Rsby evaluation chhattisgarh rfp document updated 14th september 2011

RFP for evaluation of RSBY in Chhattisgarh 1

RFP DOCUMENT

State Level EvaluationStudy of “Rastriya Swasthya Bima Yojana”

Chhattisgarh

State Nodal Agency RSBY ChhattisgarhDepartment of Health and Family Welfare

Government of ChhattisgarhRaipur

Issued / Released on 14th of September 2011


Tender document of State Nodal Agency Chhattisgarh for the Evaluation of RSBY


Government of ChhattisgarhRaipur

RFP NOTICE ( 2nd Notice)

RASHTRIYA SWASTHYA BIMA YOJANA(A scheme to provide health insurance coverage to unorganized sector workers belonging to BPL families)

Sealed bids are invited from reputed organizations/agencies having experience of carrying out evaluation studies for government schemes and programs for carrying out evaluation study of Rastriya Swasthya Bima Yojana (RSBY) Enrollment and Utilization by BPL families in divisions of Raipur viz. Raipur, Mahasamund, Dhamtari, Kawardha, Durg & Rajnandgon, Bilaspur Viz.Bilaspur, Korba, Raigarh& Janjgir, Sarguja viz. Sarguja, Koriya & Jashpur and Baster viz Baster, Narayanpur, Bijapur, Dantewada & Kanker of Chhattisgarh State

The bids are invited in two parts i.e., Technical Bid and Financial bid. Insurance companies and Third Party Administrators (Health) & their allied companies and Agencies involved with DHFWChhattisgarh are not permitted to participate in the bidding process.

The tender document for this may be downloaded from the website http://cghealth.nic.in

The technical bids and financial bids should be sealed by the bidder in a cover duly super-scribed is to be put in a bigger cover which should also be sealed and duly super-scribed.

The Technical bids will be evaluated by the Technical Bid Evaluation Committee. Financialbids of only the technically acceptable offers shall be opened before the successful bidders by the SNA for awarding of the contract. Following schedule will be observed in this regard.

Last date of submission of technical bid document: 6 PM of 17.10.2011Opening of technical bids: 18.10.2011 The completed technical Bid documents should be submitted before at the following address:-


2nd Floor Directorate of Health and Family Welfare, Old Nursing Hostel, Raipur-492001Email: [email protected] Tel: 0771-4255948

All correspondence / communications on the scheme should be made at the above address.


RFP DOCUMENT

RASHTRIYA SWASTHY A BIMA YOJANA

A number of studies have revealed that risk owing to low level of health security is endemic for informal sector workers. The vulnerability of the poor informal worker increases when they have to pay fully for their medical care with no subsidy or support. On the one hand, such a worker does not have the financial resources to bear the cost of medical treatment, on the other; the health infrastructure leaves a lot to be desired. Large numbers of people, especially those below poverty line, borrow money or sell assets to pay for the treatment in private hospitals. Thus, Health Insurance could be a way of overcoming financial handicaps, improving access to quality medical care and providing financial protection against high medical expenses. The “Rastriya Swasthya Bima Yojana” announced by the Central Government attempts to address such issues. Government of Chhattisgarh has launched this scheme in all its 18districts.

For the evaluation of the scheme, Proposals are invited from the Survey agencies. The agencies which are in agreement with scheme and its Terms of Reference, only need to participate in the bidding and any disagreement in this regard may invite disqualification / rejection of bid at technical level. Hence all the agencies are requested to go through the scheme carefully and submit their agreement in specific format given in the bid.

Agency/Organization after qualifying the Technical bid will have to make a presentation. Finally, the study will be awarded to the agency/organization that is selected by the Committee on the basis of both the Technical and Financial bid following due procedure. The selected Institution/Organization has to start the study immediately after its award, and each of the deliverables would be completed as per the time frame in the TOR. In case the selected Institute/Organization declines to take up the study after a notice of award has been issued, it would be barred from applying for any study, evaluation or assistance of any kind from Department of Health and Family Welfare, Raipur, Chhattisgarh for a period of 3 years from the date of award.

The decision of the Bids Evaluation Committee shall be final, and no enquiries, or application for review, shall be entertained.


PART-1 : TERMS OF REFERENCE FOR CONDUCTING EVALUATION STUDIES OF RASTRIYA SWASTHYA BIMA YOJANA AT STATE LEVEL

A: Introduction

State Nodal Agency RSBY Chhattisgarh invite proposals for conducting household surveys related to RSBY. This request for proposals is for carrying out a post-enrollment survey of health insurance. This type of Household Survey Study will give idea about the enrollment process for RSBY and the experience of the beneficiaries. It will also give States information about the type of facilities provided to the beneficiaries when they receive the treatment under RSBY. All the benefits which are supposed to be given by the providers to the beneficiaries whether they are getting those or not will come out through this survey. It will also provide limited information about the quality of health care provided. It will also provide results in terms of utilization pattern of public and private providers by the beneficiaries in the State of Chhattisgarh. The districts to be covered for this survey are all the 18 districts in four divisions of Chhattisgarh.

Proposals are invited from the Survey agencies (henceforth called consultants).

The following activities are to be carried out as part of the post-enrollment survey:

• Implementation of a post-enrollment and hospitalization household survey in the selected districts. • Completion of an implementation report on the household survey including cases of households

not covered due to extenuating circumstances (e.g. inability to locate or household unwilling). • Completion of the database detailing responses to the household survey in appropriate format for

subsequent analysis.

Important information regarding the RFP has been given in Annexure - 1.

B. Clarification and Amendment of RFP Document

1. Consultants may request a clarification of any of the RFP documents within 7 days of the advertisement data. Any request for clarification must be sent in writing, or by standard electronic means to the State Nodal Agency. The State Nodal Agency will respond in writing, or by standard electronic means and will send written copies of the response (including an explanation of the query but without identifying the source of inquiry) to all Consultants. Should the State Nodal Agency deem it necessary to amend the RFP as a result of a clarification, it shall do so following the procedure.

2. At any time before the submission of Proposals, the State Nodal Agency may amend the RFP by issuing an addendum in writing or by standard electronic means. The addendum shall be communicated through a public advertisement and will be binding on them. Consultants shall acknowledge receipt of all amendments. To give Consultants reasonable time in which to take an amendment into account in their Proposals the State


Nodal Agency may, if the amendment is substantial, extend the deadline for the submission of Proposals.

C: Qualifying Criteria’s:

• The bidder has a financial turnover of at least Rs. 25, 00,000 in at least one of the past three years (2007-08, 2008-09, and 2009-10). ( please attach audited statements)

• Should have done at least 3 evaluation studies projects with minimum project cost of Rs. 5,00,000/- for any Government (State/Central) / Government Autonomous Bodies / Government Corporation for building their Process Automation Systems in the last 3 years (Please attach copy of work orders and completion certificates).

• Out of this, at least 2 (two) evaluations should have been successfully completed. (Please attach copy of completion certificate from the client).

• The agency/organization should have at least 5 years relevant experience carrying out evaluations studies (Please attach copy of evidence)

• The firm / company / organization should be registered as per law. (Please attach copy of evidence).

• No consortium is allowed to bid for the study

• Applicants should not be under a declaration of ineligibility for corrupt and fraudulent practices issued by Government of India / State Governments. A self-declaration certificate should be enclosed.

D. Methodology for Evaluation

Though consultant /agency are required to provide their methodology for conducing the survey, main aspects of the methodology of the proposed survey is given as follows:

For this survey only RSBY beneficiaries needs to be surveyed. RSBY beneficiaries who are enrolled in the scheme will be part of this survey. The sample of beneficiaries will include beneficiaries who have utilized the scheme and who have not taken benefits in the scheme

a. Sampling of District – State Nodal agency shall have this exercise in the first stage in all the districts where RSBY started in the first phase.

b. Sampling – For every 1000 beneficiaries who are enrolled under RSBY in a district, at least 20 should be selected in the sample. Care should be taken that the beneficiaries who have utilized the scheme shall also be present in the sample.

c. Location of Surveys – The beneficiary in the sample should be sufficiently distributed among all the blocks of the district. Within the block also efforts should be there to have villages or clusters of villages distributed geographically.

d. Duration of Surveys – Survey training and field work shall take approximately two month. Another month will be needed to analyze the data and prepare the report.

e. Timelines – The process to start the selection of survey agency to get the final report shall take approx. 3-4 months. If a State Nodal agency starts the process in Novemberthen they shall have the final report by sometime in January.


f. Draft Tool for the Survey – The draft tool for this type of survey is attached as Annexure- 5 of this document. This tool may be modified before start of the final survey.

E. Submission of Technical and Financial Proposal:

a. Technical Proposal shall be provided in the format given in Annexure -2: i. The consultant shall provide in the technical proposal a description of the approach,

methodology and work plan for performing the assignment covering the following subjects: technical approach and methodology, work plan, and organization and staffing schedule. The list of the proposed Professional staff team by area of expertise, the position that would be assigned to each staff team member, and their tasks.

ii. Estimates of the staff input (staff-months professionals) needed to carry out the assignment. The staff-months input should be indicated separately for home office and field activities.

iii. CVs of the Professional staff. iv. A detailed description of the proposed methodology and staffing for training. v. Format for evaluation of technical proposal has been given in Annexure 4.

vi. Technical bid evaluation will be done in following steps: a. The bidders will be short listed after evaluation is done on the qualifying

criteria. b. Short listed bidders will be asked to give a presentation in the prescribed

format in front of the technical evaluation committee. c. After the presentation the bids will be evaluated on the other parameters as

mentioned in the Desirable Criteria of the Technical Proposal d. All the successful bidders who qualify after the technical bid evaluation will

be eligible for the financial bid evaluation. e. The Technical proposal shall not include any financial information. A

Technical Proposal containing financial information may be declared non responsive.

b. Financial Proposal:

i. The Financial proposal shall take into account all costs associated with the assignment (Annexure-3). The quote should be for each division separately. Bidders can quote for more than one division.

ii. No other information shall be provided along with the financial proposal.

F. Co-ordination with the State Nodal Agency

The agency will have to work closely with the State Nodal Agency in developing the methodology, training of the surveyors, and conducting the surveys. State Government will provide the necessary contact details and data for surveys.

G. Ownership of the Survey

The ownership of the survey tool and data shall lie with the State Government/ Nodal Agency.


PART –II SUBMISSION OF BIDS/ PROPOSALS

The State Nodal Agency seeks detailed proposal from agencies interested in evaluating the “Rastriya Swasthya Bima Yojana”, in the Chhattisgarh State.

The bid/proposal document should include the following:

SECTION A – TECHNICAL PROPOSAL

QUALIFYING CRITERIA:

• A. The bidder has a financial turnover of at least Rs. 25, 00,000 in at least one of the past three years (2007-08, 2008-09, and 2009-10).

• Should have done at least 3 evaluation studies projects with minimum project cost of Rs. 5,00,000/- for any Government (State/Central) / Government Autonomous Bodies / Government Corporation for building their Process Automation Systems in the last 3 years (Please attach copy of work orders).

• Out of this, at least 2 (two) evaluations should have been successfully completed. (Please attach copy of completion certificate from the client).

• The agency/organization should have at least 5 years relevant experience carrying out evaluations studies (Please attach copy of evidence)

• The firm / company / organization should be registered as per law. (Please attach copy of evidence).

• No consortium is allowed to bid for the study

• Applicants should not be under a declaration of ineligibility for corrupt and fraudulent practices issued by Government of India / State Governments. A self-declaration certificate should be enclosed.

Note: The qualifying requirements data shall be enclosed with the technical bid only. The bidder who do not qualify this criterion, will be disqualified immediately and their bids will not be considered. The Technical proposal should be sealed in an envelope clearly marked in BOLD “SECTION A – TECHNICAL PROPOSAL” and “TECHNICAL PROPOSAL FOR Evaluation of “RASHTRIYA SWASTHYA BIMA YOJANA SCHEME” written on the top of the envelope.

The Envelop should have the bidders Name and Address clearly written at the Left Bottom Corner of the envelope. The technical supporting documents in physical form should be submitted at the following address before the due date and time.

State Nodal Agency Rastriya Swasthya Bima Yojana 2nd Floor, Directorate of Health Services, Raipur, Chhattisgarh Phone: 0711-4255948, 4225196


SECTION B – FINANCIAL PROPOSAL

(KINDLY NOTE THAT ANNEXURE -3 SHOULD BE ATTACHED TO SECTION B- FINANCIAL PROPOSAL ONLY)

Annexure-3 (A) The Financial bid submission should be done physically in a separate sealed and marked envelope.

No bid will be accepted after prescribed closing time for submission of the same.

The delay will not be condoned for any reason. However, if the last date of submission of tender is declared as a holiday by government, the last date of submission of tender will be extended to the next working day.

The bids may be cancelled and not evaluated if the bidder fails to:

a. Seal the envelope properly with sealing tape. b. Submit envelopes i.e. Technical Proposal and Financial proposal in another large envelope.c. Give complete bids in all respects. d. Submit financial bids not as mentioned in the tender document.

Deadline for Submission Bids / Proposals:

Complete bid documents should be submitted by 18.00 hours on 16th of August 2011. Bid documents received later than the prescribed date and time will not be considered for evaluation.

IN NO CASES, RATE S SHOULD BE QUOTED ANYWHERE EXCEPT IN FINANCIAL BID


Annexure - 1

Instructions to the Consultants

Paragraph Reference

1 Name and Address of the State Nodal Agency:

State Nodal Agency, RSBY ChhattisgarhDepartment of Health and Family Welfare,2nd Floor, Directorate of Health Services, Old Nursing Hostel, Raipur, Chhattisgarh. Email: [email protected]: 0711-4255948, 4225196

2 The physical submission of the technical bid document address is:

State Nodal Agency, RSBY ChhattisgarhDepartment of Health and Family Welfare,2nd Floor, Directorate of Health Services, Old Nursing Hostel, Raipur, Chhattisgarh. Email: [email protected]: 0711-4255948, 4225196

Proposals must be submitted not later than the following date and time 6 pm of 17th October2011

3 Proposals must remain valid 90 days after the submission date

4 Clarifications may be requested not later than 3 days before the submission date.

5 Proposals shall be submitted in the following language: - English

6 The format of the Technical Proposal to be submitted: As per the Annexure

7 Bidder must submit the original and 2 copies of the Technical Proposal, and the original of the Financial Proposal.


Annexure-2

Details of the Technical Proposal

Technical approach, methodology and work plan are key components of the Technical Proposal. Please submit your Technical Proposal divided into the following three chapters:

a) Technical Approach and Methodology, b) Work Plan, and c) Organization and Staffing,

a) Technical Approach and Methodology. In this chapter understanding of the objectives of the assignment, approach to the services, methodology for carrying out the activities and obtaining the expected output, and the degree of detail of such output shall be explained. It should highlight the problems being addressed and their importance, and explain the technical approach that would be adopted to address them. It should also explain the methodologies which are proposed to be adopted and highlight the compatibility of those methodologies with the proposed approach.

b) Work Plan. In this chapter the main activities of the assignment, their content and duration, phasing and interrelations, milestones, and delivery dates of the reports shall be proposed. The proposed work plan should be consistent with the technical approach and methodology, showing understanding of the TOR and ability to translate them into a feasible working plan. A list of the final documents, including reports, drawings, and tables to be delivered as final output, should be included here.

c) Organization and Staffing. In this chapter the structure and composition of the team shall be

proposed. It should list the main disciplines of the assignment, the key expert responsible, and proposed technical and support staff.


Evaluation of Rastriya Swasthya Bima Yojana (RSBY) Chhattisgarh State, Division of _____________________________

A: ORGANISATIONAL PROFILE

Name of organization

Name and Designation of Contact Person

Postal Address of the Organization (with PIN CODE)

Physical Address, if different from postal address (With PIN CODE)

Telephone with STD Code

FAX No. with STD Code

Mobile No. of Contact Person

E-mail Address of Contact Person

Name and Designation of Head of the Organization responsible for the Study Contract

Establishment Details

a. Year Established

b. Type of Organization (Tick One) Educational & Research

Institution/ Consulting Organization/ Any Other (give details)

c. Regd. No. ; Name and Place of Registering Authority

(Attach attested photocopy of Registration Certificate)

B. EXPERIENCE

Experience in conducting research studies in the field of rural & social development/welfare programme/schemes/projects by the organization/agency in the past years (2006 to 2009 calendar years) that are relevant for demonstrating its expertise in the area of proposed study (attach attested photo copy of the experience certificate):

Sno. Title of the research project

Name & Address of Client

Completion time/date (Month & Year)

Duration of the project completion (in Months)

Value (Rs. Lakh)

Name of Sample State (s) As per TOR/ Agreements Actual

House Hold survey1234Health Survey12


Government survey12

B.1: Completed research project (s) (Extra-sheet may be used if activities are more than 5 in number)

B.2: On-going research projectsSr. No.

Title of theresearchproject

Name &Addressof Client

Projectstarting

date/time(Month &

Year)

Projectcompletion

time asper

ToR/Agreement

(inMonths)

Value(Rs.

Lakh)

Name ofSampleState (s)

12345

C: HUMAN RESOURCE

C. 1 Human Resources of the organization: (attach CVs) Sr. No.

Official Station (Name of place)

Professional/Technical (Numbers)

Supporting Staff (Numbers)

All

Fulltime Part-time Fulltime Part-time

1

2

34

C2: To be deployed for the proposed study/project

(a)- KEY PROFESSIONALS ** (attach CVs) Sr. No.

Name Areaof key

expertise

Highest academic/

professionalqualification

in thearea of key

expertise

Length ofexperience(years) in

thearea of key

expertise

No. of manmonths

deployed forthis study

(TeamLeader)

1

2

3

45


** Note: Care may be taken to demonstrate that each area of expertise required for the study is covered by different key professionals in above table.

(b)- SUPPORT AND FIELD STAFF

Sr. No. Job profile (e.g. Field investigator, data entry operator, analyst, etc.)

No. of personnelTotal number of man months to be

deployed.12345

Format for Team Composition1. Professional Staff

Name of Staff Firm Area of Expertise

Position Assigned

Task Assigned

2. Support Staff

Name of Staff Firm Area of Expertise

Position Assigned

Task Assigned

D: Reasons for applying for this Region: Give in detail the capability of the organization/agency and the experience etc. to support the claim.

E: Methodology and Organization of Study: The sample procedure, sample size and study tools are given in the TOR. Please suggest:

(i) sample selections in detail; (ii) Study tools refinements; (iii) How you would complete the study in time? and (iv) How to achieve quality?


F: ANY OTHER DETAIL WHICH IS RELEVANT TO THE BID CERTIFICATE

It is certified that:

1. The information given above is TRUE to the best of my knowledge. The organization shall stand liable for any information given above which is later found to be FALSE, including the forfeiture of any payment due to it.

2. The information given above is COMPLETE to the best of my knowledge and I have not willingly suppressed any material information that might lead to misjudgments while evaluating this Technical Bid.

3. The professionals, staff, equipment and all requisite infrastructural facilities mentioned in this bid shall be made available for this study in due time.

4. Our agency/organization/institution is interested to undertake the proposed evaluation.

5. I am competent to sign this Certificate.

Date: Authorized Signatory

Place: Name:

Seal of the Organization:

Designation:


Financial BidAnnexure-3

Evaluation of Rastriya Swasthya Bima Yojana (RSBY) Chhattisgarh State inDivision of :……………………………………………

(use separate sheet for each division)

Name of Bidder Agency/Organization with address: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

FINANCIAL BIDSr. No. Head Total Cost (Rs.)

1 Salary of key professionals2 Salary of field staff and support staff3 Travel for key person4 Travel for Field & Secretariat staff5 Contingent expenses6 Office expenses**7 Total (1+2+3+4+5+6)8 Institutional Overheads if any, and basis of charge9 Service Tax, if any to be charged

Grand Total (7+8+9) (In

words______________________________________________________)

** Office expenses: Include expenses for required numbers of final report and 5 Compact Disks.

Date: Authorized Signatory ______________

Place: Name: ___________________________

Seal of the Organization: Designation: ______________________


Annexure-4

Form A – Appraisal of the technical proposal

BidderNo.

Bidder Name No. of SeparateDocuments¹IncludingAnnexes

123456

1. Essential Criteria

No. Criteria1. The bidder has a financial turnover of at least Rs. 25,

00,000 in at least one of the past three years (2007-08, 2008-09, and 2009-10).

2 Should have done at least 3 evaluation studies projects with minimum project cost of Rs. 3,00,000/- for any Government (State/Central) / Government Autonomous Bodies / Government Corporation for building their Process Automation Systems in the last 3 years (Please attach copy of work orders).

3 Out of this, at least 2 (two) evaluations should have been successfully completed. (Please attach copy of completion certificate from the client).

4 The agency/organization should have at least 5 years relevant experience carrying out evaluations studies (Please attach copy of evidence)

5 The firm / company / organization should be registered as per law. (Please attach copy of evidence).

6 No consortium is allowed to bid for the study

7 Applicants should not be under a declaration of ineligibility for corrupt and fraudulent practices issued by Government of India / State Governments. A self-declaration certificate should be enclosed.


8 The bidder has a financial turnover of at least Rs. 20, 00,000 in at least one of the past three years (2007-08, 2008-09, and 2009-10).

9 Should have done at least 3 evaluation studies projects with minimum project cost of Rs. 3,00,000/- for any Government (State/Central) / Government Autonomous Bodies / Government Corporation for building their Process Automation Systems in the last 3 years (Please attach copy of work orders).

Any other remarks ______________________________________________________________________________ _____________________________________________________________________________________

If the answer to any one of the above criteria is “No”, then the bid is rejected at this stage itself. There is no need to progress any further.

¹A document is considered separate if it is stapled/ bound as a single entity. Even a one page covering letter should be considered as a separate document. ²specific years must be mentioned.

2. Desirable Criteria No. Criteria 1 2 3 4 5 6 7 8

1. Specific experience of the Consultants in conducting:

a. Household Survey-20 marks b. health surveys-10 marks

c. working with Government experience- 5 marks2. Adequacy of the proposed methodology and

work plan in responding to the Terms of Reference and demonstrating an understanding of RSBY

a. Technical approach and methodology-10 marksb. Work plan-5 marksc. Organization and staffing-10 marks

3. Key professional staff qualifications and competence for the assignment

a. Team Leader-10 marksb. Other Key Members-10 mark

4. Suitability of training program -10 marksa. Relevance of training program -5 marksb. Training approach and methodology- 5 marks

Total: 100


I hereby certify that after perusing through the documents supplied by the bidder (………………………………………………………………………………………….............) it is my opinion that this bidder should be …………………………..(accepted or rejected)³ ________________________________________ ³Please enter one of the decisions, in your own handwriting.

Bidder with more than 70% (70 marks out of 100) will be considered for Commercial Evaluation.

COMMERCIAL OPENING

Commercial opening will be done and on the basis of price quoted bidder will be termed as – L1, L2, L3 and so on… as per the rank of lowest price quoted.

BID EVALUATION

If commercial bids for bidder 1, 2, 3, 4… are taken as L1, L2, L3, L4… where Lmin is the lowest bid then the weightage given to commercial bids would be:

Lmin/L1, Lmin/L2, Lmin/L3, L4/Lmin and so on...

Similarly weightage will be calculated for Technical Evaluation: T1/Tmax, T2/Tmax, T3/Tmax, T4/Tmax and so on… for bidder 1, 2, 3, 4… respectively

Each proposal would be evaluated against the 70 – 30 Criteria. This means 70% weightage will be given to Technical Proposal 30% to Financial Proposal.

AWARD

Finally the technical and commercial scores obtained by all the vendors would be summed and the bidder with highest score would be AWARDED THE BID.

The final scores of the vendors would be as given below –

Bidder 1:

(T1/Tmax)*0.7 + (Lmin/L1*0.3)

Bidder 2:

(T2/Tmax)*0.7 + (Lmin/L2*0.3)

Bidder 3:

(T3/Tmax)*0.7 + (Lmin/L3*0.3)

Bidder 4:

(T4/Tmax)*0.7 + (Lmin/L4) *0.3

The vendor with the highest marks computed above on cost and quality basis will be awarded the bid.

19

Annexure 5

RSBY QUESTIONNAIRE

Post-enrolment Survey of the RSBY Programme

A 0 : CONSENT TO PARTICIPATE IN INTERVIEWHousehold ID : __ __ __ __ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

INTERVIEWER - Read out: Namaskar. My name is (please say your name here). I am asked by the Government of Chhattisgarh, to conduct a survey with BPL people in Chhattisgarh to understand the penetration of Rashtriya Swasthya Bima Yojana (RSBY). We will be asking you questions related to RSBY. We would appreciate your participation in this survey. The information collected would be kept confidential. The survey should take a short time to complete.

Oral consent given (circle one): YES – ContinueNO -- Stop the survey

1. Signature of Investigator_____________________

2. Date Month Year

A 1 : INTERVIEWER: COMPLETE (WHAT EVER APPLICABLE) BEFORE BEGINNING THE MODULE. Code

A1.1 State Gujarat…………..1Haryana…………..2

A1.2 District

A1.3 Village

A1.4 Hamlet name

A1.5 Block/Circle

A1.6 Rural/Urban

A1.7 Name of Gram Panchayat

A1.8 Address

A1.9 Family ID

A1.10 RSBY Status RSBY Enrolled household ………….…1RSBY hospitalized household …………….2Non RSBY household …………………….3

3. Date of visit: Day Month Year

4. Interview starting time: Hours Minutes

20

A.2.1 BPL card No. : write 0 if not available

A.2.2 Ration card No. : write 0 if not available

A.2.3 RSBY card No : 2008: , 0 if not available

A.2.4 2009 : 0 if not available

SECTION B. HOUSEHOLD ROSTER

B.1Member ID

B.2.Name

Enter the names starting with the household head

B.3.Relationshipwith the

head(use codes)

B.4.AgeIf less than one year write zero

B.5.sex M.1F..2

B.6.Marital status

(use code)

B.7. level

of education attain

ed(use

code)

B.8.main occupation

of ID?(use

codes)

B.9Presen

tly living in the houseY….1N ….2

B.10If no, why not(use

code)

Is name member of the following?Y …………1, N ………..2 B.11BPL

B.12Ration card

B.13RSBY card

B.14NREG

B.15No. of days worked in NREG(last year)

Relationship Codes Marital status Education Codes Occupational Codes Presently not living reasons

Head …………Spouse ………Father ………..Mother ……….Son …………Daughter ……BrotherSisterFather in lawMother in lawGrand sonGrand daughterGrand fatherGrand motherBrother in law Sister in lawOther (Specify)Daughter-in-law

123456789101112131415161718

Married ……...Divorced …….Separated ……Widowed ……. Never Married.

12345

Upto class 1 ………...Upto class2 …………Upto class 3 …………Upto class 4 ………… Upto class 5…………. Upto class 6………….Upto class 7 …………Upto class 8 …………Upto class 9 ………...Upto class 10 ……….Upto class 11 ……….Upto class 12 ……….Graduate and above ../Other diploma ……..Never attended schoolNursery …………….Don’t know ………..

12345678910111213141516999

Farming …………………………Livestock Rearing………………………Salaried Job …………………………….Currently not working …………………Enrolled full time in School/Madrassa ..Self Employed/ Trader …………………Employed Skilled Laborer ……………..Employed Unskilled Laborer …………..Too young to work ……………………..Housewife/Housekeeping ………………Too Old to work ………………………..Enrolled full time in College …………..Other (Specify) …………………………Does not work ………………………….Don’t know ……………………………

1234567891011121314999

Living separately in the same village ……….Moved to some other village/town …...Passed away …..Got married …..Name was never the part of this family …….. ,…

1

234

5

21

SECTION C. HOUSEHOLD CHARACTERISTICS

C.1

C.2

C.3 Do you rent or own the house you live in?

Rent…………………….1Own…………………….2 Rent Free house ............... 3

C.4

C.5 Do you have a separate toilet? Yes……………………1 No…………………….2

C.6

C.7

C.8 What is the source of drainage Open kutcha - 1, Open pucca - 2Covered pucca - 3, Under ground – 4; No drainage - 5

C.9 Does the family own any cultivable land?(in the native village)

Yes……………………1 No…………………….2 C.12Does Not Know........-999 C.12

C.10 What is the total area of cultivable land? ________Acres..........................1________Bighas........................2________Biswa .........................3Does Not Know……………-999

C.11 What is main source of drinking water for members of your household?

Piped waterPiped into residence/yard/plot…..…1Public tap……………………..…....2Public hand pump………………....3Hand pump in residence/yard/plot ..4Well waterCovered well in residence/yard/plot..5Open private well…………………..6Covered public well………………7Open public well………………….8Surface water……………………..9Spring water……………………….10Pond/Lake…………………………11Dam……………………………….12

22

Rainwater…………………………13Tanker truck………………………14Other (specify)…………………-777_____________________________

C.12 Is Water Treated Before Drinking? Yes - 1, No -2 C.19

C.13 If 1 in item , type of water treatment (code)

Ultra-violet/resin/reverse osmosis – 1, Boiling – 2, Filter – 3, Cloth – 4,Any disinfectant – 5, Others – 777

SECTION D: INCOME AND BORROWINGS

D.1 Who of the household members worked and how much did each member earn ? (INDICATE HOUSEHOLD BOARD NUMBER)

Nobody………………….1 D.2

ID Last month(in Rs.)

Last year(in Rs.) no. of days worked in a month

No. of hours worked a day

D.2 Is there any other source of income for the family? (eg. Pension, rent, remittances etc. )

Yes……………….1No………………..2 D.4 Don’t know….-999 D.4Will not answer…….-888 D.4

D.3 If yes, how much did you get from that source last month?

Source …………………………………………………..

Income

D.4 In last one year have you borrowed from somewhere for some purpose?

Yes……………….1 give detailsNo………………..2 section EDon’t know….-999 section EWill not answer…….-888 section E

D 5 Details of borrowings Sr No.

Amount borrowed

Source of borrowing (see codes below) Reason of borrowing (see codes below)

1 , ,

2 , ,

3 , ,

4 , ,

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Source of borrowing

From friends and family without interest……..1From friends and family with interest……..2From moneylender...3From bank………....4From MFI………….5From chit funds…….6From other financial institutions……….7From NGO……..…..8From SHG……..…..9Others (specify)… - 777Don’t know……-999; Will not answer……..-888

Reason of borrowing

Start a new business…………….……...1Acquire agricultural machinery or agricultural inputs …….…2Purchase stock for existing business………………………….…3Repay old debt………………………..4For health related expenses..………………………….….5Marriage…………………..…………….6Funeral………………..………………7Festival/Other Ceremony.........................8Houseold consumption/Purchase household durable…..……….9Home improvement/repair/construction….10Unemployment……………..………...11Purchase land………………..……….12Education…………………………..…13Purchase jewelry…….………………14Buy livestock…………………...…….15Other (specify)… ……………….…-777___________________________Don’t know…………………..-999

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SECTION D.1: HOUSEHOLDS SOCIAL NETWORK

D.1.1Is anyone in the family presently a member of any of the following?(multiple answers possible)

SHG ………………………. 1cooperative ………… ……...2trade union ………….…..3NGO/MFI client ……….… 4village committees (e.g. VEC; ICDS) …...... 5political party ……………… 6religious organization …..…..7RWA (urban areas) …….…8other membership-based organization ……. 9No ……………………….. 22Don’t know ……………...-999

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D.1.2Do you or your family members personally know the sarpanch/ nigam parishad/ MLA or any ward member for your gram panchayat ?

Yes...........................…..........1No ..........................…...........2Don’t Know...........…......-999.

D.1.3

D.1.4What is your main source of information about government programs ?

friends and family ….…..1media (print, visual or audio) ...2local panchayat workers/officials…….…….3administration officials ……..4religious leaders ……………..5MLA ………………………6

Local NGO ………………… 7other______ (specify) ……-777

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D.1.5How often does any member of your family travel to -

1. block HQ 2. district HQ

Every week..1At least Once a month,,,,2At least once a quarter….3At least once in Year…..4Never………………….5

1.

2.

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SECTION F: F.1 HOUSEHOLD HEALTH (FOR ALL INDIVIDUALS FROM HOUSEHOLD BOARD)

(INTERVIEWER: SHOW THE LADDER TO THE RESPONDENT WHERE EVER REQUIRED) F.1.1ID codes

F.1.3. Is he/she facing any recurrent medical problem that has lasted for more than one month? Yes….1 No…..2 F.1.6Don’t know….-99 F.1.6

F.1.4If yes, describe the condition?

F.1.5 Is he/she taking medicines regularly for this problem?Yes….1 No…..2Don’t know….-999

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F.2 HOUSEHOLD HEALTH EVENT AND HOSPITALISATION

F.2.1 Does any of your family member has some health related problem that may need hospitalization in the next 6 months?

Yes………………………………….1No…………………………………..2 F.2.3Will Not Answer……..……….…-888 F.2.3Does Not Know…………………-999 F.2.3

F.2.2 Who you think would require hospitalization and for what?

HH board no

………………

………………..

…………………………….F.2.3 Was anyone in your family very sick or severely

injured in the last two years?Yes………………………………….1No…………………………………..2 F.3Does Not Know…………………-999 F.3

F.2.4 How many cases like these happened in the last two year?

F.3 DESCRIPTION OF HEALTH EVENTSInterviewer: ask the respondent if any one in the household suffered from major health event in last twoyears. Fill the details of all the members of the household who had/ are having major health event in following table:

F.3.1. ID codes of those who had major health event

F.3.2.What was the major health event that [name]suffered?Disease….1Accident..2Complicated birth….3Other-specify…-777Don’t know.999Can’t say..-555

F.3.4.How serious was this health event / condition?Caused death…1 F.3.7Caused permanent inability to perform normal daily activities….2 F.3.6Caused temporaryinability to performnormal dailyactivities……….…3Caused no inability to perform normal dailyactivities, but was aninconvenience……4No inability wascaused…....5 F.3.6Don’t know....-999 F.3.6

F.3.5.For how long did this health event / condition cause a temporary inability OR inconvenience to perform normal daily activities?Days ….1Weeks…2Months ..3Don’t know....-999

F.3.6.Is he/she still taking a treatment for this condition?Yes…..1N…....2Don’t know....-999

F.3.7.Was [name] hospitalized as a result of this major health event?Yes…...1No….….2 Don’t know....-999

F.3.8Which type of hospital was [name] admitted?Government……1Private…2Don’t know…-999

F.3.9Did [name] have surgery as a result of this major health event?Yes….......1No…….2Don’t know…….-999

F.3.10 How many days the [name]was admitted to the hospital for more than 24 hrs?

F.3a Has it ever happened that a very serious illness/death could not be treated at hospital because of lack of money?

Yes..............................……....................1No ...............................……..................2 F.4Don’t Know........……..……............-999

F.3b Mention the member Id of that person from the above table

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F.4. HEALTH-RELATED BEHAVIOR (head of the family)

F.4.1 Do you or anyone in the family smoke? __

Yes.....................................1 No ....................................2 F.4.3

F.4.2 Indicate number of cigarettes smoked per day:(1-9) ……………………..…… 1(10-19) …………………….…. 2(20-29) ……………………….. 3(30 OR MORE) ….……….… 4

F.4.3 Do you drink alcoholic beverages? Yes................................1

No ................................2 F.4.5

F.4.4 How would you rate your consumption? Daily ………………1 3-5 days a week ………….. 2 Less than 3 days a week ……. 3 Occasionally ………………….. 4

F.4.5 Are your kids vaccinated for pulse polio? Yes.....................................1 No ....................…..............2

F.4.6 Have your kids got any other vaccination? Yes.....................................1 No ....................…..............2

SECTION G: RSBY

INTERVIEWER: FOLLOWING SECTION SHOULD BE FILLED IN ONLY FOR HOUSEHOLDS WHO ARE AWARE OF RSBY CARD/SCHEME. FOR THOSE WHO ARE NOT AWARE, DIRECTLY JUMP TO SECTION H.

G.5 Awareness of RSBY

G.5.1 Are you aware of RSBY scheme? Yes ……………………………..1 No … …………………………..2 SECTION H

G.5.2 Where did you get to know about the scheme?Through friends / neighbours ……….…1 Through Radio / TV / newspaper ..........2 Through leaflets/brochure ………..….…3 Through Health Staff ………………...…4Area Committee members/ Community Educators.... 5 Panchayat………………….6Ration shop keeper ……………………..7NGO personnel ..................................... 8Survey people ........................................9Others (specify) ……………….…..-777

G.5.3 Do you know who is eligible for the scheme? Everyone…………………1 Only BPL families ………….2 Only AAY families ……………3 Only NREGA card holders ……4 Others(specify) ....................-777 Don’t know …………...-999

G.5.4 Is your family eligible for the scheme?

Yes ………………………..1 No … ……………………..2

Don’t know …………..-..999

G.5.5 How much does it cost to enroll in this scheme? ( in Rs.) Zero ………………0 Rs 30..................................30 Others (specify) ...............-777 Don’t know……………….-999

G.5.6 What is the maximum amount per year that can be spent? ( in Rs.) Don’t know………………….-999

G.5.7 Is free treatment provided in the hospitals under this scheme?

Yes ……………………..1 No … ……………………..2

G.5.8 Are transportation allowances provided to the patient?

Yes ………………………..1 No … ………………………..2

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Don’t know …………………-999 Don’t know ………….…-999G.5.9 Do you have to pay for the medical tests during hospitalisation if you enroll in this scheme?

Yes …………………..1 No … ……………………..2

Don’t know ……….……-999

G.5.10 Do you have to pay for medicines and drugs in case of hospitalisation if you enrol in this scheme?

Yes …………………..1 No ………………..2

Don’t know……………..-..999G.5.11 How many household members can be enrolled?

At most 5 members …..1 All household members ………2 Others (specify) …………. -777

Don’t know ……………….-999

G.5.12 Which year did enrolment takeplace? (multiple answers possible) 2008 ……………12009 ……………………22010 …………………………………3

Don’t know……………-999G.6 Which year did you apply to obtain the card?

2008…………....1 G.7.22009… ………..2 G.7.1

2010Both (2008 & 2009)....3 G.7.3Didn’t apply at all ......... 4 G.7

G.7 Why didn’t you apply? (multiple answers possible) Booth too far away……….…......….1It’s of no use. ………….......…….2Get similar facilities in government hospitals.............3Didn’t find any hospital in the list which is closer to my place..….4Distrust in scheme……………...5Did not have proper documents to support family’s identity…......6Did not feel comfortable with the technology involved (eg. Use of smart cards)…….... ...7Didn’t understand the scheme……...8Not eligible for the scheme ............ 9Others (specify) .........................-777 Section H

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G.7.1 Why didn’t you apply in the first round? Booth too far away……….…...............................….1Didn’t know about the scheme at that time............ 2Didn’t get to know about enrolments .. ............... 3Didn’t find any hospital in the list which is closer to my place..........................................................….4Did not have proper documents to support family’s identity…..............................................................5Didn’t understand the scheme…......................…...6

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G.7.2 why didn’t you reapply? Booth too far away……….…......….1Didn’t get to know about enrolments......2Had bad experience with hospital ..........3Was not satisfied in first round .............5Didn’t get chance to use card in first round .....................................................6Didn’t find any hospital in the list which is closer to my place this time.............7Name on on the list ............................. 8

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Interviewer: select whichever year family has enrolled in. choose the latest year if family has enrolled both the times.

29

G.8 For those who appliedG.8.1 Was any list of eligible families publicly displayed before enrolment began?

Yes …………………………..1 No … …………………..2

Don’t know ……………-999

G.8.2 When did enrolment happen? Don’t know …………..999

G.8.4 How much time did it take to reach enrolment station?

5-10 mins …………………1 10-20 mins …………………..2 20-30 mins ……….…….……3

>30 mins …………………4 Don’t know …………..…-999

G.8.5 How far was the enrollment station from your house? (in kms) within 2 km ……………1 2-5 kms …………...2 5-8kms ……………3

more than 8 kms ………….4 Don’t know.……………-999

G.8.6 How did you get to know when and where enrolment was happening?

From Posters displayed in the village..................................... 1From Word of mouth.............. 2From NGO personnel............. 3From Sarpanch....................... 4From ANMs...........................5From AWWs ........................6From ASHA.........................7

From district/ block officials...... 8From Loudspeaker announcement......9From Wall writings.......... 10From Nukkad natak ......... 11From Aanganwadi Worker... 12Others (pl. specify) .......... 999

G.9 Did you obtain the RSBY card? Round 1. ...........................................Round 2 …………………………….. Yes ……………….1 Section G.10 No … …………...2 G.9.1

G.9.1 Why didn’t you obtain it? ? (multiple answers possible) First round .Second round Household head died …….……….1Household not on the BPL list ……2Didn’t have required documents ….3Wait was too long …………………4Were asked to come again …………5Refused without any reason ………6There were problems at enrolment station…………...7Didn’t apply ................. 8Other ( specify ) …………………999

Section H

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G.10 For RSBY card holders

G.10.1 PLEASE SHOW YOUR RSBY CARD.Showed it………….….….….1Did not want to show……..….2Lost it………………..…………3Someone has taken it (is with some one) .…4Its with hospital ..………………5Other (specify)…………….…-777

G.10.2 What problems did you face in obtaining the card? ( Add extra sheets if required)

G.10.3 How many members of the family are covered?

G.10.4 How long did it take you to complete the whole enrolment process? Less than one hour ………….11-2 hours …………………22-4 hours………….……….34-6 hours ………………….4more than a day ……….…..5

G.10.5 Did you get smart card on the spot? Yes …………………………..1 No … ………………………..2

G.10.8 Did you make any payments to get hold of it?

Zero …………………0Rupees 30 ..................30Don’t know.……….-999

G.10.7 Which of the following pieces of information did you get along with the card?

List of hospitals………………..1 How to use the card………….….2 Who to contact in case of any query…..3Information about district kiosk .......... 4

Didn’t get any ..................................... 5Other (specify)……………………-777

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G.10.6 Were you told about the date when you could start using the smart card?Yes …. 1 No …. 2

G.10.8 Which is the nearest RSBYempanelled hospital?

Don’t know ...................-999_________

G.10.9 Are you satisfied with the scheme? Yes ……………………………..1

No … …………………………..2

G.10.10 Would you like to enrol next year also?Yes ………………………..1 No … ……………………..2Don’t know ……………………-999

G.11 INDIVIDUAL ENROLMENTG.11.1ID

G.11.2Is ID enrolled in

G.11.3 If no, why not?Five person limit …………….…..1;

At school at the time of enrolment…..2Out of village at the time of enrolment...4

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RSBY scheme? Yes ……..1 No……...2 G.11.3

At work at the time of enrolment……..3; Was not well on the day of enrolment....5; Name not on the BPL list ……..…..8Did not know that name needed to show up ..10Not required ( person is healthy enough) ..12Passed away …………………........ 14

Not eligible by relationship ……….6Name is not on the ration card …….7; Refused by enrolment team …………..9 Was not at home at the time of enrolment .11 Married …………………………………. 13 Others (specify) ………………………..-777

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SECTION H: MEDICAL TREATMENT (inpatient/outpatient)Interviewer: Ask respondent who in their family needed outpatient services in the last 30days. (explain properly what OPD is- that they were not hospitalized but had consulted the doctor, chemist, quack, local vaidya, and had bought medicine/ paid consultation fee etc.)H.1. Particulars of medical treatment received as Outpatient during the last 30 days H.1.1 sr1. no. of the OPD case 1 2 3 4 5H.1.2 Name & srl. no. of member (as

in col. 1, block 4/5) hospitalised

H.1.3 Age (years) (as in col. 5, block 4 / col. 4, block 5)

H.1.4 Date of First Visit

H.1.5 Number of visitsH.1.6 Total Expenditure during the

OPD visit (in Rs.) H.1.7 Medicine (in Rs.)H.1.8 Diagnostic test (in Rs.)H.1.9 Transportation (in Rs.)H.1.10 Whether the person was

Covered by RSBY?(Yes -1, No 2)

H.2a: Maternity experience Last Pregnancy

Next to Last Pregnancy

Second from Last pregnancy

H.2a.1 Who in your family got pregnant in the last 5 years? (starting with the most recent ones) ( continue with the same lady if she has successive birth histories otherwise switch to another) Noone H.3 H.2a.2 Member id from roster

H.2a.3 Date of Birth If dead ………………….. 88 H.2a.6 H.2a.5 What is the present age of child born? Living …..1, dead……. 2

H.2a.6 Where did birth take Home…………………………1 Govt/Munic Hospital………….2GovtDispensary………………..3 PHC/CHC………………..….…4Sub- Centre…………..…….….5 Anganwadi Centre………..….6

place?Village clinic at ANM…….….7 Other Public Health Facility..8NGO/Trust Hospital…………………9Pvt Hosp/Maternity Home……..….10Other private……………………..…11Other………………….………..…..999

H.2a.7 If the delivery did not take Costs too much……………..…1 Facility not open………….....2No nearby centre………….…...3 Don’t trust facility/ Poor Service…………...4

place in a health facility then what was the reason?No Female Provider at Service….5Husband/ Family did not allow……6Not Necessary……… …..……..…..7Not Customary……………………..8Other……… …(Specify) 999

33

Ask respondent about all hospitalization cases in the family in the last two years ( including maternity hospitalization)H.2. Particulars of medical treatment received as Inpatient of a hospital during the last two yearsH.2.1 sr1. no. of the hospitalisation case 1 2 3 4 5H.2.2 Name & srl. no. of member (as in col. 1, block 4/5)

hospitalisedH.2.3 Type of hospital: Public hospital(PHC/sub centres/CHC).1,

public dispensary(incl. CGHS/ESI) ……….2, private hospital………..3Add hospital name

H.2.4 When was patient admitted? (month/ year)H.2.5 Duration of stay in hospital (days)H.2.6 Whether patient was hospitalized using RSBY card? (Yes -

1, No 2)H.2.7 If no, why not?

Name not on RSBY card……………………………………….1; Name is there but it was an emergency ……………………. 2; Bad experience with RSBY ……………………….…………..3 ; Neighbors had bad experience with RSBY……..…………. 4No nearby hospital …………………………………………... 5 ; Card didn’t work in hospital ………………………….…….6No balance in the card ………………………………………7 ; Hospital refused ………………………….…..………………. 8this disease was not covered………….…………………..…9; didn’t know disease was covered………………………..….10 Others ……(specify..…….999

H.3 Details of medical services receivedH.3.1 srl. no. of the hospitalization caseH.3.2 Name and srl. no. of member hospitalized H.3.3 Why this particular hospital was chosen for treatment?Close to home…..…1,Reputation is good..2,Suggested by the relative/ friends…...3, Referred by doctors….4, Always go to this hospital……5, there is no other RSBY empanelled hospitals nearby…6, Other( specify)....999H.3.4 Did surgery take place? Yes … 1 No …….2

H.3.5 Did patient take medicine ?Yes … 1 No …….2

H.3.6 Were X-ray/ECG/EEG/Scan/ Diagnostic tests conducted?Yes … 1 No …….2H.3.7 Whether treatment availed before hospitalisation? Yes … 1 No …….2H.3.8 If yes above, what is source of treatment public hospital (incl. PHC/ sub-centres/CHC)…..… 1, public dispensary (incl. CGHS/ESI)………….2, private hospital ……….. 3, private doctor …..…… 4 H.3.9 Whether treatment continued after discharge from hospital ? Yes … 1 No …….2H.3.9a What was the source of treatment?Public hospital (incl. PHC/ sub-centres/CHC)…..… 1, public dispensary (incl. CGHS/ESI)…..….2,private hospital …… 3, private doctor …..…… 4H.3.9b Duration of treatment

H.3.10 Did you buy medicine on your own? Yes … 1 No …….2H.3.11 If yes, how much did you spend on medicine?(in Rs.)

H.3.12 Did you spend anything for getting diagnostic tests done? Yes … 1 No …….2H.3.13 If yes, how much? (in Rs.)H.3.14 Any other amount that is incurred on this health event besides medicine and tests? (in Rs.) (mention the cause also)H.3.15 What is the total cost incurred by the household for this health event? (in Rs.)H.3.16 What was the source of this expenditure? Household savings/ income ..1

Contribution from friends/relatives ………2Borrowings……….. 3

Sale of assets/ ornaments…. 4H.3.17 Received any reimbursement (Rs) from any source such as government, employer, insurance company, or other agencies?Yes …1 , No …….2

H.4: TransportationH.4.1 How far is the hospital from your house (Approximately)?H.4.2 How did the patient go to the hospital?) Bus-1 Metro……….2 ; Rickshaw………3; Two wheeler…..4 Three wheeler……..5; Car……....6; Bus…………7 Others (please specify)-……………………..999H.4.3 What was the estimated cost to reach the hospital?H.4.4 Did the hospital reimburse the cost of transport? Yes ....1; No ......2H.4.5 How much was the reimbursement? (in Rs.)

H.5: Inpatient experienceH.5.1 Was there a separate RSBY help desk at the hospital or it was at the reception only?Yes ....1; No ......2H.5.2 How long did the patient have to wait before he/she was attended by the staff?Less than 15 minute-1; 15 to 30 minutes…….2,; 30 to 60 minutes……3; More than 60 minutes..4 Others, specify-……..999H.5.3 Was fingerprint verification done through a fingerprint scanner?Yes ....1; No ......2 H.5.4 Was the family told about the cost involved for treating the patient in advance?Yes ....1; No ......2 H.5.5 If yes, what was the cost?(in Rs.)H.5.6 Was the family told about the money left in the smart card? Yes ....1; No ......2 H.5.7 Was the money in the card sufficient to pay for this treatment? Yes ....1; No ......2 H.5.8 If the money in the card was not sufficient was the patient told that he would have to pay the difference? Yes ....1; No ......2 H.5.9 How much was the shortfall in the card from the package/ treatment rate? (in Rs.)H.5.10 How was the admission advised through?

Emergency……….1 ;OPD……….2; Referral…………3; Other (Please Specify)……………….-999H.5.11 Was the staff at the RSBY help-desk polite and helpful? Yes ....1; No ......2

H.5.13 Was the patient provided with food during stay at the hospital? Yes ....1; No ......2

H.6: DischargeH.6.1 On discharge was discharge summary provided to the family? Yes ....1; No ......2 H.6.2 Was the fingerprint verification done at the time of discharge? Yes ....1; No ......2 H.6.3 When did you get the RSBY card back?After swiping at the time of admission ........1 H.6.6On discharge ........2 H.6.6Next day......3;

two days later ......4Others specify).......................-999H.6.5 What was the reason for holding back the card? Staff wanted money for returning the card……...1 Staff wanted to keep the card till insurance claims were settled……….2; Staff said the card will stay deposited at the hospital …3Others, specify-………….999H.6.6 Were you told about the amount of money left in the card at the time of discharge?Yes ....1; No ......2 H.6.7 Do you know about 5 day post hospitalization expenses coverage in RSBY?Yes ....1; No ......2 H.6.8 Was the patient prescribed any medicines after the discharge? Yes ....1; No ......2 H.6.9 For how many days the medicines needed to be taken after discharge?H.6.10 Were these medicines provided by the hospital? Yes ....1; No ......2 H.6.11 These medicines were for how many days?H.6.12 Was the patient prescribed any tests after discharge? Yes ....1; No ......2 H.6.13 Within how many days

of discharge those tests were supposed to be done?H.6.14 Were facilities for those tests organized by the hospital free of cost?Yes ....1; No ......2 H.6.15 How is health of patient now comparing when he was admitted to the hospital?Has died …..1; No improvement ……2Partially improved …3; Has improved completely ….4H.6.17 Diagnosis

……………. ……………. ……………. …………….H.6.17aTreatment given …………….Medical ……………………Surgical ……………………..Duration of stay ……………If surgical ,surgery type …….If the investigator is unable to find specific answers please get a photocopy of the discharge summary

………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………

………………………………………………………………………………………………

………………………………

H.6.18 Was there a suggestion for follow-upYes ....1; No ......2

H.7 : Details of patients who died after receiving treatmentH.7.1 When did the patient die?During the Hospital Stay-1Immediately after discharge-2Within a week after discharge-3Within a fortnight-4Within a month-5Others, specify-999

H.7.2 Probable cause of death from hospital documents if any?…………………….No documents available-77

H.7.3 Did the patient receive any medical care before he/she died?

Yes ……………………..1 No … ………………..2 H.8: Patient SatisfactionH.8.1 Were all your patient related queries answered during your visit to hospital for treatment under RSBY?

Yes ……………………..1 No … ………………..2

H.8.2 How would you rate your satisfaction about the treatment provided at the hospital? Excellent-1 Very good-2 Good-3Average-4 Poor-5

H.8.3 Where would you have gone if scheme had not been there?To the same hospital……..1 To any other private hospital..2To government hospital……….3 Doctors private clinic………4 Nowhere………………….5Other ( specify) …………….999Don’t know ……….777

H.8.4 Were you forced to give money to any staff member?

Yes …………………..1 No … ………………..2 H.8.6

H.8.5 if yes, how much did you pay? (in Rs.)

H.8.6 Will you recommend your relatives/friends to take treatment

from the same hospital?Yes ……..1 section I

No … …………..2 H.8.7 If no Why?Treated badly-1Poor quality care-2Not receptive to RSBY patients-3There is no money in the RSBY card-4

Will you go back to the same hospital if the need arise again?YesNo

If no Why?Treated badly-1Poor quality care-2Not receptive to RSBY patients-3

I: RESPONDENT DETAILSI.1 Who answered the survey?

(INDICATE Household board number)Name _________________

I.2 Was there another respondent present during the interview?

Yes………………………………..1No…………………………………2 J

I.3 What is the name of this respondent?(INDICATE Household board number)

Name ______________________

Name not on the board……..990

SECTION J

THANK THE RESPONDENT FOR TAKING HIS TIME OUT FOR THE INTERVIEW.

MAKE SURE TO GET THE SIGNATURE ON THIS SHEET.

INTERVIEW ENDING TIME: HOURS MINUTES

COMMENTS

_______________________________________________________________________________

______________________________________________________________________________

Signature of the respondent___________________________

Economy & Finance

Rsby evaluation chhattisgarh rfp document updated 14th september 2011