_Figure 2 - Provider-household linkages_ <!-- Start of picture text -->
| Public |<br>Government<br>* expenditure ----------- Household Health<br>* policy outcomes<br>* regulation<br><!-- End of picture text -->

Work on the link between households and providers dates back to the 1970s, when the World Fertility Survey (WFS) started collected data to measure the impact of health service availability on fertility and mortality (Turner and others 2001). Initially, data were collected at community level through interviews with key community informants. This practice was continued in the context of the DHS surveys, which took over from the WFS in 1984.' Many LSMS surveys also included community modules that collected information on, _inter alia,_ the availability of public services.

From collecting community data on service delivery, it was a natural extension to visit the actual service delivery units. In the late 1980s, a number of LSMS surveys (e.g., C6te d'Ivoire and Jamaica) experimented with health facility and/or school surveys to complement the household data. A more systematic approach-Situation Analysis (SA)-was introduced by the Population Council in 1989, where the focus was on family-planning and reproductive health services. At least in part, the approach was motivated by findings emerging from the DHS surveys, which indicated that weaknesses on the supply side were important in explaining low contraceptive prevalence (Miller and others 1997, 1998). Unlike the LSMS facility surveys, the SA did not also collect household data, although client interviews were carried out at the sample sites. More recently, facility surveys have been implemented in conjunction or coordination with DHS household surveys. These so called Service Provision Assessments (SPAs) are ambitious in scope, and seek to provide information about the characteristics of health services, including extensive information about quality, resource availability, and infrastructure.<sup>2</sup>

# _Measuring and understandingproviderperformance_

In some surveys, the facility rather than the household is the object of interest. Facility data can serve monitoring or program evaluation purposes, but may also provide the basis for empirical work on the determinants of facility performance. In other words, how do we

> ' In the context of the DHS surveys, these conununity surveys were referred to as the Service Availability Module.

> 2 Linking household and facility data raises important sampling questions. For example, if data are only collected from the facility that is closest to the community, **it** may only be possible to capture the local health care market in a very limited sense. This issue is particularly problematic in urban and peri-urban setting. Also, analysis of bypassmg and choice between providers is precluded. The alternative is to collect data from a more comprehensive sample of health care providers in the community. However, the survey can impossibly cover the "full" market for health care, and the appropriate interpretation of empirical results on the effect of facility characteristics on health outcomes and behavior is often far from clear. Moreover, as a consequence of the inevitable clustenng of facilities, the precision of point estimates of facility variables is likely to be reduced. These issues are discussed in considerable detail in Turner et al. (2001).

3