Planning for Health System Development - QUESTIONNAIRE for PROFESSIONALS/HEALTHCARE FACILITIES

QUESTIONNAIRE for HEALTH SYSTEM DEVELOPMENT - GOA 2001 to 2011

MEDICAL PROFESSIONALS or ADMINISTRATORS of HEALTHCARE FACILITIES of Goa

I 1	Date	2000
	Name of Respondent
	Name of Facility
	Address
II 1	What is the level of your facility?
II 2	Decipline of medicine followed
III 1	Type of management
III 2	What is the surrounding environment like?	describe the neighbourhood
III 3	What is the area / population served by the facility?
III 4	a. What is the area? (in m²)	plot built up
	b. How many sides have open spaces?
	c. What is the condition of the structure?
	d. Type of tenure
III 5	a. What is the width of the main access road?
	b. Is it motorable?
	c. What is the road surface?
	d. How is the accessibility to your facility?
III 6	a. Do you have ambulance/s?
	b. Do you have adequate parking spaces for staff?	two wheeler four wheeler
	c. Do you have adequate parking spaces for visitors?	two wheeler four wheeler
IV 1	List the major epidemics you have faced over the last year
IV 2	How many inpatients does the facility have?	male female paediatric
	What are the visiting hours?
IV 3	How many outpatients does the facility have during	peak season off-peak season
IV 4	How many beds does the facility have?	medical surgical maternity ic paediatric isolation other
IV 5	a. How many doctors does the facility have?	resident non resident
	c. How many nurses does the facility have?	resident non resident
	e. How many other staff does the facility have?	resident non resident
IV 6	a. How much electricity does the facility use?	HT LT
	b. How much water does the facility use?	municipal line well bore well
	c. How does the facility dispose rainwater?
	d. How does the facility dispose sewage?
	e. How does the facility dispose medical waste?
V 1	a. What is the annual income of the facility?
	b. What is the annual expenditure of the facility?
V 2	Does the facility have any growth or expansion plans for the near future?
VI 1	How would patients rate your facility in terms of
	Service (docs/ nurses/ staff/ etc.)	Would you care to elaborate?
	Infrastructure (facility/ diagnostics/ etc.)	Would you care to elaborate?
	Materials (consumables/ drugs/ food/ etc.)	Would you care to elaborate?
	Hygiene (cleanliness/ sterility/ etc.)	Would you care to elaborate?
	Concern for patient (privacy/ etc.)	Would you care to elaborate?
	Concern for relatives (sensitivity/ etc.)	Would you care to elaborate?
	Overall Rating	Below 25% 25-50% 50-75% Above 75% Would you care to elaborate?
VII 1	In your opinion, how good is health awareness in Goa state?	Would you care to elaborate?
VII 2	In your opinion, how good is medical education in Goa state?	Would you care to elaborate?
VII 3	Are you aware of any religio-cultural reservations to medicine within Goa?	Would you care to elaborate?
VII 4	Any other comments about the health system in Goa	Would you care to elaborate?


Thank You!

List of abbreviations used:
CHC Community Health Centre SHC Subsidiary Health Centre HIV Human Imuno Virus TGM Tar Bound Macadam WBM Water Bound Macadam HT High Tension AIIMS All India Institute of Medical Sciences	PHC Primary Health Centre RMD Rural Medical Dispensary AIDS Acquired Imuno Deficiency Syndrome CC Cement Concrete m meters LT Low Tension

Appendix I - Questionnaires for Collecting Primary Data
Appendix II a - Census of India, 1991, Plan of Sanguem Taluk
Appendix II b - Census of India, 1991, Series 6, Part XII - A & B (in part)
Appendix III - DALYs for India, 1990
Appendix IV - Resource Persons

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Quais Fatehi, 2001