RFP        DOCUMENT                                 State Level Evaluation                       Study of “Rastriya Swasth...
Tender document of State Nodal Agency Chhattisgarh for the Evaluation of                                  RSBY            ...
RFP DOCUMENTRASHTRIYA SWASTHY A BIMA YOJANAA number of studies have revealed that risk owing to low level of health securi...
PART-1 : TERMS OF REFERENCE FOR CONDUCTING EVALUATIONSTUDIES OF RASTRIYA SWASTHYA BIMA YOJANA AT STATELEVELA: Introduction...
Nodal Agency may, if the amendment is substantial, extend the deadline for the submission of            Proposals.C: Quali...
f.   Draft Tool for the Survey – The draft tool for this type of survey is attached             as Annexure- 5 of this doc...
PART –II SUBMISSION OF BIDS/ PROPOSALSThe State Nodal Agency seeks detailed proposal from agencies interested in evaluatin...
SECTION B – FINANCIAL PROPOSAL(KINDLY NOTE THAT ANNEXURE -3 SHOULD BE ATTACHED TO SECTION B- FINANCIAL PROPOSAL ONLY)     ...
Annexure - 1                               Instructions to the ConsultantsParagraph Reference1 Name and Address of the Sta...
Annexure-2                              Details of the Technical ProposalTechnical approach, methodology and work plan are...
Evaluation of Rastriya Swasthya Bima Yojana (RSBY) Chhattisgarh State,Division of _____________________________A: ORGANISA...
Government survey    1    2B.1: Completed research project (s) (Extra-sheet may be used if activities are more than 5 in n...
** Note: Care may be taken to demonstrate that each area of expertise required for the study is covered by differentkey pr...
F: ANY OTHER DETAIL WHICH IS RELEVANT TO THE BID CERTIFICATE It is certified that:1. The information given above is TRUE t...
Financial Bid                                                                                   Annexure-3            Eval...
Annexure-4                      Form A – Appraisal of the technical proposalBidder                          Bidder Name   ...
8               The bidder has a financial turnover of at least Rs. 20,            00,000 in at least one of the past thr...
I hereby certify that after perusing through the documents supplied by the bidder(………………………………………………………………………………………….........
Annexure 5                                              RSBY QUESTIONNAIRE                          Post-enrolment Survey ...
A.2.1 BPL card No. :                                                                                              write 0 ...
SECTION C. HOUSEHOLD CHARACTERISTICSC.1C.2C.3    Do you rent or own the house you live        Rent…………………….1       in?    ...
Rainwater…………………………13                                                            Tanker truck………………………14                  ...
Source of borrowing                             Reason of borrowingFrom friends and family without interest……..1   Start a...
SECTION D.1: HOUSEHOLDS SOCIAL NETWORK        Is anyone in the family presently a       SHG ………………………. 1D.1.1   member of ...
SECTION F:      F.1 HOUSEHOLD HEALTH (FOR ALL INDIVIDUALS FROM HOUSEHOLD                                                 B...
F.2 HOUSEHOLD HEALTH EVENT AND HOSPITALISATION      F.2.1      Does any of your family member has some health         Yes…...
F.4. HEALTH-RELATED BEHAVIOR (head of the family) F.4.1    Do you or anyone in the family smoke? __         F.4.2 Indicate...
Don’t know …………………-999                                                           Don’t know ………….…-999G.5.9 Do you have to...
G.8 For those who appliedG.8.1      Was any list of eligible families                             G.8.2   When did enrolme...
G.10     For RSBY card holdersG.10.1 PLEASE SHOW YOUR RSBY                                           G.10.2      What prob...
RSBY          At work at the time of enrolment……..3;          Not eligible by relationship ……….6scheme?       Was not well...
SECTION H: MEDICAL TREATMENT (inpatient/outpatient)Interviewer: Ask respondent who in their family needed outpatient servi...
Ask respondent about all hospitalization cases in the family in the last two years ( including maternityhospitalization)H....
H.3 Details of medical servicesreceivedH.3.1 srl. no. of thehospitalization caseH.3.2 Name and srl. no. ofmember hospitali...
H.3.12 Did you spend anythingfor getting diagnostic tests done?  Yes … 1 No …….2H.3.13 If yes, how much? (inRs.)H.3.14 Any...
H.4: TransportationH.4.1 How far is the hospitalfrom your house(Approximately)?H.4.2 How did the patient go tothe hospital...
Emergency……….1;OPD……….2;Referral…………3; Other (PleaseSpecify)……………….-999H.5.11 Was the staff at theRSBY help-desk polite an...
of discharge those tests weresupposed to be done?H.6.14 Were facilities for thosetests organized by the hospitalfree of co...
from the same hospital?                                                                        Yes ……..1 section I       ...
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Rsby evaluation chhattisgarh rfp document updated 14th september 2011

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Rsby evaluation chhattisgarh rfp document updated 14th september 2011

  1. 1. 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 2011RFP for evaluation of RSBY in Chhattisgarh 1
  2. 2. Tender document of State Nodal Agency Chhattisgarh for the Evaluation of RSBY State Nodal Agency RSBY Chhattisgarh Department of Health and Family Welfare 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 outevaluation studies for government schemes and programs for carrying out evaluation study of RastriyaSwasthya 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 andThird Party Administrators (Health) & their allied companies and Agencies involved with DHFWChhattisgarh are not permitted to participate in the bidding process.The tender document for this may be downloaded from the website http://cghealth.nic.inThe technical bids and financial bids should be sealed by the bidder in a cover duly super-scribed is to beput 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. Financialbids of only the technically acceptable offers shall be opened before the successful biddersby 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 17.10.2011Opening of technical bids: 18.10.2011The completed technical Bid documents should be submitted before at the following address:- State Nodal Agency RSBY Chhattisgarh Department of Health and Family Welfare 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 for evaluation of RSBY in Chhattisgarh 2
  3. 3. RFP DOCUMENTRASHTRIYA SWASTHY A BIMA YOJANAA number of studies have revealed that risk owing to low level of health security is endemic for informalsector workers. The vulnerability of the poor informal worker increases when they have to pay fully fortheir medical care with no subsidy or support. On the one hand, such a worker does not have the financialresources to bear the cost of medical treatment, on the other; the health infrastructure leaves a lot to bedesired. Large numbers of people, especially those below poverty line, borrow money or sell assets to payfor the treatment in private hospitals. Thus, Health Insurance could be a way of overcoming financialhandicaps, improving access to quality medical care and providing financial protection againsthigh medical expenses. The “Rastriya Swasthya Bima Yojana” announced by the Central Governmentattempts to address such issues. Government of Chhattisgarh has launched this scheme in all its 18districts.For the evaluation of the scheme, Proposals are invited from the Survey agencies. The agencies which arein agreement with scheme and its Terms of Reference, only need to participate in the bidding andany disagreement in this regard may invite disqualification / rejection of bid at technicallevel. Hence all the agencies are requested to go through the scheme carefully and submit their agreementin 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 theCommittee 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 thedeliverables would be completed as per the time frame in the TOR. In case the selectedInstitute/Organization declines to take up the study after a notice of award has been issued, it would bebarred from applying for any study, evaluation or assistance of any kind from Departmentof 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, orapplication for review, shall be entertained. RFP for evaluation of RSBY in Chhattisgarh 3
  4. 4. PART-1 : TERMS OF REFERENCE FOR CONDUCTING EVALUATIONSTUDIES OF RASTRIYA SWASTHYA BIMA YOJANA AT STATELEVELA: IntroductionState Nodal Agency RSBY Chhattisgarh invite proposals for conducting household surveys related toRSBY. This request for proposals is for carrying out a post-enrollment survey of healthinsurance. This type of Household Survey Study will give idea about the enrollment processfor RSBY and the experience of the beneficiaries. It will also give States information about the type offacilities provided to the beneficiaries when they receive the treatment under RSBY. All the benefits whichare supposed to be given by the providers to the beneficiaries whether they are getting those or not willcome out through this survey. It will also provide limited information about the quality of health careprovided. It will also provide results in terms of utilization pattern of public and privateproviders by the beneficiaries in the State of Chhattisgarh. The districts to be covered for thissurvey 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 RFP for evaluation of RSBY in Chhattisgarh 4
  5. 5. 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 EvaluationThough 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 inthe scheme will be part of this survey. The sample of beneficiaries will include beneficiaries who haveutilized 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. RFP for evaluation of RSBY in Chhattisgarh 5
  6. 6. 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 AgencyThe 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 contactdetails and data for surveys.G. Ownership of the SurveyThe ownership of the survey tool and data shall lie with the State Government/ Nodal Agency. RFP for evaluation of RSBY in Chhattisgarh 6
  7. 7. PART –II SUBMISSION OF BIDS/ PROPOSALSThe State Nodal Agency seeks detailed proposal from agencies interested in evaluating the “RastriyaSwasthya Bima Yojana”, in the Chhattisgarh State.The bid/proposal document should include the following:SECTION A – TECHNICAL PROPOSALQUALIFYING 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 bidderwho do not qualify this criterion, will be disqualified immediately and their bids will not beconsidered.The Technical proposal should be sealed in an envelope clearly marked in BOLD“SECTION A – TECHNICAL PROPOSAL” and “TECHNICAL PROPOSAL FOREvaluation of “RASHTRIYA SWASTHYA BIMA YOJANA SCHEME” written on the top of theenvelope.The Envelop should have the bidders Name and Address clearly written at the Left Bottom Corner of theenvelope. The technical supporting documents in physical form should be submitted at the followingaddress 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 RFP for evaluation of RSBY in Chhattisgarh 7
  8. 8. 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 isdeclared as a holiday by government, the last date of submission of tender will be extended to the nextworking 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 documentsreceived 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 RFP for evaluation of RSBY in Chhattisgarh 8
  9. 9. Annexure - 1 Instructions to the ConsultantsParagraph Reference1 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, 42251962 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 20113 Proposals must remain valid 90 days after the submission date4 Clarifications may be requested not later than 3 days before the submission date.5 Proposals shall be submitted in the following language: - English6 The format of the Technical Proposal to be submitted: As per the Annexure7 Bidder must submit the original and 2 copies of the Technical Proposal, and the original of the Financial Proposal. RFP for evaluation of RSBY in Chhattisgarh 9
  10. 10. Annexure-2 Details of the Technical ProposalTechnical approach, methodology and work plan are key components of the Technical Proposal. Pleasesubmit your Technical Proposal divided into the following three chapters:a) Technical Approach and Methodology,b) Work Plan, andc) 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. RFP for evaluation of RSBY in Chhattisgarh 10
  11. 11. Evaluation of Rastriya Swasthya Bima Yojana (RSBY) Chhattisgarh State,Division of _____________________________A: ORGANISATIONAL PROFILEName of organizationName and Designation of Contact PersonPostal Address of the Organization (with PIN CODE)Physical Address, if different from postal address (With PIN CODE)Telephone with STD CodeFAX No. with STD CodeMobile No. of Contact PersonE-mail Address of Contact PersonName and Designation of Head of the Organization responsible for the Study ContractEstablishment Detailsa. Year Establishedb. Type of Organization (Tick One) Educational & ResearchInstitution/ Consulting Organization/ Any Other (give details)c. Regd. No. ; Name and Place of Registering Authority(Attach attested photocopy of Registration Certificate)B. EXPERIENCEExperience in conducting research studies in the field of rural & socialdevelopment/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 ofproposed 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 RFP for evaluation of RSBY in Chhattisgarh 11
  12. 12. Government survey 1 2B.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 ofNo. research Address starting completion Value Sample project of Client date/time time as (Rs. State (s) (Month & per Lakh) Year) ToR/ Agreement (in Months)12345C: HUMAN RESOURCEC. 1 Human Resources of the organization: (attach CVs)Sr. Official Station Professional/Technical Supporting Staff AllNo. (Name of place) (Numbers) (Numbers) Fulltime Part-time Fulltime Part-time1234C2: 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 expertise12345 RFP for evaluation of RSBY in Chhattisgarh 12
  13. 13. ** Note: Care may be taken to demonstrate that each area of expertise required for the study is covered by differentkey 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.12345 Format for Team Composition1. Professional StaffName of Staff Firm Area of Position Assigned Task Assigned Expertise2. Support StaffName of Staff Firm Area of Position Assigned Task Assigned ExpertiseD: 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? RFP for evaluation of RSBY in Chhattisgarh 13
  14. 14. 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: AuthorizedSignatory Place: Name: Seal of the Organization: Designation: RFP for evaluation of RSBY in Chhattisgarh 14
  15. 15. 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 BIDSr. No. Head Total Cost (Rs.)1 Salary of key professionals2 Salary of field staff and support staff3 Travel for key person4 Travel for Field & Secretariat staff5 Contingent expenses6 Office expenses**7 Total (1+2+3+4+5+6)8 Institutional Overheads if any, and basis of charge9 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 5Compact Disks.Date: Authorized Signatory ______________Place: Name: ___________________________Seal of the Organization: Designation: ______________________ RFP for evaluation of RSBY in Chhattisgarh 15
  16. 16. Annexure-4 Form A – Appraisal of the technical proposalBidder Bidder Name No. of Separate No. Documents¹ Including Annexes1234561. Essential Criteria No. Criteria1.  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 years (Please attach copy of work orders).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 study7  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. RFP for evaluation of RSBY in Chhattisgarh 16
  17. 17. 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 years (Please attach copy of work orders).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 consideredas a separate document.²specific years must be mentioned.2. Desirable CriteriaNo. Criteria 1 2 3 4 5 6 7 81. Specific experience of the Consultants in conducting: a. Household Survey-20 marks b. health surveys-10 marks c. working with Government experience- 5 marks2. 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 marks3. Key professional staff qualifications and competence for the assignment a. Team Leader-10 marks b. Other Key Members-10 mark4. Suitability of training program -10 marks a. Relevance of training program -5 marks b. Training approach and methodology- 5 marks Total: 100 RFP for evaluation of RSBY in Chhattisgarh 17
  18. 18. I hereby certify that after perusing through the documents supplied by the bidder(………………………………………………………………………………………….............) it is myopinion 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 CommercialEvaluation.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.AWARDFinally the technical and commercial scores obtained by all the vendors would be summed andthe 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) *0.3The vendor with the highest marks computed above on cost and quality basis will be awarded thebid. RFP for evaluation of RSBY in Chhattisgarh 18
  19. 19. Annexure 5 RSBY QUESTIONNAIRE Post-enrolment Survey of the RSBY ProgrammeA 0 : CONSENT TO PARTICIPATE IN INTERVIEWHousehold ID : __ __ __ __ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _INTERVIEWER - Read out: Namaskar. My name is (please say your name here). I am asked by the Government ofChhattisgarh, to conduct a survey with BPL people in Chhattisgarh to understand the penetration of Rashtriya SwasthyaBima Yojana (RSBY). We will be asking you questions related to RSBY. We would appreciate your participation in thissurvey. 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 YearA 1 : INTERVIEWER: COMPLETE (WHAT EVER APPLICABLE) BEFORE BEGINNING THE MODULE. CodeA1.1 State Gujarat…………..1 Haryana…………..2A1.2 DistrictA1.3 VillageA1.4 Hamlet nameA1.5 Block/CircleA1.6 Rural/UrbanA1.7 Name of Gram PanchayatA1.8 AddressA1.9 Family IDA1.10 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
  20. 20. 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 ROSTERB.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 ………..2mbe Enter the names onship If M.1 l status of occup tly why B.11 B.12 B.13 B.14 B.15r 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
  21. 21. SECTION C. HOUSEHOLD CHARACTERISTICSC.1C.2C.3 Do you rent or own the house you live Rent…………………….1 in? Own…………………….2 Rent Free house ............... 3C.4C.5 Do you have a separate toilet? Yes……………………1 No…………………….2C.6C.7C.8 What is the source of drainage Open kutcha - 1, Open pucca - 2 Covered pucca - 3, Under ground – 4; No drainage - 5C.9 Does the family own any cultivable Yes……………………1 land? No…………………….2  C.12 (in the native village) Does Not Know........-999  C.12C.10 What is the total area of cultivable land? ________Acres..........................1 ________Bighas........................2 ________Biswa .........................3 Does Not Know……………-999C.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
  22. 22. 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 BORROWINGSD.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.4D.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 ED5 Details of borrowings Amount Source of borrowing (see codes below) Reason of borrowing (see codes below) Sr No. borrowed 1 , , 2 , , 3 , , 4 , , 22
  23. 23. Source of borrowing Reason of borrowingFrom friends and family without interest……..1 Start a new business…………….……...1From friends and family with interest……..2 Acquire agricultural machinery or agricultural inputs …….…2From moneylender...3 Purchase stock for existing business………………………….…3From bank………....4 Repay old debt………………………..4From MFI………….5 For health related expenses..………………………….….5From chit funds…….6 Marriage…………………..…………….6From other financial institutions……….7 Funeral………………..………………7From NGO……..…..8 Festival/Other Ceremony.........................8From SHG……..…..9 Houseold consumption/Purchase household durable…..……….9Others (specify)… - 777 Home improvement/repair/construction….10Don’t know……-999; Unemployment……………..………...11Will not answer……..-888 Purchase land………………..……….12 Education…………………………..…13 Purchase jewelry…….………………14 Buy livestock…………………...…….15 Other (specify)… ……………….…-777 ___________________________ Don’t know…………………..-999 23
  24. 24. SECTION D.1: HOUSEHOLDS SOCIAL NETWORK Is anyone in the family presently a SHG ………………………. 1D.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...........................…..........1D.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 ….…..1D.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..1D.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
  25. 25. 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 IsID 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
  26. 26. 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 Howcodes of What was the health event / condition? For how long did Is he/she still Was [name] Which type Did [name] have many daysthose 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 admittedhealth 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
  27. 27. 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 aboutG.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) ……………….…..-777G.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 …………...-999G.5.5 How much does it cost to enroll in this G.5.6 What is the maximum amount perscheme? ( in Rs.) year that can be spent? ( in Rs.) Zero ………………0 Don’t know………………….-999 Rs 30..................................30 Others (specify) ...............-777 Don’t know……………….-999G.5.7 Is free treatment provided in the hospitals G.5.8 Are transportation allowancesunder this scheme? provided to the patient? Yes ……………………..1 Yes ………………………..1 No … ……………………..2 No … ………………………..2 27
  28. 28. Don’t know …………………-999 Don’t know ………….…-999G.5.9 Do you have to pay for the medical tests G.5.10 Do you have to pay for medicinesduring hospitalisation if you enroll in this and drugs in case of hospitalisation if youscheme? enrol in this scheme? Yes …………………..1 Yes …………………..1 No … ……………………..2 No ………………..2 Don’t know ……….……-999 Don’t know……………..-..999G.5.11 How many household members can be G.5.12 Which year did enrolment takeenrolled? 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……………-999G.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 HG.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……….…......….1Didn’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 ..........3Didn’t find any hospital in the list which is closer to Was not satisfied in first round .............5my place..........................................................….4 , Didn’t get chance to use card in firstDid not have proper documents to support family’s round .....................................................6identity…..............................................................5 Didn’t find any hospital in the list whichDidn’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
  29. 29. G.8 For those who appliedG.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 ……………-999G.8.4 How much time did it take to reach G.8.5 How far was the enrollmentenrolment 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.……………-999G.8.6 How did you get to know when andwhere 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.........................7G.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 roundNo … …………...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
  30. 30. G.10 For RSBY card holdersG.10.1 PLEASE SHOW YOUR RSBY G.10.2 What problems did you face inCARD. obtaining the card?Showed it………….….….….1 ( Add extra sheets if required)Did not want to show……..….2Lost it………………..…………3Someone has taken it (is with some one) .…4Its with hospital ..………………5Other (specify)…………….…-777G.10.3 How many members of the family G.10.4 How long did it take you to completeare 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 ……….…..5G.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.……….-999G.10.7 Which of the following pieces of G.10.6 Were you told about the date wheninformation 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 ..................................... 5Other (specify)……………………-777G.10.8 Which is the nearest RSBY G.10.9 Are you satisfied with the scheme?empanelled hospital? Yes ……………………………..1 _________ No … …………………………..2Don’t know ...................-999G.10.10 Would you like to enrol next yearalso?Yes ………………………..1No … ……………………..2 Don’t know ……………………-999 G.11 INDIVIDUAL ENROLMENTG.11.1 G.11.2Is ID G.11.3 If no, why not? At school at the time of enrolment…..2ID enrolled in Five person limit …………….…..1; Out of village at the time of enrolment...4 30
  31. 31. RSBY At work at the time of enrolment……..3; Not eligible by relationship ……….6scheme? 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
  32. 32. 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, localvaidya, and had bought medicine/ paid consultation fee etc.)H.1. Particulars of medical treatment received as Outpatient during the last 30 daysH.1.1 sr1. no. of the OPD case 1 2 3 4 5H.1.2 Name & srl. no. of member (as in col. 1, block 4/5) hospitalisedH.1.3 Age (years) (as in col. 5, block 4 / col. 4, block 5)H.1.4 Date of First VisitH.1.5 Number of visitsH.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 pregnancyH.2a.1 Who in your family got pregnant in the last 5 years? (startingwith the most recent ones) ( continue with the same lady if she hassuccessive birth histories otherwise switch to another)Noone  H.3H.2a.2 Member id from rosterH.2a.3 Date of Birth If dead ………………….. 88  H.2a.6H.2a.5 What is the present age of child born? Living …..1, dead……. 2H.2a.6 Where did birth take place?Home…………………………1 Village clinic at ANM…….….7Govt/Munic Hospital………….2 Other Public Health Facility..8GovtDispensary………………..3 NGO/TrustPHC/CHC………………..….…4 Hospital…………………9Sub- Centre…………..…….….5 Pvt Hosp/MaternityAnganwadi Centre………..….6 Home……..….10 Other private……………………..…11 Other………………….………..…..999H.2a.7 If the delivery did not place in a health facility then whattake was the reason?Costs too much……………..…1 No Female Provider at Service….5Facility not open………….....2 Husband/ Family did not allow……6No nearby centre………….…...3 Not Necessary……… …..……..…..7Don’t trust facility/ Poor Not Customary……………………..8Service…………...4 Other……… …(Specify) 999 32
  33. 33. Ask respondent about all hospitalization cases in the family in the last two years ( including maternityhospitalization)H.2. Particulars of medical treatment received as Inpatient of a hospital during the last two yearsH.2.1 sr1. no. of the hospitalisation case 1 2 3 4 5H.2.2 Name & srl. no. of member (as in col. 1, block 4/5) hospitalisedH.2.3 Type of hospital: Public hospital(PHC/sub centres/CHC).1, public dispensary(incl. CGHS/ESI) ……….2, private hospital………..3 Add hospital nameH.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
  34. 34. H.3 Details of medical servicesreceivedH.3.1 srl. no. of thehospitalization caseH.3.2 Name and srl. no. ofmember hospitalizedH.3.3 Why this particular hospitalwas 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 RSBYempanelled hospitals nearby…6,Other( specify)....999H.3.4 Did surgery take place? Yes … 1 No …….2H.3.5 Did patient take medicine ?Yes … 1 No …….2H.3.6 Were X-ray/ECG/EEG/Scan/ Diagnostictests conducted?Yes … 1 No …….2H.3.7 Whether treatment availedbefore hospitalisation? Yes … 1 No …….2H.3.8 If yes above, what issource of treatment publichospital (incl. PHC/ sub-centres/CHC)…..… 1,public dispensary (incl.CGHS/ESI)………….2,private hospital ……….. 3,private doctor …..…… 4H.3.9 Whether treatmentcontinued after discharge fromhospital ? Yes … 1No …….2H.3.9a What was the source oftreatment?Public hospital (incl. PHC/ sub-centres/CHC)…..… 1,public dispensary (incl.CGHS/ESI)…..….2,private hospital …… 3,private doctor …..…… 4H.3.9b Duration of treatmentH.3.10 Did you buy medicineon your own? Yes … 1 No …….2H.3.11 If yes, how much didyou spend on medicine?(in Rs.)
  35. 35. H.3.12 Did you spend anythingfor getting diagnostic tests done? Yes … 1 No …….2H.3.13 If yes, how much? (inRs.)H.3.14 Any other amount that isincurred on this health eventbesides medicine and tests? (inRs.) (mention the cause also)H.3.15 What is the total costincurred by the household for thishealth event? (in Rs.)H.3.16 What was the source ofthis expenditure? Household savings/ income ..1Contribution fromfriends/relatives ………2 Borrowings……….. 3Sale of assets/ ornaments…. 4H.3.17 Received anyreimbursement (Rs) from anysource such as government,employer, insurance company, orother agencies?Yes …1 , No …….2
  36. 36. H.4: TransportationH.4.1 How far is the hospitalfrom your house(Approximately)?H.4.2 How did the patient go tothe hospital?) Bus-1Metro……….2 ;Rickshaw………3; Twowheeler…..4 Threewheeler……..5; Car……....6;Bus…………7 Others (pleasespecify)-……………………..999H.4.3 What was the estimatedcost to reach the hospital?H.4.4 Did the hospitalreimburse the cost of transport?Yes ....1; No ......2H.4.5 How much was thereimbursement? (in Rs.)H.5: Inpatient experienceH.5.1 Was there a separateRSBY help desk at the hospital orit was at the reception only?Yes ....1; No ......2H.5.2 How long did the patienthave to wait before he/she wasattended by the staff?Less than 15 minute-1; 15 to30 minutes…….2,; 30 to 60minutes……3; More than 60minutes..4 Others, specify-……..999H.5.3 Was fingerprintverification done through afingerprint scanner?Yes ....1; No ......2H.5.4 Was the family told aboutthe cost involved for treating thepatient in advance?Yes ....1; No ......2H.5.5 If yes, what was the cost?(in Rs.)H.5.6 Was the family told aboutthe money left in the smart card?Yes ....1; No ......2H.5.7 Was the money in the cardsufficient to pay for thistreatment? Yes ....1; No ......2H.5.8 If the money in the cardwas not sufficient was the patienttold that he would have to pay thedifference? Yes ....1; No......2H.5.9 How much was theshortfall in the card from thepackage/ treatment rate? (in Rs.)H.5.10 How was the admissionadvised through?
  37. 37. Emergency……….1;OPD……….2;Referral…………3; Other (PleaseSpecify)……………….-999H.5.11 Was the staff at theRSBY help-desk polite andhelpful? Yes ....1; No ......2H.5.13 Was the patient providedwith food during stay at thehospital? Yes ....1; No ......2H.6: DischargeH.6.1 On discharge wasdischarge summary provided tothe family? Yes ....1; No ......2H.6.2 Was the fingerprintverification done at the time ofdischarge? Yes ....1; No ......2H.6.3 When did you get theRSBY card back?After swiping at the time ofadmission ........1 H.6.6On discharge ........2 H.6.6 Next day......3;two days later ......4Others specify).......................-999H.6.5 What was the reason forholding back the card?Staff wanted money for returningthe card……...1 Staff wanted tokeep the card till insurance claimswere settled……….2; Staffsaid the card will stay deposited atthe hospital …3Others, specify-………….999H.6.6 Were you told about theamount of money left in the cardat the time of discharge?Yes ....1; No ......2H.6.7 Do you know about 5 daypost hospitalization expensescoverage in RSBY?Yes ....1; No ......2H.6.8 Was the patient prescribedany medicines after the discharge?Yes ....1; No ......2H.6.9 For how many days themedicines needed to be taken afterdischarge?H.6.10 Were these medicinesprovided by the hospital? Yes....1; No ......2H.6.11 These medicines were forhow many days?H.6.12 Was the patientprescribed any tests afterdischarge? Yes ....1; No......2H.6.13 Within how many days
  38. 38. of discharge those tests weresupposed to be done?H.6.14 Were facilities for thosetests organized by the hospitalfree of cost?Yes ....1; No ......2H.6.15 How is health of patientnow comparing when he wasadmitted to the hospital?Has died …..1; Noimprovement ……2Partially improved …3; Hasimproved completely ….4H.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 dischargesummaryH.6.18 Was there a suggestionfor follow-upYes ....1; No ......2H.7 : Details of patients who died after receiving treatmentH.7.1 When did the patient die? H.7.2 Probable cause of deathDuring the Hospital Stay-1 from hospital documents if any?Immediately after discharge-2 …………………….Within a week after discharge-3 No documents available-77Within a fortnight-4Within a month-5Others, specify-999H.7.3 Did the patient receive anymedical care before he/she died? Yes ……………………..1 No … ………………..2H.8: Patient SatisfactionH.8.1 Were all your patient H.8.2 How would you rate yourrelated queries answered during satisfaction about the treatmentyour 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-5H.8.3 Where would you have H.8.4 Were you forced to givegone if scheme had not been money to any staff member?there? Yes …………………..1To the same hospital……..1 No … ………………..2To any other private hospital..2 H.8.6To government hospital……….3Doctors private clinic………4Nowhere………………….5Other ( specify) …………….999Don’t know ……….777H.8.5 if yes, how much did you H.8.6 Will you recommend yourpay? (in Rs.) relatives/friends to take treatment
  39. 39. from the same hospital? Yes ……..1 section I No … …………..2H.8.7 If no Why? Will you go back to the sameTreated badly-1 hospital if the need arise again?Poor quality care-2 YesNot receptive to RSBY patients-3 NoThere is no money in the RSBYcard-4If no Why?Treated badly-1Poor quality care-2Not receptive to RSBY patients-3I: RESPONDENT DETAILSI.1 Who answered the survey? Name (INDICATE Household board number) _________________I.2 Was there another respondent present Yes………………………………..1 during the interview? No…………………………………2 JI.3 What is the name of this respondent? Name (INDICATE Household board number) ______________________ Name not on the board……..990SECTION JTHANK THE RESPONDENT FOR TAKING HIS TIME OUT FOR THE INTERVIEW.MAKE SURE TO GET THE SIGNATURE ON THIS SHEET.INTERVIEW ENDING TIME: HOURS MINUTESCOMMENTS_____________________________________________________________________________________________________________________________________________________________Signature of the respondent___________________________

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