Rsby evaluation chhattisgarh rfp document updated 14th september 2011

RFP DOCUMENT

State Level Evaluation
Study of “Rastriya Swasthya Bima Yojana”
Chhattisgarh

State Nodal Agency RSBY Chhattisgarh
Department of Health and Family Welfare
Government of Chhattisgarh
Raipur

Issued / Released on 14th of September 2011

RFP for evaluation of RSBY in Chhattisgarh 1

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

Government of Chhattisgarh
Raipur

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 DHFW
Chhattisgarh 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. Financial
bids 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 17.10.2011
Opening 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-492001
Email: rsbycg@gmail.com 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 18
districts.

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 November
then 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 Chhattisgarh
Department of Health and Family Welfare,
2nd Floor, Directorate of Health Services, Old
Nursing Hostel, Raipur, Chhattisgarh. Email: rsbycg@gmail.com
Phone: 0711-4255948, 4225196
2 The physical submission of the technical bid document address is:

State Nodal Agency, RSBY Chhattisgarh
Department of Health and Family Welfare,
2nd Floor, Directorate of Health Services, Old
Nursing Hostel, Raipur, Chhattisgarh. Email: rsbycg@gmail.com
Phone: 0711-4255948, 4225196

Proposals must be submitted not later than the following date and time 6 pm of 17th October
2011
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 Name & Completion Duration Value Name of
the Address time/date of (Rs. Sample
research of Client (Month & the Lakh) State (s) As
project Year) project per
completion TOR/
(in Months) Agreements
Actual

House Hold survey
1
2
3
4
Health Survey
1
2

Government survey
1
2

B.1: Completed research project (s) (Extra-sheet may be used if activities are more than 5 in number)
B.2: On-going research projects
Sr. Title of the Name & Project Project Name of
No. research Address starting completion Value Sample
project of Client date/time time as (Rs. State (s)
(Month & per Lakh)
Year) ToR/
Agreement
(in
Months)
1
2
3
4
5

C: HUMAN RESOURCE
C. 1 Human Resources of the organization: (attach CVs)
Sr. Official Station Professional/Technical Supporting Staff All
No. (Name of place) (Numbers) (Numbers)

Fulltime Part-time Fulltime Part-time

1
2
3
4

C2: To be deployed for the proposed study/project
(a)- KEY PROFESSIONALS ** (attach CVs)
Sr. No. Highest Length of No. of man (Team
Name Area academic/ experience months Leader)
of key professional (years) in deployed for
expertise qualification the this study
in the area of key
area of key expertise
expertise
1
2
3
4
5


** 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 No. of personnel
entry operator, analyst, etc.) Total number of man months to be
deployed.
1
2
3
4
5

Format for Team Composition
1. Professional Staff

Name of Staff Firm Area of Position Assigned Task Assigned
Expertise

2. Support Staff

Name of Staff Firm Area of Position Assigned Task Assigned
Expertise

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 Bid
Annexure-3

Evaluation of Rastriya Swasthya Bima Yojana (RSBY) Chhattisgarh State in
Division of :……………………………………………
(use separate sheet for each division)

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

FINANCIAL BID
Sr. No. Head Total Cost (Rs.)

1 Salary of key professionals
2 Salary of field staff and support staff
3 Travel for key person
4 Travel for Field & Secretariat staff
5 Contingent expenses
6 Office expenses**
7 Total (1+2+3+4+5+6)
8 Institutional Overheads if any, and basis of charge
9 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

Bidder Bidder Name No. of Separate
No. Documents¹
Including
Annexes
1
2
3
4
5
6

1. Essential Criteria

No. Criteria
1.  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
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

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 marks
2. 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 marks
b. Work plan-5 marks
c. Organization and staffing-10 marks
3. Key professional staff qualifications and
competence for the assignment
a. Team Leader-10 marks
b. Other Key Members-10 mark
4. Suitability of training program -10 marks
a. Relevance of training program -5 marks
b. 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.


Annexure 5
RSBY QUESTIONNAIRE
Post-enrolment Survey of the RSBY Programme
A 0 : CONSENT TO PARTICIPATE IN INTERVIEW
Household 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…………..1
Haryana…………..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 ………….…1
RSBY hospitalized household …………….2
Non RSBY household …………………….3

3. Date of visit: Day Month Year
4. Interview starting time: Hours Minutes

19

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.1 B.2. B.3. B.4. B.5. B.6. B.7. B.8. B.9 B.10 Is name member of the following?
Me Name Relati Age sex Marita level main Presen If no, Y …………1, N ………..2
mbe Enter the names onship If M.1 l status of occup tly why B.11 B.12 B.13 B.14 B.15
r ID starting with the with less F..2 educ ation living not BPL Ration RSBY NREG No. of
household head the than (use ation of ID? in the (use card card days
head one code) attain (use house code) worked
(use year ed codes) Y….1 in
codes) write (use N ….2 NREG(l
zero code) ast year)

Relationship Codes Marital status Education Codes Occupational Codes Presently not living
reasons
Head …………
1
Spouse ……… Upto class 1 ………... 1
2
Father ……….. Upto class2 ………… 2 Farming ………………………… 1
3
Mother ………. Upto class 3 ………… 3 Livestock Rearing……………………… 2
4
Son ………… Upto class 4 ………… 4 Salaried Job ……………………………. 3 Living separately
5 Married ……... 1
Daughter …… Upto class 5…………. 5 Currently not working ………………… 4 in the same
6 Divorced ……. 2
Brother Upto class 6…………. 6 Enrolled full time in School/Madrassa .. 5 village ………. 1
7 Separated …… 3
Sister Upto class 7 ………… 7 Self Employed/ Trader ………………… 6 Moved to some
8 Widowed ……. 4
Father in law Upto class 8 ………… 8 Employed Skilled Laborer …………….. 7 other 2
9 Never Married. 5
Mother in law Upto class 9 ………... 9 Employed Unskilled Laborer ………….. 8 village/town …... 3
10
Grand son Upto class 10 ………. 10 Too young to work …………………….. 9 Passed away ….. 4
11
Grand daughter Upto class 11 ………. 11 Housewife/Housekeeping ……………… 10 Got married …..
12
Grand father Upto class 12 ………. 12 Too Old to work ……………………….. 11 Name was never
13
Grand mother Graduate and above ../ 13 Enrolled full time in College ………….. 12 the part of this 5
14
Brother in law Other diploma …….. 14 Other (Specify) ………………………… 13 family …….. ,…
15
Sister in law Never attended school 15 Does not work …………………………. 14
16
Other (Specify) Nursery ……………. 16 Don’t know …………………………… 999
17
Daughter-in- Don’t know ……….. 999
18
law

20

SECTION C. HOUSEHOLD CHARACTERISTICS

C.1

C.2

C.3 Do you rent or own the house you live Rent…………………….1
in? Own…………………….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 - 2
Covered pucca - 3, Under ground – 4;
No drainage - 5
C.9 Does the family own any cultivable Yes……………………1
land? No…………………….2  C.12
(in the native village) Does Not Know........-999  C.12

C.10 What is the total area of cultivable land? ________Acres..........................1
________Bighas........................2
________Biswa .........................3
Does Not Know……………-999
C.11 What is main source of drinking water Piped water
for members of your household? Piped into residence/yard/plot…..…1
Public tap……………………..…....2
Public hand pump………………....3
Hand pump in residence/yard/plot ..4
Well water
Covered well in residence/yard/plot..5
Open private well…………………..6
Covered public well………………7
Open public well………………….8
Surface water……………………..9
Spring water……………………….10
Pond/Lake…………………………11
Dam……………………………….12

21

Rainwater…………………………13
Tanker truck………………………14
Other (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 Ultra-violet/resin/reverse osmosis – 1,
(code) Boiling – 2, Filter – 3, Cloth – 4,
Any disinfectant – 5, Others – 777

SECTION D: INCOME AND BORROWINGS

D.1 Who of the household Nobody………………….1  D.2
members worked and Last month(in Last year(in Rs.) no. of days worked No. of hours
how much did each ID
Rs.) in a month worked a day
member earn ?
(INDICATE
HOUSEHOLD BOARD
NUMBER)

D.2 Is there any other source Yes……………….1
of income for the No………………..2  D.4
family? (eg. Pension, Don’t know….-999  D.4
rent, remittances etc. ) Will not answer…….-888  D.4
D.3 If yes, how much did Income
Source
you get from that source
…………………………
last month?
………………………..
D.4 In last one year have you Yes……………….1  give details
borrowed from No………………..2  section E
somewhere for some Don’t know….-999  section E
purpose? Will not answer…….-888  section E
D5 Details of borrowings Amount Source of borrowing (see codes below) Reason of borrowing (see codes below)
Sr No. borrowed
1 , ,
2 , ,
3 , ,
4 , ,

22

Source of borrowing Reason of borrowing

From friends and family without interest……..1 Start a new business…………….……...1
From friends and family with interest……..2 Acquire agricultural machinery or agricultural inputs …….…2
From moneylender...3 Purchase stock for existing business………………………….…3
From bank………....4 Repay old debt………………………..4
From MFI………….5 For health related expenses..………………………….….5
From chit funds…….6 Marriage…………………..…………….6
From other financial institutions……….7 Funeral………………..………………7
From NGO……..…..8 Festival/Other Ceremony.........................8
From SHG……..…..9 Houseold consumption/Purchase household durable…..……….9
Others (specify)… - 777 Home improvement/repair/construction….10
Don’t know……-999; Unemployment……………..………...11
Will not answer……..-888 Purchase land………………..……….12
Education…………………………..…13
Purchase jewelry…….………………14
Buy livestock…………………...…….15
Other (specify)… ……………….…-777
___________________________
Don’t know…………………..-999

23

SECTION D.1: HOUSEHOLDS SOCIAL NETWORK

Is anyone in the family presently a SHG ………………………. 1
D.1.1 member of any of the following? cooperative ………… ……...2 , ,
(multiple answers possible) trade union ………….…..3
NGO/MFI client ……….… 4 , ,
village committees (e.g. VEC; ICDS) …...... 5 ,
political party ……………… 6
religious organization …..…..7
RWA (urban areas) …….…8
other membership-based organization ……. 9
No ……………………….. 22
Don’t know ……………...-999
Do you or your family members Yes...........................…..........1
D.1.2 personally know the sarpanch/ nigam No ..........................…...........2
parishad/ MLA or any ward member for Don’t Know...........…......-999
your gram panchayat ? .

D.1.3

What is your main source of information friends and family ….…..1
D.1.4 about government programs ? media (print, visual or audio) ...2 , ,
local panchayat workers/officials…….…….3
administration officials ……..4 , ,
religious leaders ……………..5
MLA ………………………6
Local NGO ………………… 7
other______ (specify) ……-777
How often does any member of your Every week..1
D.1.5 family travel to - At least Once a month,,,,2 1.
1. block HQ At least once a quarter….3
2. district HQ At least once in Year…..4
Never………………….5 2.

24

SECTION F: F.1 HOUSEHOLD HEALTH (FOR ALL INDIVIDUALS FROM HOUSEHOLD
BOARD)
(INTERVIEWER: SHOW THE LADDER TO THE RESPONDENT WHERE EVER REQUIRED)
F.1.1 F.1.3 F.1.4 F.1.5 Is
ID codes . Is he/she If yes, he/she
facing any describe taking
recurrent the medicines
medical condition? regularly
problem that for this
has lasted for problem?
more than one Yes….1
month? No…..2
Yes….1 Don’t
No…..2  know….-
F.1.6 999
Don’t know….-
99 F.1.6

25

F.2 HOUSEHOLD HEALTH EVENT AND HOSPITALISATION

F.2.1 Does any of your family member has some health Yes………………………………….1
related problem that may need hospitalization in No…………………………………..2 F.2.3
the next 6 months? Will Not Answer……..……….…-888 F.2.3
Does Not Know…………………-999 F.2.3
F.2.2 Who you think would require hospitalization and HH board no
for what?
………………
………………..
…………………………….
F.2.3 Was anyone in your family very sick or severely Yes………………………………….1
injured in the last two years? No…………………………………..2 F.3
Does Not Know…………………-999 F.3

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

F.3 DESCRIPTION OF HEALTH EVENTS
Interviewer: ask the respondent if any one in the household suffered from major health event in last two
years. Fill the details of all the members of the household who had/ are having major health event in
following table:
F.3.1. ID F.3.2. F.3.4.How serious was this F.3.5. F.3.6. F.3.7. F.3.8 F.3.9 F.3.10 How
codes of What was the health event / condition? For how long did Is he/she still Was [name] Which type Did [name] have many days
those who major health Caused death…1 F.3.7 this health event / taking a hospitalized as a of hospital surgery as a the [name]
had major event that Caused permanent inability to condition cause a treatment for result of this was [name] result of this was admitted
health event [name] perform normal daily temporary this condition? major health admitted? major health to the
suffered? activities….2 F.3.6 inability OR Yes…..1 event? Governmen event? hospital for
Disease….1 Caused temporary inconvenience to N…....2 Yes…...1 t……1 Yes….......1 more than 24
Accident..2 inability to perform perform normal Don’t know....- No….….2 Don’t Private…2 No…….2 hrs?
Complicated normal daily daily activities? 999 know....- Don’t Don’t know
birth….3 activities……….…3 Days ….1 999 know…- …….-999
Other-specify Caused no inability to perform Weeks…2 999
…-777 normal daily Months ..3
Don’t know.999 activities, but was an Don’t know....-999
Can’t say..-555 inconvenience……4
No inability was
caused…....5 F.3.6
Don’t know....-999 F.3.6

F.3a Has it ever happened that a very serious illness/death could Yes..............................……....................1
not be treated at hospital because of lack of money? No ...............................……..................2 F.4
Don’t Know........……..……............-999
F.3b Mention the member Id of that person from the above table

26

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

F.4.1 Do you or anyone in the family smoke? __ F.4.2 Indicate number of cigarettes smoked per
day:
Yes.....................................1 (1-9) ……………………..…… 1
No ....................................2  F.4.3 (10-19) …………………….…. 2
(20-29) ……………………….. 3
(30 OR MORE) ….……….… 4
F.4.3 Do you drink alcoholic beverages? F.4.4 How would you rate your consumption?
Yes................................1 Daily ………………1
No ................................2  F.4.5 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? F.4.6 Have your kids got any other vaccination?
Yes.....................................1 Yes.....................................1
No ....................…..............2 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.5.2 Where did you get to know about
G.5.1 Are you aware of RSBY scheme? the scheme?
Yes ……………………………..1 Through friends / neighbours ……….…1
No … …………………………..2  Through Radio / TV / newspaper ..........2
SECTION H Through leaflets/brochure ………..….…3
Through Health Staff ………………...…4
Area Committee members/ Community
Educators.... 5
Panchayat………………….6
Ration shop keeper ……………………..7
NGO personnel ..................................... 8
Survey people ........................................9
Others (specify) ……………….…..-777
G.5.3 Do you know who is eligible for the scheme? G.5.4 Is your family eligible for the
Everyone…………………1 scheme?
Only BPL families ………….2 Yes ………………………..1
Only AAY families ……………3 No … ……………………..2
Only NREGA card holders ……4 Don’t know …………..-..999
Others(specify) ....................-777
Don’t know …………...-999
G.5.5 How much does it cost to enroll in this G.5.6 What is the maximum amount per
scheme? ( in Rs.) year that can be spent? ( in Rs.)
Zero ………………0 Don’t know………………….-999
Rs 30..................................30
Others (specify) ...............-777
Don’t know……………….-999
G.5.7 Is free treatment provided in the hospitals G.5.8 Are transportation allowances
under this scheme? provided to the patient?
Yes ……………………..1 Yes ………………………..1
No … ……………………..2 No … ………………………..2

27

Don’t know …………………-999 Don’t know ………….…-999
G.5.9 Do you have to pay for the medical tests G.5.10 Do you have to pay for medicines
during hospitalisation if you enroll in this and drugs in case of hospitalisation if you
scheme? enrol in this scheme?
Yes …………………..1 Yes …………………..1
No … ……………………..2 No ………………..2
Don’t know ……….……-999 Don’t know……………..-..999
G.5.11 How many household members can be G.5.12 Which year did enrolment take
enrolled? place? (multiple answers possible)
At most 5 members …..1 2008 ……………1
All household members ………2 2009 ……………………2
Others (specify) …………. -777 2010 …………………………………3
Don’t know ……………….-999
Don’t know……………-999
G.6 Which year did you apply to obtain the card? G.7 Why didn’t you apply? (multiple , ,
2008…………....1  G.7.2 answers possible)
2009… ………..2  G.7.1 Booth too far away……….…......….1 , ,
2010 It’s of no use. ………….......…….2
Both (2008 & 2009)....3  G.7.3 Get similar facilities in government
Didn’t apply at all ......... 4  G.7 hospitals.............3
Didn’t find any hospital in the list which
is closer to my place..….4
Distrust in scheme……………...5
Did not have proper documents to support
family’s identity…......6
Did not feel comfortable with the
technology involved (eg. Use of smart
cards)…….... ...7
Didn’t understand the scheme……...8
Not eligible for the scheme ............ 9
Others (specify) .........................-777
 Section H
G.7.1 Why didn’t you apply in the first round? , G.7.2 why didn’t you reapply? , ,
Booth too far away……….…...............................….1 Booth too far away……….…......….1
Didn’t know about the scheme at that time............ 2 , Didn’t get to know about enrolments......2 , ,
Didn’t get to know about enrolments .. ............... 3 , Had bad experience with hospital ..........3
Didn’t find any hospital in the list which is closer to Was not satisfied in first round .............5
my place..........................................................….4 , Didn’t get chance to use card in first
Did not have proper documents to support family’s round .....................................................6
identity…..............................................................5 Didn’t find any hospital in the list which
Didn’t understand the scheme…......................…...6 is closer to my place this time.............7
Name on on the list ............................. 8

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

28

G.8 For those who applied
G.8.1 Was any list of eligible families G.8.2 When did enrolment happen?
publicly displayed before enrolment began?
Yes …………………………..1 Don’t know …………..999
No … …………………..2
Don’t know ……………-999
G.8.4 How much time did it take to reach G.8.5 How far was the enrollment
enrolment station? station from your house? (in kms)
5-10 mins …………………1 within 2 km ……………1
10-20 mins …………………..2 2-5 kms …………...2
20-30 mins ……….…….……3 5-8kms ……………3
>30 mins …………………4 more than 8 kms ………….4
Don’t know …………..…-999 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..................................... 1 From district/ block officials...... 8
From Word of mouth.............. 2 From Loudspeaker announcement......9
From NGO personnel............. 3 From Wall writings.......... 10
From Sarpanch....................... 4 From Nukkad natak ......... 11
From ANMs...........................5 From Aanganwadi Worker... 12
From AWWs ........................6 Others (pl. specify) .......... 999
From ASHA.........................7
G.9 Did you obtain the RSBY card? G.9.1 Why didn’t you obtain it? ?
Round 1. ........................................... (multiple answers possible)
Round 2 …………………………….. First round . , , ,
Yes ……………….1  Section G.10 Second round
No … …………...2  G.9.1 Household head died …….……….1 , , ,
Household not on the BPL list ……2
Didn’t have required documents ….3
Wait was too long …………………4
Were asked to come again …………5
Refused without any reason ………6
There were problems at enrolment
station…………...7
Didn’t apply ................. 8
Other ( specify ) …………………999

 Section H

29

G.10 For RSBY card holders
G.10.1 PLEASE SHOW YOUR RSBY G.10.2 What problems did you face in
CARD. obtaining the card?
Showed it………….….….….1 ( Add extra sheets if required)
Did not want to show……..….2
Lost it………………..…………3
Someone has taken it (is with some one) .…4
Its with hospital ..………………5
Other (specify)…………….…-777
G.10.3 How many members of the family G.10.4 How long did it take you to complete
are covered? the whole enrolment process?
Less than one hour ………….1
1-2 hours …………………2
2-4 hours………….……….3
4-6 hours ………………….4
more than a day ……….…..5

G.10.5 Did you get smart card on the spot? G.10.8 Did you make any payments to get
Yes …………………………..1 hold of it?
No … ………………………..2
Zero …………………0
Rupees 30 ..................30
Don’t know.……….-999

G.10.7 Which of the following pieces of G.10.6 Were you told about the date when
information did you get along with the card? , , you could start using the smart card?
List of hospitals………………..1 Yes …. 1 No …. 2
How to use the card………….….2 ,
Who to contact in case of any query…..3
Information about district kiosk .......... 4
Didn’t get any ..................................... 5
Other (specify)……………………-777
G.10.8 Which is the nearest RSBY G.10.9 Are you satisfied with the scheme?
empanelled hospital? Yes ……………………………..1
_________ No … …………………………..2
Don’t know ...................-999

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

G.11 INDIVIDUAL ENROLMENT
G.11.1 G.11.2Is ID G.11.3 If no, why not? At school at the time of enrolment…..2
ID enrolled in Five person limit …………….…..1; Out of village at the time of enrolment...4

30

RSBY At work at the time of enrolment……..3; Not eligible by relationship ……….6
scheme? Was not well on the day of enrolment....5; Name is not on the ration card …….7;
Yes ……..1 Name not on the BPL list ……..…..8 Refused by enrolment team …………..9
No……...2 Did not know that name needed to show up ..10 Was not at home at the time of enrolment .11
 G.11.3 Not required ( person is healthy enough) ..12 Married …………………………………. 13
Passed away …………………........ 14 Others (specify) ………………………..-777

31

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 5
H.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 visits
H.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 Next to Last Second from
Pregnancy Pregnancy 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 place?
Home…………………………1 Village clinic at ANM…….….7
Govt/Munic Hospital………….2 Other Public Health Facility..8
GovtDispensary………………..3 NGO/Trust
PHC/CHC………………..….…4 Hospital…………………9
Sub- Centre…………..…….….5 Pvt Hosp/Maternity
Anganwadi Centre………..….6 Home……..….10
Other
private……………………..…11
Other………………….………..…..999
H.2a.7 If the delivery did not place in a health facility then what
take was the reason?
Costs too much……………..…1 No Female Provider at Service….5
Facility not open………….....2 Husband/ Family did not allow……6
No nearby centre………….…...3 Not Necessary……… …..……..…..7
Don’t trust facility/ Poor Not Customary……………………..8
Service…………...4 Other……… …(Specify) 999

32

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 years
H.2.1 sr1. no. of the hospitalisation case 1 2 3 4 5
H.2.2 Name & srl. no. of member (as in col. 1, block 4/5)
hospitalised
H.2.3 Type of hospital: Public hospital(PHC/sub centres/CHC).1,
public dispensary(incl. CGHS/ESI) ……….2,
private hospital………..3
Add 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……..…………. 4
No nearby hospital …………………………………………... 5 ;
Card didn’t work in hospital ………………………….…….6
No balance in the card ………………………………………7 ;
Hospital refused ………………………….…..………………. 8
this disease was not covered………….…………………..…9;
didn’t know disease was covered………………………..….10
Others ……(specify..…….999

33

H.3 Details of medical services
received
H.3.1 srl. no. of the
hospitalization case
H.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)....999
H.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 …….2
H.3.7 Whether treatment availed
before hospitalisation?
Yes … 1 No …….2
H.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 …….2
H.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 …..…… 4
H.3.9b Duration of treatment
H.3.10 Did you buy medicine
on your own?
Yes … 1 No …….2
H.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 …….2
H.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 ………2
Borrowings……….. 3
Sale of assets/ ornaments…. 4
H.3.17 Received any
reimbursement (Rs) from any
source such as government,
employer, insurance company, or
other agencies?
Yes …1 , No …….2

H.4: Transportation
H.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)-……………………..999
H.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 ......2
H.4.5 How much was the
reimbursement? (in Rs.)

H.5: Inpatient experience
H.5.1 Was there a separate
RSBY help desk at the hospital or
it was at the reception only?
Yes ....1; No ......2
H.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-
……..999
H.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)……………….-999
H.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: Discharge
H.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.6.6
On discharge ........2 H.6.6
Next day......3;
two days later ......4
Others specify).......................-999
H.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 …3
Others, specify-………….999
H.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 ……2
Partially improved …3; Has
improved completely ….4
H.6.17 Diagnosis
……………. ……………. ……………. …………….
H.6.17a ……………… ……………… ……………… ………………
Treatment 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-up
Yes ....1; No ......2

H.7 : Details of patients who died after receiving treatment
H.7.1 When did the patient die? H.7.2 Probable cause of death
During the Hospital Stay-1 from hospital documents if any?
Immediately after discharge-2 …………………….
Within a week after discharge-3 No documents available-77
Within a fortnight-4
Within a month-5
Others, specify-999
H.7.3 Did the patient receive any
medical care before he/she died?
Yes ……………………..1
No … ………………..2
H.8: Patient Satisfaction
H.8.1 Were all your patient H.8.2 How would you rate your
related queries answered during satisfaction about the treatment
your visit to hospital for treatment provided at the hospital?
under RSBY? Excellent-1 Very good-2
Yes ……………………..1 Good-3
No … ………………..2 Average-4 Poor-5
H.8.3 Where would you have H.8.4 Were you forced to give
gone if scheme had not been money to any staff member?
there? Yes …………………..1
To the same hospital……..1 No … ………………..2
To any other private hospital..2 H.8.6
To government hospital……….3
Doctors private clinic………4
Nowhere………………….5
Other ( specify) …………….999
Don’t know ……….777
H.8.5 if yes, how much did you H.8.6 Will you recommend your
pay? (in Rs.) relatives/friends to take treatment

from the same hospital?
Yes ……..1 section I
No … …………..2
H.8.7 If no Why? Will you go back to the same
Treated badly-1 hospital if the need arise again?
Poor quality care-2 Yes
Not receptive to RSBY patients-3 No
There is no money in the RSBY
card-4
If no Why?
Treated badly-1
Poor quality care-2
Not receptive to RSBY patients-3

I: RESPONDENT DETAILS
I.1 Who answered the survey? Name
(INDICATE Household board number) _________________

I.2 Was there another respondent present Yes………………………………..1
during the interview? No…………………………………2 J
I.3 What is the name of this respondent? Name
(INDICATE Household board number)
______________________

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
___________________________

Rsby evaluation chhattisgarh rfp document updated 14th september 2011

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Rsby evaluation chhattisgarh rfp document updated 14th september 2011