An Assessment of the Pharmaceutical Sector in Ghana: ANNEXES: Annex 4: Survey forms (Level II, Household) [1-14]

Annex 4: Survey forms (Level II, Household)

Survey form 1: Public health facility pharmacy

Indicator:	% of expired drugs Availability of key drugs		Public Health Facility Pharmacy Facility #____ (1-30)

Facility	________________________	Date	______________
Location	________________________	Investigator	______________

Key drugs to treat common conditions [A]	Price	In stock Yes=1, No=0 [B]	Expired drugs in stock Yes=1, No=0 [C]
1. ORS
2. Cotrimoxazole tabs
3. Chloroquine tablets
4. Chloroquine syrup
5. Ferrous tabs
6. Folic acid
7. Mebendazole
8. Tetracycline Eye Ointment
9. Iodine
10. Benzoic acid/salicylic acid
11. Paracetamol tablets
12. Paracetamol syrup
13. Amoxycillin Suspension
14. Amoxycillin capsules
[A¹] = Total no. of key drugs =		Total "yes" [B¹] =	Total "yes" [C¹] =
[B²] = % in stock = [B¹] ÷ [A¹] × 100 =
[C²] = % expired = [C1] ÷ [A1] × 100 =

*Notes:*
[A]	List of 10-15 key drugs previously identified at national level must be printed before starting the survey. The process is described on page 21. Add the total number of key drugs [A¹].
[B]	Mark "1" if stock is available (even if only one dosage form is available). Mark "0" if the drug is not physically available. Add the total at the bottom [B¹]. Calculate the percentage in stock [B²] by dividing the total in stock [B¹] by the total number of key drugs [A¹] and multiplying by 100.
[C]	For all drugs in stock, check if expired or not. If any of the product is expired, mark "1" for yes. Add all the "Yes" answers [C¹]. Calculate the percentage expired [C²] by dividing the total expired [C¹] by the total number of key drugs [A¹] and multiplying by 100.

Survey form 2: Public health facility pharmacy

Indicator:	Stockout duration		Public Health Facility Pharmacy Facility #____ (1-30)

Facility	________________________	Date	______________
Location	________________________	Investigator	______________

key drugs to treat common conditions (only collect data for drugs with records covering at least six months)	No. of days out of stock	No. of days covered by the review	Equivalent no. of days/year [D]=[B] × 365÷[C]
[A]	[B]	[C]	[D]
1. ORS
2. Cotrimoxazole tabs
3. Chloroquine tablets
4. Chloroquine syrup
5. Ferrous tabs
6. Folic acid
7. Mebendazole
8. Tetracycline Eye Ointment
9. Iodine
10. Benzoic acid/salicylic acid
11. Paracetamol tablets
12. Paracetamol syrup
13. Amoxycillin Suspension
14. Amoxycillin capsules
[A¹] = Total no. of key drugs =			[D¹] = Sum of [D] =
[E] = Average number of stockout days = [D¹] ÷ [A¹] =

Example:

Key drugs to treat common conditions (only collect data for drugs with records covering at least six months)	No. of days out of stock	No. of days covered by the review	Equivalent no. of days/year [D]=[B] × 365÷ [C]
[A]	[B]	[C]	[D]
Cotrimoxazole	90	180	182.5
Paracetamol	30	365	30
Total no. of key drugs [A¹] = 2			[D¹] = Sum of [D] = 212.5
[E] = Average number of stock out days = [D¹] ÷ [A¹] = 106.25

*Notes:*
[A]	List of 10-15 key drugs previously identified at national level must be printed in before starting the survey [A]. The process is described on page 21. Add the total number of key drugs [A1].
[B]	Go through the stock cards covering the review period. Indicate the number of days that each drug is not available or marked "0" on the stock card [B]. A drug is considered in stock if any equivalent product is available in either generic or branded form.
[C]	The review should cover a six month to one year period. Indicate the number of days actually reviewed for each drug [C].
[D]	Compute the equivalent number of stockout days per year for each drug [D] by multiplying [B] by 365 and dividing by [C]. Add the total number of stockout days [D1]. [E] Calculate the average number of stockout days [E] by dividing the total number of stockout days [D1] by the total number of key drugs [A1].

Survey form 3: Public health facility pharmacy

Indicator:	Adequate storage		Public Health Facility Pharmacy

Facility	________________________	Date	______________
Location	________________________	Investigator	______________

Checklist	Store Room Yes=1, No=0	Dispensing Area/Room Yes=1, No=0
	[A]	[B]
1. There are working locks in the storeroom.
2. Storage area and shelves are clean (no dust or litter).
3. No evidence of pests is seen in the area.
4. There is a secure ceiling.
5. There are windows that can be opened or there are air vents.
6. No direct sunlight enters the area (glass window panes are painted white or there are curtains/blinds to protect against sunrays).
7. Area is free from moisture (leaking drains and taps).
8. Drugs are not stored directly on the floor.
9. There is a separate storage and dispensing area for issuing drugs.
10. Drugs are sorted in a systematic way (alphabetical, first expiry-first out).
11. There is stock record system.
12. There is a cold storage with temperature chart.
Rating	Total "Yes" [A¹] =	Total "Yes" [B¹] =

Survey form 4: Public health facility pharmacy

Indicator:	Affordability of key drugs (treating adults and children with pneumonia without hospitalization)		Public Health Facility Pharmacy Facility #____ (1-30)

Facility	________________________	Date	______________
Location	________________________	Investigator	______________

Drug/INN and Preparation	Unit price (inj. vial, tablet, or capsule)	No. of units needed to complete treatment	Total cost of treatment [D]= [B] × [C]	Affordability [F] = [D] ÷ [E]
[A]	[B]	[C]	[D]	[F]
*Adult drug of choice:* Amoxycillin 250 mg Capsule		42
*Child drug of choice:* Amoxycillin 125mg/5ml syrup		2 × 100 mls bottles
[E] = Lowest daily government salary = 7,200 cedis

*Notes:*
[A]	Before the survey, identify antibiotic drug of choice (based on standard treatment guidelines) that are being used for adult and child pneumonia
[B]	The field worker will indicate the unit price in the local currency. If there are flat charges paid for each drug given to patients, then this amount should be recorded as the price of the drug. Indicate "0" if drugs are given free. Add cost of syringe to unit price, if applicable.
[C]	Before starting the field test, check the STG to determine the number of units needed for the duration of treatment. Print this number on the form for each drug listed.
[D]	Calculate total cost of treatment [D] by multiplying the unit price [B] by the number of units needed [C]. Only one drug (antibiotic) should be used to calculate cost of treatment and not a combination of drugs.
[E]	Record the lowest daily salary of government worker/public servant.
[F]	Calculate the affordability of the treatment [F] by dividing the total cost of treatment [D] by the lowest daily government salary [E].

Example:

Drug/INN and Preparation	Unit price (inj. vial, tablet, or capsule)	No. of units needed to complete treatment	Total cost of treatment [D]= [B] × [C]	Affordability [F] = [D] ÷ [E]
[A]	[B]	[C]	[D]	[F]
*Adult drug of choice:* Procaine penicillin 1g 1 mill IU	280 for injection plus syringe	3	840	11.2
*Child drug of choice:* Amoxicillin 25 mg/ml suspension in 100 ml bottle	220 per bottle	1	220	2.93
[E] = Lowest daily government salary = 75

Survey form 5: Public health facility: Rational drug use - Prescribing indicator form

Indicator:	Average number of drugs % drugs on EDL	% patients receiving injection % patients receiving antibiotics	Public Health Facility Facility #____ (1-30)

Facility	___________________	Date	______________
Location	__________________	Investigator	______________

Type (R/P)	Patient Gender (M/F)	Date of Rx	No. of drugs prescribed	Antibiotics Yes=1, No=0	Injections Yes=1, No=0	No. of drugs on EDL
[A]	[C]		[D]	[E]	[F]	[G]
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
[B] = Total no. of cases =	[C¹] = Total no. of females =		[D¹] = Sum of [D] =	[E¹] = Sum of "Yes" =	[F¹] = Sum of "Yes" =	[G¹] = Sum of [G] =
	[C²] = Total no. of males =		[D²] = Average no. of drugs = [D¹] ÷ [B] =	[E²] = % antibiotics = [E¹]÷[B] × 100=	[F²]= % injections = [F¹]÷[B] x100=	[G²]= % on EDL = [G¹]÷[D¹] × 100=

*Notes:*
[A]	Select from outpatient treatment records 30 patients seen within the last 12 months (R = retrospective); or, if records are not available, from patients currently being treated (P = prospective). Record whether patient is selected retrospectively or prospectively [A]. Sample of cases can be a combination of P and R. The patient selection process is described on pages 20-21.
[B]	Record the total number of cases reviewed.
[C]	Record the total number of females [C¹] and the total number of males [C²] reviewed.
[D]	Record the number of drugs prescribed for each case [D]. Sum the total number of drugs prescribed for all patients [D¹]. Calculate the average number of drugs prescribed [D²] by dividing the total number of drugs prescribed [D¹] by the total number of patients cases reviewed [B].
[E]	Indicate "0" if no antibiotic was prescribed and "1" if one or more types of antibiotics were given. Sum the total number of cases with antibiotics [E¹]. Calculate the percentage of cases with antibiotics [E²] by dividing the total number of cases with antibiotics [E¹] by the total number of cases reviewed [B] and multiplying by 100.
[F]	Indicate "0" if no injection was given and "1" if one or more injections were given. Sum the total number of cases with injections [F¹]. Calculate the percentage of cases with injections [F²] by dividing the total number of cases with injections [F¹] by the total number of cases reviewed [B] and multiplying by 100.
[G]	Record the number of drug prescribed for the case which are included on the EDL [G]. Sum the total number of drugs for all cases which are listed on the EDL [G¹]. Calculate the percentage of prescribed drugs included on the EDL [G²] by dividing the total number of drugs for all cases which are listed on the EDL [G¹] by the total number of drugs prescribed for all cases [D¹] and multiplying by 100.

Survey form 6: Public health facility: Rational drug use - Patient care form

Indicator:	% of drugs dispensed % drugs with adequate label	% of patients who know how to take drugs	Public Health Facility Pharmacy

Facility	___________________	Date	____________
Location	__________________	Investigator	____________

Patient Gender (M/F)	No. of drugs prescribed	No. of drugs dispensed	No. of drugs adequately labeled	Patient has adequate knowledge Yes=1, No=0
[A]	[B]	[C]	[D]	[E]
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
[A] = Total no. of cases =	[B¹]= Sum of [B] =	[C¹]= Sum of [C] =	[D¹]= Sum of [D] =	[E¹]= Sum of [E] =
[A¹] = Total no. of females =	[B²]=Average no. of drugs = [B¹]÷[A]=	[C²]=% dispensed = [C¹] ÷ [B¹] × 100=	[D²] = % adequately labeled = [D¹] ÷ [C¹] × 100 =	[E²] = % of patients with adequate knowledge = [E¹] ÷ [A] × 100 =
[A²]=Total no. of males =

*Notes:*
[A]	Interview 30 patients leaving the dispensing area/pharmacy. The process is described on page 21. Record the total number of cases [A], the total number of females [A¹], and the total number of males [A2].
[B]	Record the number of drugs prescribed for each patient [B]. Sum the number of drugs prescribed for all patients [B¹]. Calculate the average number of drugs prescribed [B²] by dividing the total number of drugs prescribed for all patients [B¹] by the total number of cases [A].
[C]	Record how many drugs (chemical entity, INN, generic) were given to each patient. Sum the total number of drugs given to all patients [C¹]. Calculate the percentage of drugs dispensed [C²] by dividing the number of drugs given to all patients [C¹] by the total number of drugs prescribed [B¹] and multiplying by 100.
[D]	Check to see if drugs are adequately labeled (name of drug, dosage and duration plus any additional criteria specified by the country). A drug is adequately labeled only if all criteria are met. Sum the total number of adequately labeled drugs [D¹]. Calculate the percentage of drugs which are adequately labeled [D²] by dividing the total number of adequately labeled drugs [D¹] by the total number of drugs dispensed [C¹] and multiplying by 100.
[E]	Determine if patient has adequate knowledge about the drugs dispensed. Ask patient if he/she knows how to take each drug. Indicate:
	"1" If patient can correctly give the name of all drugs or state what the drugs are for and how they should be taken plus any additional criteria specified by the country.
	"0" If the patient cannot give the name of even one drug, cannot state what a drug is for, does not know how to take one of the drugs given, or does not meet any additional criteria specified by the country.
	Sum the total number of patients with adequate knowledge [E¹]. Calculate the percentage of patients with adequate knowledge [E²] by dividing the number of patients with adequate knowledge [E¹] by the total number of cases [A] and multiplying by 100.

Survey form 7: Public health facility

Indicator:	Availability of STG for common local conditions Availability of Essential Drug List (EDL) at the facility		Public Health Facility Facility #____ (1-30)

Facility	________________________	Date	______________
Location	________________________	Investigator	______________

Standard treatment guidelines (STG) available at facility	Yes=1, No=0
National STG
STG for Upper Respiratory Tract Infection
STG for Pneumonia
STG for Diarrhoea
STG for Malaria
STG for Tuberculosis
STG for Sexually Transmitted Infections
Others (describe):

EDL available at the facility	Yes=1, No=0
National EDL
Provincial/District
Health Facility EDL
Others (describe):

Survey form 8: Public health facility

Indicator:	% tracer cases treated using recommended treatment		Public Health Facility Facility #____ (1-30)

Facility	________________________	Date	______________
Location	________________________	Investigator	______________

Diseases/Drug prescribed

Case (Yes=1, No=0)
[A]

Total "yes"
[B]

Total no. of cases
[C]

Percentage
[D]= [B])[C] × 100
[D]

Diarrhoea in Children under age 5

ORS

Antibiotic

Antidiarrheal and/or Antispasmodic

Mild/moderate Pneumonia in Children under age 5

Any one of 1^st line antibiotics (Procaine penicillin, Amoxicillin, Cotrimoxazole)

Anyone receiving >1 antibiotic

Non-pneumonia acute respiratory tract infection (ARI)

Antibiotic

[E] Tracer condition 4: (optional)

Drug 1:

Drug 2:

Drug 3:

[E] Tracer condition 5: (optional)

Drug 1:

Drug 2:

Drug 3:

*Notes:*
[A]	Select at random 30 patients (10 with diarrhea, 10 with pneumonia, and 10 with ARI). Choose only single disease encounters. If sufficient patients are not available in the general outpatient records, use the under 5 ledgers. Always write "1" or "0" to indicate each drug received.
[B]	Sum the total number of yes responses for each row.
[C]	Record the total number of cases reviewed for each row.
[D]	Calculate the percentage of patients receiving each drug [D] by dividing the number of patients who received each medicine [B] by the number of cases reviewed for the disease [C] and multiplying by 100.
[E]	Countries may choose to include other tracer diseases for assessment of compliance to STG or recommended treatment protocol. If other tracer diseases are included, print up to three drugs to be used to measure adherence to these guidelines before starting the survey.

Survey form 9: Private pharmacy

Indicator:	Affordability of key drugs (treating adults and children with without hospitalization)		Private Pharmacy Facility #____ (1-30)

Facility	________________________	Date	______________
Location	________________________	Investigator	______________

Drug/INN and Preparation	Unit price (inj. Vial, tablet, or capsule)	No. of units needed to complete treatment	Total cost of treatment [D]= [B] × [C]	Affordability [F] = [D] ÷ [E]
[A]	[B]	[C]	[D]	[F]
*Adult drug of choice:* Amoxycillin 250 mg Capsule		42
*Child drug of choice:* Amoxycillin 125mg/5ml syrup		2 × 100 mls bottles
[E] = Lowest daily government salary = 7,200 cedis

*Notes:*
[A]	Before the survey, identify antibiotic drug of choice (based on standard treatment guidelines) that are being used for adult and child pneumonia
[B]	The field worker will indicate the unit price in the local currency. If there are flat charges paid for each drug given to patients, then this amount should be recorded as the price of the drug. Indicate "0" if drugs are given free. Add cost of syringe to unit price, if applicable.
[C]	Before starting the field test, check the STG to determine the number of units needed for the duration of treatment. Print this number on the form for each drug listed.
[D]	Calculate total cost of treatment [D] by multiplying the unit price [B] by the number of units needed [C]. Only one drug (antibiotic) should be used to calculate cost of treatment and not a combination of drugs.
[E]	Record the lowest daily salary of government worker/public servant.
[F]	Calculate the affordability of the treatment [F] by dividing the total cost of treatment [D] by the lowest daily government salary [E].

Example:

Drug/INN and Preparation	Unit price (inj. Vial, tablet, or capsule)	No. of units needed to complete treatment	Total cost of treatment [D]= [B] × [C]	Affordability [F] = [D] ÷ [E]
[A]	[B]	[C]	[D]	[F]
*Adult drug of choice:* Procaine penicillin 1g 1 mill IU	280 for injection plus syringe	3	840	11.2
*Child drug of choice:* Amoxicillin 25 mg/ml suspension in 100 ml bottle	220 bottle per	1	220	2.93
[E] = Lowest daily government salary = 75

Survey form 10: Private pharmacy

Indicator:	% of expired drugs Availability of key drugs		Private Pharmacy Facility #____ (1-30)

Facility	________________________	Date	______________
Location	________________________	Investigator	______________

Key drugs to treat common conditions	In stock Yes=1, No=0	Expired drugs in stock Yes=1, No=0
[A]	[B]	[C]
1. ORS
2. Cotrimoxazole tabs
3. Chloroquine tablets
4. Chloroquine syrup
5. Ferrous tabs
6. Folic acid
7. Mebendazole
8. Tetracycline Eye Ointment
9. Iodine
10. Benzoic acid/salicylic acid
11. Paracetamol tablets
12. Paracetamol syrup
13. Amoxycillin Suspension
14. Amoxycillin capsules

[A¹] = Total no. of key drugs =	Total "yes" [B¹] =	Total "yes" [C¹] =
[B²] = % in stock = [B¹] ÷ [A¹] × 100 =
[C²] = % expired = [C¹] ÷ [A¹] × 100 =

*Notes:*
[A]	List of 10-15 key drugs previously identified at national level must be printed before starting the survey. The process is described on page 21. Add the total number of key drugs [A¹].
[B]	Mark "1" if stock is available (even if only one dosage form is available). Mark "0" if the drug is not physically available. Add the total at the bottom [B¹]. Calculate the percentage in stock [B²] by dividing the total in stock [B¹] by the total number of key drugs [A¹] and multiplying by 100.
[C]	For all drugs in stock, check if expired or not. If any of the product is expired, mark "1" for yes. Add all the "Yes" answers [C¹]. Calculate the percentage expired [C²] by dividing the total expired [C¹] by the total number of key drugs [A¹] and multiplying by 100.

Survey form 11: Central/district warehouse

Indicator:	% of expired drugs Availability of key drugs		Central/ District Warehouse Facility #____ (1-30)

Facility	________________________	Date	______________
Location	________________________	Investigator	______________

Key drugs to treat common conditions	In stock Yes=1, No=0	Expired drugs in stock Yes=1, No=0
[A]	[B]	[C]
1. ORS
2. Cotrimoxazole tabs
3. Chloroquine tablets
4. Chloroquine syrup
5. Ferrous tabs
6. Folic acid
7. Mebendazole
8. Tetracycline Eye Ointment
9. Iodine
10. Benzoic acid/salicylic acid
11. Paracetamol tablets
12. Paracetamol syrup
13. Amoxycillin Suspension
14. Amoxycillin capsules

[A¹] = Total no. of key drugs =	Total "yes" [B¹] =	Total "yes" [C¹] =
[B²] = % in stock = [B¹] ÷ [A¹] × 100 =
[C²] = % expired = [C¹] ÷ [A¹] × 100 =

*Notes:*
[A]	List of 10-15 key drugs previously identified at national level must be printed before starting the survey. The process is described on page 21. Add the total number of key drugs [A¹].
[B]	Mark "1" if stock is available (even if only one dosage form is available). Mark "0" if the drug is not physically available. Add the total at the bottom [B¹]. Calculate the percentage in stock [B²] by dividing the total in stock [B¹] by the total number of key drugs [A¹] and multiplying by 100.
[C]	For all drugs in stock, check if expired or not. If any of the product is expired, mark "1" for yes. Add all the "Yes" answers [C¹]. Calculate the percentage expired [C²] by dividing the total expired [C¹] by the total number of key drugs [A¹] and multiplying by 100.

Survey form 12: Central/district warehouse

Indicator:	Stockout duration		Central/ District Warehouse Facility #____ (1-30)

Facility	________________________	Date	______________
Location	________________________	Investigator	______________

Key drugs to treat common conditions (only collect data for drugs with records covering at least six months)	No. of days out of stock	No. of days covered by the review	Equivalent no. of days/year [D] = [B] × 365÷[C]
[A]	[B]	[C]	[D]
1. ORS
2. Cotrimoxazole tabs
3. Chloroquine tablets
4. Chloroquine syrup
5. Ferrous tabs
6. Folic acid
7. Mebendazole
8. Tetracycline Eye Ointment
9. Iodine
10. Benzoic acid/salicylic acid
11. Paracetamol tablets
12. Paracetamol syrup
13. Amoxycillin Suspension
14. Amoxycillin capsules

[A¹] = Total no. of key drugs =			[D¹] = Sum of [D] =
[E] = Average number of stockout days = [D¹] ÷[A¹] =

Notes:
[A]	List of 10-15 key drugs previously identified at national level must be printed in before starting the survey [A]. The process is described on page 21. Add the total number of key drugs [A¹].
[B]	Go through the stock cards covering the review period. Indicate the number of days that each drug is not available or marked "0" on the stock card [B]. A drug is considered in stock if any equivalent product is available in either generic or branded form.
[C]	The review should cover a six month to one year period. Indicate the number of days actually reviewed for each drug [C].
[D]	Compute the equivalent number of stockout days per year for each drug [D] by multiplying [B] by 365 and dividing by [C]. Add the
[E]	total number of stockout days [D¹]. Calculate the average number of stockout days [E] by dividing the total number of stockout days [D¹] by the total number of key drugs [A¹].

Example:

Key drugs to treat common conditions (only collect data for drugs with records covering at least six months)	No. of days out of stock	No. of days covered by the review	Equivalent no. of days/year [D]=[B] × 365÷ [C]
[A]	[B]	[C]	[D]
Cotrimoxazole	90	180	182.5
Paracetamol	30	365	30
Total no. of key drugs [A¹] = 2			[D¹] = Sum of [D] = 212.5
[E] = Average number of stock out days = [D¹] ÷ [A¹] = 106.25

Survey form 13: Central/district warehouse

Indicator:	Adequate storage		Central/ District Warehouse Facility #____ (1-30)

Facility	________________________	Date	______________
Location	________________________	Investigator	______________

Checklist	Store Room Yes=1, No=0 [A]
1. There are working locks in the store room.
2. Storage area and shelves are clean (no dust or litter).
3. No evidence of pests is seen in the area.
4. There is a secure ceiling.
5. There are windows that can be opened or there are air vents.
6. No direct sunlight enters the area (glass window panes are painted white or there are curtains/blinds to protect against sunrays).
7. Area is free from moisture (leaking drains and taps).
8. Drugs are not stored directly on the floor.
9. There is a separate storage and dispensing area for issuing drugs.
10. Drugs are sorted in a systematic way (alphabetical, first expiry-first out).
11. There is stock record system.
12. There is a cold storage with temperature chart.
Rating	Total "Yes" [A¹] =

Survey form 14: Household: Access and use of medicines

Household
# ____
(1-25)
Geographic
Area

Facility _________________ Location _____________________ Investigator

Ask if anyone in the household has been ill in the last two weeks, excluding hospital admission. If yes, complete form. If no, go to next household.
1.	Sex of person who has been ill (record only one illness episode per household, even if more than one person has been ill)
	Male Female
2.	Age (in years) of person who has been ill
	Under 1	1-5		6-15	16-54			55 and older
3.	Educational attainment of household head
	No Education Primary Secondary				Vocational			University				Post graduate
4.	What were the person's symptoms? (mark one or more)
	Diarrhoea Cough Fever
	Others (specify) _____________________________________________________________
5.	What was the person's diagnosis, if any? ______________________________________________
6.	What was done? (mark one or more)
	Consulted traditional healer				Sought advice from friend/neighbour/family
	Consulted public health clinic/hospital				Bought medicine without consultation
	Consulted private health clinic/hospital				Used medicine left from another illness
	Consulted mission/NGO clinic				Did nothing
	Consulted pharmacist				(If no one was consulted, skip to question 12)
	Consulted drug seller
7.	Was medication prescribed?
	Yes No
8.	Which medicines were obtained?
	All Some None
9.	If not all, why not? (mark one or more)
	Price was too high				Traditional healer did not have all the medicines
	Did not have enough money				Public pharmacy did not have all the medicines
	Not able to borrow enough money				Private pharmacy did not have all the medicines
	Too many medicines were prescribed				Mission/NGO facility did not have all the medicines
	Did not believe all the medicines were needed				Drug seller did not have all the medicines
	Started to feel better				Already had some of the medicines at home
	No time to get all the medicines				Other
10.	How much of the prescribed medicine was taken?
	All Some None
11.	What medicines were used? (include traditional medicines) (list one per line)		Amount spent out-of-pocket in local currency (write "0" if free)		Mark an X through the source as numbered (1-10)
					1. Traditional healer 2. Public health centre/hospital 3. Private health centre/hospital 4. Mission/NGO facility 5. Drug store						6. Private pharmacy 7. Local store/marketplace 8. Friends/neighbours/family 9. Medicines already owned 10. Other
					1	2	3		4	5	6		7	8	9	10
					1	2	3		4	5	6		7	8	9	10
					1	2	3		4	5	6		7	8	9	10
					1	2	3		4	5	6		7	8	9	10
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[A]=Total amount spent on medicines_______
12. [B] = Total household expenses last week in local currency = ________________________
13. [C] = Total amount spent ÷ total household expenses last week × 100 = [A] ÷ [B] × 100=___________