2001). However, it is also known that there are considerable problems in interpreting subjective perceptions of health care quality. In part, this is due to "courtesy bias", such that individuals may provide responses that they deem socially acceptable.<sup>33</sup> However, it is also the case that subjective perceptions of health care quality depend on both needs and expectations, which in turn are underpinned by the explanatory models held by different individuals regarding the functioning of the body, etiology, and the appropriateness of different remedies and interventions in response to a given symptom (Atkinson 1993). There may be important systematic differences across demographic and socio-economic groups in respect of these explanatory models, possibly making client perceptions poor proxies for objective assessments of different dimensions of quality.

There are two other approaches relating to client perceptions and satisfaction that, despite not relying strictly on facility surveys, deserve mention in this context. First, following the publication of the 2000 World Health Report (WHO 2000), the concept of health system responsiveness has gained increased currency. The concept of responsiveness is different from patient satisfaction in that it is seen to pertain solely to non-health enhancing aspects of the health system, and in its focus on health systems rather than individual providers (de Silva 1999). In addition, the methodology for measuring responsiveness seeks to overcome some of the perceived weaknesses of measures of patient satisfaction, in particular in respect of relativity arising from differences in expectations and experiences.<sup>3 4</sup> While the methodology is far from uncontested (see, e.g., Williams 2001), the framework may contribute to improved measurement of client satisfaction in the context of facility surveys.

Second, there is a host of approaches that seek to gather "community-based evidence" on service delivery. This includes service delivery surveys, "report cards" on public services, and other related approaches.<sup>3 5</sup> These approaches cannot in general be described as facility surveys, nor are they always limited to the health sector. Rather, the purpose is to use a range of different tools - e.g., household interviews, focal groups, institutional reviews of service providers, interviews with service providers - to elicit information about awareness and experiences of services, and opinions about prices, quality, waiting times, courtesy, etc. Despite their simplicity, the approaches can usefully inform the formulation of hypotheses about service delivery, as well as the design of quantitative surveys. Moreover, they have proved effective (at least from a monitoring and advocacy perspective), and may in the future complement and support facility surveys.

**33** For example, Bitran (1995) found that regardless of facility scores on quality of diagnostic and treatment norms, and availability of drugs and supplies, patients generally reported being satisfied with the treatment they received, and mdicated that they would return for future treatment. Many other studies have noted an inconsistency in responses, where high levels of overall satisfaction are combined with widespread complaints about specific aspects of care or the health care system. With a view to reconcile these findings, it has been suggested that positive and negative comnments about health care are typically not reducible to satisfaction and dissatisfaction, and a more careful methodology is required to collect meaningful qualitative data on patient perceptions (Atkinson 1993).

**34** The different aspects of responsiveness considered in the WHO methodology are: dignity, autonomy, confidentiality, prompt attention, quality of basic amnenities, access to social support networks during care, choice of care provider (de Silva 1999).

**35** For service delivery surveys, see e.g., Cockcroft et al. (1999) and CIET international (1996). See also www.ciet.org. For report cards, see, e.g., Paul (1992; 2000) and World Bank (2001a).

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