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Afghanistan Mortality Survey 2010 - Measure DHS

Afghanistan Mortality Survey 2010 - Measure DHS

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SECTION 4. INPATIENT HEALTH EXPENDITURES401 CHECK Q.114:ONE OR MORE NO 501INPATIENTSINPATIENTSCHECK QS.102,114: ENTER LINE NUMBER AND NAME OF EACH HOUSEHOLD MEMBER WHO WAS AN INPATIENT.READ: Now I would like to ask some questions about the household members who stayed overnight in a health facility in the last 12 months.402 LINE NUMBER INPATIENT 1 INPATIENT 2 INPATIENT 3FROM Q.114IN HOUSEHOLD SCHEDULE LINE LINE LINENUMBER . . . . . . . . . . . . NUMBER . . . . . . . . . . . . . NUMBER . . . . . . . . . . . . .NAME FROM Q.102403 How many timesdid [NAME] get admitted in a NUMBER OF NUMBER OF NUMBER OFhealth facility in the last 12 TIMES . . . . . . . . . . . TIMES . . . . . . . . . . . TIMES . . . . . . . . . . . .months.404 Where did (NAME) most recently PUBLIC PUBLIC PUBLICstay overnight for health care? NATIONAL HOSP. . . . . . . . . . . 21 NATIONAL HOSP. . . . . . . . 21 NATIONAL HOSP. . . . . . . . 21REGIONAL HOSP . . . . . . . . . . 22 REGIONAL HOSP . . . . . . . 22 REGIONAL HOSP . . . . . . . 22IF THE FACILITY IS A HOSPITAL PROVINCIAL HOSP . . . . . . . 23 PROVINCIAL HOSP . . . . . . . 23 PROVINCIAL HOSP . . . . . . . 23OR CLINIC WRITE THE NAME OF DISTRICT HOSP . . . . . . . . . . 24 DISTRICT HOSP . . . . . . . 24 DISTRICT HOSP . . . . . . . 24THE PLACE. PROBE FOR THE CHC/POLYCLINIC . . . . . . . . . . 25 CHC/POLYCLINIC . . . . . . . 25 CHC/POLYCLINIC . . . . . . . 25TYPE OF SOURCE AND CIRCLE OTHER 26 OTHER 26 OTHER 26THE APPROPRIATE CODE. (SPECIFY) (SPECIFY) (SPECIFY)PRIVATE PRIVATE PRIVATEPVT. HOSPITAL . . . . . . . . . . 31 PVT. HOSPITAL . . . . . . . 31 PVT. HOSPITAL . . . . . . . 31NAME OF FACILITY PVT. CLINIC . . . . . . . . . . . . . . . . 32 PVT. CLINIC . . . . . . . . . . . . . 32 PVT. CLINIC . . . . . . . . . . . . . 321ST INPATIENT OTHER 36 OTHER 36 OTHER 36(SPECIFY) (SPECIFY) (SPECIFY)NAME OF FACILITY OTHER 96 OTHER 96 OTHER 962ND INPATIENT (SPECIFY) (SPECIFY) (SPECIFY)NAME OF FACILITY3RD INPATIENT405 For the most recent TOTAL TOTAL TOTALinpatient care for [NAME] COST COST COSTwhat was the total cost? AFGHANI AFGHANI AFGHANIThis includes costs NO COST/FREE . . . . . . . . . . . . 000000 NO COST/FREE . . . . . . . . . . . 000000 NO COST/FREE . . . . . . . . . . . 000000associated with [NAME] going (SKIP TO 410) (SKIP TO 410) (SKIP TO 410)to and from the inpatient DON'T KNOW . . . . . . . . 999998 DON'T KNOW . . . . . . . . . . . 999998 DON'T KNOW . . . . . . . . . 999998facility, costs for theinpatient room, health serviceproviders, medicines, diagnostictests, and other costs such asfor food for [NAME] while aninpatient.406 How much of this total cost, TOTAL TOTAL TOTALwas paid for just COST COST COSTmedicines? AFGHANI AFGHANI AFGHANINO COST/FREE . . . . . . . . . . . . 000000 NO COST/FREE . . . . . . . . . . . 000000 NO COST/FREE . . . . . . . . . . . 000000DON'T KNOW . . . . . . . . 999998 DON'T KNOW . . . . . . . . . 999998 DON'T KNOW . . . . . . . . . 999998407 How much of this total cost, TOTAL TOTAL TOTALwas paid for just diagnostic COST COST COSTservices (ex. lab test, x-ray)? AFGHANI AFGHANI AFGHANINO COST/FREE . . . . . . . . . . . . 000000 NO COST/FREE . . . . . . . . . 000000 NO COST/FREE . . . . . . . . . 000000DON'T KNOW . . . . . . . . . . . . 999998 DON'T KNOW . . . . . . . . . 999998 DON'T KNOW . . . . . . . . . 999998408 How much of this total cost TOTAL TOTAL TOTALwas paid for transportation COST COST COST(non-ambulance), to and from AFGHANI AFGHANI AFGHANIthe inpatient facility and home? NO COST/FREE . . . . . . . . . . . . 000000 NO COST/FREE . . . . . . . . . . . 000000 NO COST/FREE . . . . . . . . . . . 000000DON'T KNOW . 999998 DON'T KNOW . . . . . . . . . 999998 DON'T KNOW . . . . . . . . . 999998409 How much of this total cost TOTAL TOTAL TOTALwas paid for food and accom- COST COST COSTmodation when traveling to and AFGHANI AFGHANI AFGHANIfrom home, or for food while NO COST/FREE . . . . . . . . . . . . 000000 NO COST/FREE . . . . . . . . . . . 000000 NO COST/FREE . . . . . . . . . . . 000000in the facility? DON'T KNOW 999998 DON'T KNOW . . . . . . . . . 999998 DON'T KNOW . . . . . . . . . 999998208 | Appendix F

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