Department of Humanities Bangladesh University of Engineering and Technology ID Number Research topic: Determinants of Healthcare Expenditure of the Households of Rickshaw Pullers: A Case Study in Dhaka City Instrument Category: Quantitative Survey Respondent type: Rickshaw Pullers in Dhaka City Scanned with CamScanner‘You can ask me if you have any further queries, (If the respondent has any questions, try to give appropriate answers) Can I start an interview now with your consent? Yo k 1. (go to the next question) No 2. (otherwise, stop asking questions) [Name of the interviewer Date of interview Q Date Month oO hy When to start the interview Hours Minute At the end of the interview 0 a © A! Hours Minute Section 1: Personal information of the information provider/interviewee/respondent and his/her household (HH) members Serial | Question Answer Code Skip Number i Name of the rickshaw [Exon mo \l& puller/respondent 12 12.1 Present address | Ward number 5°) City carperat uth k 122 Permanent | Upazila: copa gans sacax ; address District: GLOPUEAAN) 13 ‘Mobile _number/Phone | 6) (31 R06 ie number \ 14.1 What is the Lae a aa members/HH size? sso a Scanned with CamScanner14.2 What is the number of income generating/eaming HH members? Main Profession 15.1 Husband joke haw 15.2 Wife hount vibe 1.5.3 Father 1.5.4 Mother ho arAeeite 1.5.5 Child] = 1.5.6 Child 2 1.5.7 Others How many years do you pull rickshaw in} 25 Dhaka City? Do you live in Dhaka} City’ with your HH| |'Yen members? Age (in years) 1.8.1 Husband 18.2 Wife 1.8.3 Father = ey 1.8.4 Mother oF 18.5 Child a 1.8.6 Child 2 18.7 Others ‘Years of Schooling 1.9.1 Husband 1.9.2 Wife 1.9.3 Father 1.9.4 Mother 1.9.5 Child] = 1.9.6 Child 2 1.10.7 Others 1.10 Marital Status 1.10.1 Husband 1.10.2 Wife Scanned with CamScanner1.103 Father cna Married Separated, Widow Others 1.10.4 Mother Unniaiiied, Married Separated Widow Others 1105 Child Uanttgoed Married Separated Widow Others 1.10.6 Child 2 Unmarried Married Separated Widow Others 1.10.7 Others ‘Unmarried Married Separated Widow Others Section 2: Household Income and Wealth/Assets Status Serial | Question ‘Answer Code Skip Do you pull your own rickshaw? 2.2.1 How many hours you and your HH members work on average daily/each day? 2.2.1.1 Husband 2.2.1.2 Wife 2.2.1.3 Father 2.2.1.4 Mother Scanned with CamScanner2.2.2 How many days you and your HH members work on Average each week? 2.2.2.1 Husband 6 2.2.2.2 Wife. 2.2.2.3 Father 2.2.2.4 Mother 2.2.2.5 Child! 2.2.2.6 Child 2 2.2.2.7 Others 23.1 [Average Monthly income of HH members (Taka) 23.1.1 Husband 250°C 23.1.2 Wife 2.3.13 Father 23.1.4 Mother 23.1.5 Child) 2.3.1.6 Child 2 2.3.1.7 Others 232 ‘Average Monthly income of HH members (Taka) from other sources if any 2.3.2.1 Husband Bese: 23.2.2 Wife 2.3.2.3 Father 2.3.2.4 Mother 2.3.2.5 Child] 23.2.6 Child 2 2.3.2.7 Others 24 | Amount of wealth 2.4.1 What is the total value of your Homestead/home/house if} “7 (OOOO. sell it now? 2.4.2 What is the structure of Puget your house Semi-pucea Kucca 243 Do you have publicly Yes provided gas connection in Now your house 2.44 Do you have electricity 45 Do you have drinking supply in your house? Do you have sani in your house? Scanned with CamScanner2.4.7 Value of land other than house/home 29 00009 2.4.8 Value of omaments Ean 2.4.9 Value of rickshaw/Van if alba G §Oop 2.4.9 Value of other Assets paves! 25 25.1 Do your HH have any Yes savings? 2.5.2 If yes, what is the amount (Taka)? 2.53 Do your HH have any Yes loan? Now 2.5.4 If yes, what is the amount (Taka)? Section 3: Health Seeking Behavior of Household Members Serial Question Answer Code ‘Skip Number 3.1 Self Reported Health Status 3.11 Are youlyour HH members physically healthy? 3.1.1.1 Husband Very good 3.1.1.2 Wife Very good 3.1.1.3 Father Scanned with CamScanner3.1.5 Child) a 3.1.1.6 Child 2 3.17 Others Moderate Bad Very bad 32 32.1 Are” you/your HH members mentally healthy? 3.2.1.1 Husband Very good Good Moderate Bad Very bad 3.2.1.2 Wife Very good— Good Moderate Bad 3.2.13 Father 3.2.1.4 Mother3.2.1.7 Others Very good Good Moderate Bad Very bad 33 331 Did you and your HH Yes members suffer from any disease in the last year? we 3.3.2 If yes, then what type of ‘A. General illness/disease you illness (fever, experienced/suffered from in coughing, the last year? headache ete.) Chronic illness (minimum 1 Nae diabetes, heart disease or cardiovascul ar disease, TBetc) C. Maternity (pregnant in the last year, age 15-49) 2 1 Do you spend money for treatment when you become ill (willingness (0 pay)? b) No if Yes, what isthe highest amount of money you spent for a single visit tothe doctor in (he 2 £0? Take No, what are the reasons? center/hospital when you become ill? ©) Both you go to the ee it (Inpatient Department, IPD) or outpatient(Outpatient Scanned with CamScanner.4. » what of health center/hospital it is? % me ee 5 Private c)NGO based) Local pharmacy/Drug store _¢)Others 3.5.1 General illness (fever, coughing, headache etc.): Family members | Name of the | Number of sick | Number of days | Number of days diseases you | daysin the last _| stay in hospital in | absent in work and your year the last year | in the last year family due to illness suffered from 3.5.1.1 Husband 3.5.1.2 Wife 3.5.1.3 Father 3.5.1.4 Mother 3.5.15 Child! 3.5.1.6 Child 2 3.5.1.7 Others Total Number of days 3.5.2 Income lost due to illness as going to work was not possible in the last year: Family members | Number of days | _ Average daily Total income lost due to absent in work income (2) illness in the last year in the last year (1X2) due to illness (1) Scanned with CamScanner3.5.3 Number of visits to the health care center/hospital in the last year HH members Number of visits 3.5.3.1 Husband 3.5.3.2 Wife 3.5.3.3 Father 3.5.3.4 Mother 3.5.3.5 Child! 3.5.3.6 Child 2 3.5.3.7 Others Total Number of visits 3.5.4 Cost Estimation per visit Family User Medici | Test/Lab/ | Bed Fee Package | Distance | Transp Food | others members | fee/Cons | ne/ Diagnosis! fee e to | ortatio ultation | Drug Investigati Hospit | n cost fee/Adm on al/healt ission heare fee center from home Scanned with CamScanner3.6.1 Chronic illness (minimum 1 year: diabetes, heart disease or cardiovascular disease, TB etc.) Family members | Name of the | Number of sick | Number of days | Number of days diseases you | days in the last stay in hospital in | absent in work and your | year the last year in the last year family | due to illness suffered from 3.6.1.1 Husband a 3.6.1.2 Wife 3.6.1.3 Father s 3.6.1.4 Mother c 7 a rer 3.6.1.5 Child] 3.6.1.6 Child 2 3.6.1.7 Others Total Number of days 3.6.2 Income lost due to illness as going to work was not possible in the last year: Family members | Number of days | Average daily Total income lost due to absent in work | income (2) in the last year due to illness (1) in the last year (1X2) 3.6.2.1 Husband 3.6.2.2 Wife 3.6.2.3 Father 3.6.2.4 Mother 3.6.2.5 Child] 3.6.2.6 Child 2 3.62.7 Others Total Number of days ~ Scanned with CamScanner3.6.3 Number of visits to the health care center/hospital in the last year _3.6.3 Number of visits to the health care cet HH members. Number of visits. 3.6.3.1 Husband 3.6.3.2 Wife 3.6.3.3 Father 3.6.3.4 Mother 3.6.3.5 Child! 3.6.3.6 Child 2 3.6.3.7 Others Total Number of visits 3.6.4 Cost Estimation per visit Family [User | Medici | Test/Lab/_ | Bed Fee Package |Distanc | Transp |Food | others members | fee/Cons | ne! Diagnosis! fee eto | ortatio uitation | Drug | Investigati Hospit | n cost fee/Adm on al/healt ission heare fee center from home Scanned with CamScanner3.7.1 Maternity (pregnant in the last year, age 15-49) Family members | Name of the | Number of sick | Number of days | Number of days diseases you | _daysin the last | stay in hospi absent in work and your year the last year | in the last year family due to illness suffered from 3.7.1.1 Husband 3.7.1.2 Wife 3.7.13 Father 3.7.1.4 Mother 3.7.1.5 Child! 3.7.1.6 Child 2 3.7.1.7 Others Total Number of days 3.7.2 Income lost due to illness as going to work was not possible in the last year: Family members Number of days absent in work in the last year due to illness (1) ‘Average daily income (2) Total income lost due to illness in the last year (1X2) 3.7.2.1 Husband 3.7.2.2 Wife 3.7.2.3 Father 3.7.2.4 Mother 3.7.2.5 Child! 3.7.2.6 Child 2 3.7.2.7 Others Total Number of days 3.7.3 Number of visits to the health care center/hospi in the last year HH members Number of visits 3.7.3.1 Husband 3.7.3.2 Wife 3.7.3.3 Father 3.7.3.4 Mother 3.7.3.5 Child) 3.6 Child 2 3.7.3.7 Others [Total Number of visits Scanned with CamScanner ~3.7.4 Cost Estimation per visit Family [User | Medici Ged Fee | Package | Distanc | Transp [Food | others members | fee/Cons | ne! te eat lati) ultation | Drug Hospit | n cost fee/Adm al/healt ission heare fee center from 3.74.1 home Husband 3.742 ] Wife 3.7.43 Father 3.744 Mother 3.745 Child] 3.746 Child 2 3.74.7 Others Total cost 3.8 Cl Did your household female members take Antenatal care (three months interval (4 times)? Ayes B)No 3.9. Type of delivery Normal een section (C- section) Did your household female members take Postnatal care (three months interval (4 2 B) No | How much time do you spendineed to visit a doctor (starting from home until ing at homelwork)? 9). Usually do you drive rickshaw (on the other day) at the hours when you visit @ 15 Scanned with CamScannermuch time do you wait (waiting time) in the medical center/hospital to see the hysician? 2 Wo ur 3.13.1 Is there any cheap substitute health care fa Dispensary/medicine seller) available in the area where you live? a) Yes \DYNo c) Do not know fies (Kabiraj, Quack, 3.13.2.1 Do you visit there during the last one year? a) Yes b) No 3.13.2.2 If yes, how many times in a year (last year)? 3.14 Does any micro health insurance company/NGO work in the area? aLYes b) No c) Do not know 3.15 Is the quality of health care of the medical centre satisfactory? ‘es b) No 3.16 Is the quality of healthcare service of the medical centre satisfactory? re. b) No 3.171 Do you or your family member take any drug (Biri, Betel leaf, Cigarette, Injection, Phencidyle or Others) a) Yes \brio 2 If Yes, how much money is spent for that per day? : 0 you want to say anything more about the research?