QUESTIONNAIRE for HEALTH SYSTEM DEVELOPMENT - GOA 2001 to 2011
INDIVIDUALS or FAMILIES Resident in Goa
I 1 Date 2000
Name of Respondent
Address
I 2 Religion
Monthly Income of family

Less than Rs. 2000 Rs. 2000-5000

Rs. 5000-10000 More than Rs. 10000
Number of people in family Males Below 7 yr.

 

 Males 7 yr. and above
Females Below 7 yr.
Females 7 yr. and above
II 1 No of times in the last year you or your family visited the following health facilities

Referral Hospital (AIIMS/ Bangalore/ Belgaum/ Chennai/ Mumbai):
State Hospital (Goa Medical College)
District Hospital (Hospicio/ Asilo)
Taluk Health Centre (CHC/ PHC/ Pvt. Hospital/Nursing Home)
Neighbourhood/Village Health Facility (SHC/ RMD/ Clinic/ Pharmacy)
II 2 Decipline of medicine followed
III 1 How accessible are the health facilities in terms of
a. time
b. convenience
c. safety
d. cost
e. comfort
Would you care to elaborate?
IV 1 Would you prefer a Public or a Private facility?
IV 2 Why?
V 1 List the major illnesses you or your family have had over the last year
VI 1 What was last year's total spending on health by your family? Less than Rs.500 Rs.500-1000 Rs.1000-2500 Rs.2500-5000 More than Rs.5000
VI 2 How much should we pay for health services (vis-a-vis state sponsored serives)? (Right now, it is free in govt health facilities.) Nothing 25% 50% 75% All
VII 1 How would you rate the health delivery system in terms of
Service (docs/ nurses/ staff/ etc.)

Infrastructure (facility/ diagnostics/ etc.)

Materials (consumables/ drugs/ food/ etc.)

Hygiene (cleanliness/ sterility/ etc.)

Concern for patient (privacy/ etc.)

Concern for relatives (sensitivity/ etc.)

Overall Rating

Below 25% 25-50% 50-75% Above 75%
VIII 1 In your opinion, how good is health awareness in Goa state?
VIII 2 In your opinion, how good is medical education in Goa state?
VIII 3 Are you aware of any religio-cultural reservations to medicine within your family?
VIII 4 Any other comments about the health system in Goa
 
Thank You!
List of abbreviations used:  
CHC Community Health Centre
SHC Subsidiary Health Centre
HIV  Human Imuno Virus
AIIMS All India Institute of Medical Sciences 		PHC Primary Health Centre
RMD Rural Medical Dispensary
AIDS Acquired Imuno Deficiency Syndrome
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