationabout tablets?

How manytetanusinjections wereyouadministeredduringpregnancy?

How many packets ofiron (red) tablets didyou get during preg-

nancy?

3 times-


Yes, complete information

Information not given -

2 times-

1 or 2-

Not given-

3 packets-

Less than 2 packets-

5

6

7

8

2 packets-


~~ ~~ ~~ ~~ ~~ ~~ ~~V~~ ~~ ~~ ~~ ~~ ~~ ~~28



14. Maternal health

A. Services available in pregnancy


When did youreceive theregistrationcard for thepregnancy?

How many timeswas your weighttaken duringpregnancy?

How many timeswas your bloodpressurechecked duringpregnancy?

Was your blood(heamoglobin)checked duringpregnancy?

Healthcentre In first 3 months-

Not received-

3-4 times-

2 times-


After 4 months-

3-4 times-

2 times-

Once-

Yes-

No-

1

2

3

4

Interview No.-2Take interviews of two women from the marginalized group,

who are 7 to 9 months pregnant,

who have delivered in the last 6 months.or

~~ ~~ ~~ ~~ ~~ ~~ ~~V~~ ~~ ~~ ~~ ~~ ~~ ~~


29


How many timesduring pregnancy,an examination wasdone over yourstomach?

While giving irontablets did thenurse give theentireinformation abouttablets?

How many tetanusinjections wereyou administeredduring pregnancy?

How many packets ofiron (red) tablets didyou get duringpregnancy?

3 times-


Yes, complete information-

Information not given-

2 times-

1 or 2-

Not given-

3 packets-

Less than 2 packets-

5

6

7

8

2 packets-

Give the total points in the Village Health Report card,,,,, by combiningpoints in section 14 A interview 1 and 2.

Red colour Green colour Yellow colour

If there is only one pregnant woman in the village, then colour should befilled in the report card, based on the interview of that woman.


Serious situationless than 16

circles

Somewhat satisfactorysituation

16 to 23 circles

ÚInterview 1+2 =====






~~ ~~ ~~ ~~ ~~ ~~ ~~V~~ ~~ ~~ ~~ ~~ ~~ ~~30



14. Maternal health

B. Services given to women who have delivered

Interview with 2 women from the marginalsied group who havedelivered in the last 6 months


Was your nameregisteredduringpregnancy?

Was theregistration cardgiven duringpregnancy?

Where did thedelivery takeplace?

How manytimes were

youexamined

duringpregnancy

this?

Healthcentre

Government-

Private hospital-

1

2

3

4

Interview No.-1

Yes-

No-

Yes-

No-

3-4 times-

2 times-

At home-

Less than 2 times-

Hospitalnù´ÉÉJÉÉxªÉÉSÉÒ ´Éä³ý-

--------------

----------------

----------------

------------------

------------------

~~ ~~ ~~ ~~ ~~ ~~ ~~V~~ ~~ ~~ ~~ ~~ ~~ ~~


31


Serious situationless than 7 or 7

circles



Withinhow many

days ofthe

deliverydid theNurse

visit you?

Did you get calciumtablets after thedelivery?

Did you get irontablets afterdelivery?

Within 7 days-

Did not visit-

Got tablets-

Did not get tablets-

More than 7 days-

Got tablets-

5

6

7



~~ ~~ ~~ ~~ ~~ ~~ ~~V~~ ~~ ~~ ~~ ~~ ~~ ~~32



14. Maternal health

B. Services given to women who have delivered

Interview with 2 women from the marginalsied group

who have delivered in the last 6 months


Was your nameregisteredduringpregnancy?

Was theregistration cardgiven duringpregnancy?

Where did thedelivery takeplace?

How manytimes were

youexamined

duringpregnancy

this?

Healthcentre

Government-

Private hospital-

1

2

3

4

Interview No.-2

Yes-

No-

Yes-

No-

3-4 times-

2 times-

At home-

Less than 2 times-

Hospitalnù´ÉÉJÉÉxªÉÉSÉÒ ´Éä³ý-

--------------

----------------

----------------

------------------

------------------

~~ ~~ ~~ ~~ ~~ ~~ ~~V~~ ~~ ~~ ~~ ~~ ~~ ~~


33

Give the total points in the Village Health Report card,,,,, bycombining points in section 14 A interview 1 and 2.


If there is only one pregnant woman in the village, then colour should befilled in the report card, based on the interview of that woman.


Serious situation15 or less than

15 circles


16 to 23 circles




Serious situationless than 7 to 7 circles



Within how manydays of the

delivery did theNurse visit you?

Did you getcalcium tabletsafter thedelivery?

Did you get irontablets afterdelivery?

Within 7 days-

Did not visit-

Got tablets-


More than 7 days-

Got tablets-

5

6

7



~~ ~~ ~~ ~~ ~~ ~~ ~~V~~ ~~ ~~ ~~ ~~ ~~ ~~34


Name of woman- Age- No. of deliveries before this -

15. Janani Suraksha Yojana

Interviews with 2 women from the marginalized group

who have delivered in the last 6 months


How much moneydid you getfrom the JananiSurakshaYojana afteryour delivery?

Did you have to givesome money to theNurse or in the PHCto receive thesanctioned amount?

Did you faceany trouble ingetting thesanctionedmoney underthe scheme?

1

2

3

Interview No.-1

Rs. 700/-

Less than Rs. 700/-

Yes-

No-

Received moneywithin 15 days-

Received moneyafter 15 days-

money not yet received-

Did not get money-





~~ ~~ ~~ ~~ ~~ ~~ ~~V~~ ~~ ~~ ~~ ~~ ~~ ~~


35

Fill the Village Health Report card No. 15 Janani SurakshaYojana, based on points from both interviews


If there is only one woman who has availed of Janani Suraksha Yojana inthe village, fill colour in the report card based on the one interview.


Serious situationless than 6

circles


6 to 8 circles



Note down the names of the women, who have not received Rs. 700/-under the Janani Suraksha Yojana, in the last 3 months.

Fill in colour asper situation




Name of woman- Age- No. of deliveries before this -

How much money didyou get from theJanani SurakshaYojana after yourdelivery?

Did you have to give somemoney to the Nurse or inthe PHC to receive thesanctioned amount?

Did you face anytrouble in getting thesanctioned moneyunder the scheme?

2

3

Rs. 700/-

Less than Rs. 700/-

Yes-

No-

Received money within 15 days-

Received money after 15 days-

money not yet received-

Did not get money-



1

Interview No.-2

15. Janani Suraksha Yojana

Interviews with 2 women from the marginalized group who havedelivered in the last 6 months

~~ ~~ ~~ ~~ ~~ ~~ ~~V~~ ~~ ~~ ~~ ~~ ~~ ~~36


Date-

Name of individual-

Full address -

Age - Sex-

Date of incident-

1. For what illness did you visit the hospital / health centre?

2. Which hospital / health centre did you go to?

3. What treatment were you given?(e.g. only medicines were given, no examination was done, directly sent to other hospital)

4. What do you think were the gaps in the treatment provided to you?

5. Was the quality of health care compromised / affected due to the non-availability ofcrucial / important equipment?

If an individual visiting a Government Health Centre for health services,has been denied any health service, then the following information shouldbe collected.

Information to be taken from individual who has beendenied health service

~~ ~~ ~~ ~~ ~~ ~~ ~~V~~ ~~ ~~ ~~ ~~ ~~ ~~


37

Medical Service given to the patient-1. Who examined you when you went to the health centre?

= Doctor

= Nurse/ ANM

= Health worker / MPW

= Compounder

= Nobody was present

2. On reaching the health centre, after how long you were examined?-

3. Did you require emergency health care and not get it? Write the details.

4. Did you get all medicines free from the health centre? Yes No

If ‘No’ , from where were you asked to get the medicines?: ---------------------------------------------------------------------

5. How much expense for your illness, was undertaken by you or your relatives?--------------------------------------------

------

6. Did you have to give money in the Government health centre?

Yes If ‘yes’, how much? ---------------- No

7. Did you get a receipt for your paid money? Yes No

8. Were you advised to go to next level hospital / health centre for treatment?

Yes No

If ‘Yes’, was arrangement made for vehicle?= Vehicle arranged without asking for money= Vehicle arranged after taking money= Vehicle not arranged

9. How much total expense you had to bear in the health centre?

10. How did you manage this expense?= Through money available with the family= Money taken from relatives= Borrowed from others= Had to sell household items, jewellary, animals= Had to sell family land

11. Due to gaps in treatment given to the patient, was there any serious impact on the patients’health? (threat to life due to unavailability of emergency services and medicines, disability,death)

***

Documents

Questionnaire for collecting information on Health Services …cbmpmaharashtra.org/documents/tools/Village level Health... · 2018. 8. 23. · Information on Health Services at village