Items:

 1. Where did (NAME) most recently stay overnight for health care?

Response Options:
Public Sector
Government hospital
Government health center
Government health post
Other public sector (specify)
Private Medical Sector
Private Hospital
Private Clinic
Other private medical sector (specify)
NGO Medical Sector
NGO Hospital
NGO Clinic
Other NGO medical sector (specify)
Other (specify)

 2. What was the main reason for (NAME) to seek care this most recent time?

Response Options:
Pregnancydelivery
Illness
Accidentinjury
Other(specify)
Don’t know

 3. How much money was spent on treatment and services (NAME) received during the most recent overnight stay? We want to know about all the costs for the stay, including any charges for laboratory tests, drugs, or other items.

Response Options:
Cost (5-digit numeric)
No costfree
In kind only
Don’t know

 4. Is (NAME) covered by any health insurance?

Response Options:
Yes
No
Don’t know

 5. What is (NAME)’s main type of health insurance?

Response Options:
Mutual health organizationcommunity-based health insurance
Health insurance through employer
Social security
Other privately purchased commercial health insurance
Other (specify)
Don’t know

 6. Now I would like to ask some questions about health care that (NAME) received in the last four weeks, without having to stay overnight. Where did (NAME) get care most recently without staying overnight?

Response Options:
Public Sector
Government hospital
Government health center
Government health post
Other public sector (specify)
Private Medical Sector
Private hospital
Private clinic
Pharmacy
Private doctor
Mobile clinic
FieldworkerCommunity health worker
Other private medical sector (specify)
NGO Medical Sector
NGO Hospital
NGO Clinic
Other NGO medical sector(specify)
Other Source
Shop
Traditional practitioner
Other (specify)

 7. How much money was spent on treatment and services (NAME) received from (NAME OF PROVIDER)? Please include the consulting fee and any expenses for other items including drugs and tests.

Response Options:
Cost (5-digit numeric)
No cost free
In kind only
Don’t know

 8. What was the main reason for (NAME) to seek care this most recent time?

Response Options:
Family planning
Antenatal caredelivery
Malaria
Fever
Diarrhea
HIVAIDSSTD
Other Illness
Check-upPreventive Care
AccidentInjury
Vaccination
Other(specify)

 9. Did (NAME) get care another time in the last four weeks from a health provider, a pharmacy, or a traditional healer, without staying overnight?

Response Options:
Yes
No

 10. How many other times did (NAME) get care in the last four weeks?

Response Options:
Number of outpatient visits (2-digit numeric)
Don’t know

 11. How many times was money spent?

Response Options:
Number of outpatient visits paid money (2-digit numeric)
Don’t know