Questionnaire

Household survey regarding the Health expenditure and

Health Insurance

Schedule A – Family details

1.1 Name of the panchayat or municipality

1.2 Name of the district
1.3 Name of the Taluk

1.4 Name of the respondent

1.5 Religion and caste of the household

1.6 Whether your family is APL /BPL?

1.7 Number of members in the family Male Female

1.8 Details of the family members

Relationship
Sl. Marital Educational Employment Monthly
Name with the Age Sex
No status status status income
respondent
1
2
3
4
5

1.9 Type of house

a) pucca b) semi pucca c) kucha

1.10 Ownership of house

a) Own b) Rented

1.11. How much land your family posses?

a) <10 cent b) 10-20 cent c) 21-30 cent d) 31-40 cent e) 41-50

cent f) >50 cent

1.12 Amenities of the family

a) News paper b) Electricity c) Telephone d) LPG e) Motor cycle f)

car g) TV h) fridge i) washing machine k) Mobile phone

1.13 Number of rooms in the house

a) one b) two c) three d) more than three

1.14 Sources of drinking water

a) own well b) public tap c) neighbor’s well d) other sources

1.15 Whether sanitary facilities are available in the house?

a) Yes b) No

1.16 Sources of energy used for lighting

a) Electricity b) kerosene oil c) others

1.17 Sources of energy used for cooking purpose

a) Firewood b) Kerosene oil c) Electricity d) LPG

1.18 Monthly income of the household

a) < Rs.10000 b) Rs. 10000-15000 c) Rs.15000-20000

d) > Rs.20000
1.19 Percapita income of the household

a) < Rs.2000 b) Rs. 2000-3000 c) Rs.3000-4000 d) > 4000

1.20. Monthly expenditure of the household

a) < Rs.6000 b) Rs.6000-8000 c) Rs.8000-10000 d) > Rs.10000

1.21 Consumption pattern of the family

Items Monthly expenses (in rupees)

Food

Stationery items

Clothing

Education

Health

Personal expenses

Others

Total

Schedule B- Personal data of the worker

2.1 Category of work

a) Agricuture b) Manufacturing and construction c) Service sector

2.2 Labour status

a) Casual b) Seasonal c) Contract d) Temporary e) Permanent

2.3 Place of work

a) Own house b) Fixed location c) Mobile work

2.4 Duration of the work

a) Specific time b) Not specific time

2.5 How much time do you work daily?

a) More than 8 hours b) 8 hours c) Less than 8 hours

2.6 At what time do you start work?

2.7 What is your present wage rate?

2.8 How is wage given?

a) Daily b) Monthly c) Weekly

2.9 Whether the earnings from your work are enough for the family?

a) Yes b) No

2.10 Are you aware of minimum wages Act implemented by the state?

a) Yes b) No

2.11 Does your income form a major portion of the family income?

a) Yes b) No

2.12 For what item do you spend most of your income?

a) Food b) Medicine c) Clothing d) Recreation e) Household

expenditure

2.13 Have you any savings?

a) Yes b) No

2.14 If so, how much do you save per week/ month?

2.15 Mode of savings

a) Post office b) Chit funds c) Bank d) Gold

2.16 Do you have to borrow from others?

a) Yes b) No

2.17 If so, how much?

2.18 Sources of borrowing

a) Money lenders b) Bank c) Friends and neighbors

d) lease of gold or other assets

2.19 Purpose of borrowing

a) To meet consumption expenditure b) to meet educational

expenditure c) to meet health expenditure d) To construct house or
purchase home appliances.

2.20 Do you smoke?

a) Yes b) No

2.21 On an average, how many times do you smoke per day?

2.22 Do you drink alcohol?

a) Yes b) No

2.23 Average amount of money spent for alcohol, drugs and similar items
per month

a) Below 500 b) 500-1000 c) 1000-1500 d) 1500-2000 e) Above

2000
Schedule C–Health status of workers

3.1 Do you have any health problems?

a) Yes b) No

3.2 If so, state the nature

Fever, cold/ cough, Head ache, Tooth ache, Diarrhea, Skin disease,
Body pain, Fracture, Chest pain, Asthma, Bronchitis, Typhoid,
Cholera, Gyneac problems, Heart diseases, B P problems, Diabetes,
Knee/ Joint pain, Back / Neck pain, Chronic diseases (TB, Cancer
etc), any other diseases.

3.3 Do you consider it as due to the nature of the work?

a) Yes b) No

3.4 How long do you suffer from these problems?

3.5 Frequency of health problems

a) Regularly b) Weekly c) Monthly d) Rarely

3.6 Are you taking medicine? (Yes or No)

3.7 If yes, which type of medicine is used?

a) Allopathy b) Homeopathy c) Ayurveda

3.8 Type of hospital in which treatment is taken

a) Private b) Government

3.9 Why do you select government hospital?

a) Less distance b) Lesser finance c) Proper diagnosis d) Free

medicine e) Better treatment
3.10 Whether sufficient staff is provided at the government medical centre?

a) Yes b) No

3.11 Whether adequate medicines are available at the nearest Health centre?

a) Yes b) No

3.12 If no, from where do you get the medicine?

a) From nearest town b) go to other hospitals

3.13 Why do you select private hospitals?

a) Less distance b) Better care and treatment c) Proper diagnosis

d) Better facilities of private hospitals

3.14 Are you satisfied with the services rendered by the private hospitals?

a) Yes b) No

3.15 In your opinion, which hospital provide the better services?

a) Private b) Public

3.16 Are you hospitalized during the last year?

a) Yes b) No

3.17 If yes, for how many days?

3.18 Have you postponed medical treatment at the time of illness at any
time during the last year?

a) Yes b) No
3.19 If yes, state the reasons for postponement of medical treatment

a) Lack of money b) Lack of time c) Lack of medical facilities d)

any other reasons

3.20. How much amount of money is spent for medical treatment during
the last year?

Item Cost (in rupees)

practitioners fees and medicines
surgery and hospitalization
diagnostic test
Transport cost
Total

3.21 Number of working days lost due to illness for your family members
during the last year?

3.22 Amount of money lost due to loss of working days for you and your
family members?

3.23 Have you spent money for special diet or any other items related to
the diseases?

a) Yes b) No

3.24 If yes, how much amount is spent?

3.25 Amount of money spend for health care in a year?

3.26 Whether health expenditure seriously affect your consumption

pattern and other day to day expenditure?

a) Yes b) No
3.27 If yes, give the details

3.28 How do you get money to pay for medical treatment?

a) Cash at hand / savings b) Money lenders c) Selling of Jewellery or

Assets or Land d) Selling of Livestock e) Borrowing from friends or
neighbors f) Other sources

3.29 Whether you feel that health expenditure is really a burden to your
family?

a) Yes b) No

Schedule D-Health insurance of workers

4.1 Do you know about any health insurance scheme?

a) Yes b) No

4.2 Have you joined in any health insurance scheme?

a) Yes b) No

4.3 If yes, state the name of the scheme

4.4 State the premium per month

4.5 Do you have perfect knowledge about the provisions and benefits of
the insurance scheme?

a) Yes b) No

4.6 Why did you join the insurance scheme?

a) High burden of health expenditure b) Less premium and high

benefit c) Other reasons
4.7 Did you obtain any benefit from the health insurance scheme during
the last year?

a) Yes b) No

4.8 If yes, state the mode of benefits

4.9 How much of the medical expenditure is covered by the insurance

benefits?

4.10 Do you know about RSBY/CHIS Scheme?

a) Yes b) No

4.11 Have you joined the scheme?

a) Yes b) No

4.12 Have you get smart card?

a) Yes b) No

4.13 What is your opinion about this insurance scheme?

4.14 Why are you not joining any health insurance scheme?

a) Lack of money for premium payment b) Lack of interest c) Lack

of knowledge about the scheme e) Any other reasons

4.15 Are you a member of any welfare board?

a) Yes b) No

4.16 If yes, date of joining the scheme?

4.17 What is your monthly contribution for the scheme?

4.18 Did you get any benefit from the welfare board during the last year?

a) Yes b) No

4.19 If yes, state the nature of benefit