1 2
3 4
1 2 3 4 5 6 7
1 2 3 4 5 6 1 2 3 4 5 6 7
1 2 3 4 5 6 1 2 3 4 5 6 7
1 2 3 4 5 6 7 5 12
SECTION 3a: MARKET ACCESS
3.1 Where did most of the households in this community
buy their foodstuffs in the last month?
3.2 What is the name of that district and province?
Province name District name
for office code
3.3 What is the time taken to get to the nearest
permanent food market in the past month?
3.4 What is the cost of return
transport to the permanent food
market, including
overnight accommodation if
needed, in the past month?
3.5 What is the frequency of vehicle
transport to the nearest permanent food
market in the past month?
3.6 What is the cost of transporting 50 kg of wheat from
the permanent food market to the community in the past month?
excluding purchase cost of wheat
Footanimal
Shared public
transport bus
Private vehicletaxi
Bicycle 7463411534
1 2 3 4 5 6 7 1 2 3 4 5 6 7
1 2 3 4 5 6 7
1 2 3 4 5 6 7 1 2 3 4 5 6 7
1 2 3 4 5 6 7
1 2 3 4 5 6 7 1 2 3 4 5 6 7
1 2 3 4 5 6 7
1 2 3 4 5 6 7 1 2 3 4 5 6 7
1 2 3 4 5 6 7
1 2 3 4 5 6 7 1 2 3 4 5 6 7
1 2 3 4 5 6 7 6 12
SECTION 4: HEALTH ACCESS
4.1 How long does it take to reach the nearest ________
by footanimal in the last month? Based on one way
travel
4.2 How long does it take to reach the nearest ________
by sharedpublic transport in the last month? Based on
one way travel 4.3 What is the
cost of one way transport from
your community to this service
provider by shared public
transport in the last month
cost per person of one
way transportation
only?
4.4 How long does it take to reach the nearest ________ by
private vehicletaxi in the last month? Based on one
person one-way travel 4.5 What is the cost of one
way transport from your community to this service
provider by private vehicletaxi in the last
month cost of transportation only?
1 No time - in community 2.6
2 Near community - 1 hr or less 3 Less than 14 day 1 - 3 hrs
4 14 to 12 day 3 - 6 hrs 5 12 to one full day 6-12 hrs
6 More than one full day 12 hrs
7 Not applicable2.4
Health post
house of community
health worker
Public Clinic may
be Basic or Comprehens
ive Health Center
District or Provincial
Hospital
Private doctors
office or private
hospital
Private pharmacy
Type of service
provider 3384411532
1 2
3 1
2 3
1 2
3 1
2 3
1 2
3 1
2 3
1 2
3 1
2 3
1 2
3 1
2 3
1 2
3 1
2 3
1 2
3 1
2 3
1 2
3 1
2 3
1 2
3 1
2 3
1 2
3
1 2
3 4
Type of service
provider
Health post
house of community
health worker
Public Clinic may
be Basic or Comprehens
ive Health Center
District or Provincial
Hospital
Private doctors
office or private
hospital
Female CHW Male CHW
Female doctor Female nurse
Female midwife Male doctor
Male nurse Female doctor
Female nurse Female midwife
Male doctor Male nurse
Female doctor Female nurse
Female midwife Male doctor
Male nurse Yes
NO Dont
Know Yes
NO Dont
Know
Private pharmacy
Female doctor Male doctor
4.6 Are the following types of staff present in the nearest _________?
4.7 Where do most community members get medicines when they are sick?
