composite indicators can be constructed to provide information on the capacity of the health facility to perform basic clinical tasks. This type of exercise can focus on defined "tracer conditions".<sup>4 2</sup> In general, this type of information can be used to estimate total resource needs and to support decisions about the allocation of resources within the sector. In principle, surveys can be used to estimate unit costs for the delivering different types of services in different contexts. This could then form the basis for calculating total resource needs to meet certain service standards, and for making decisions about the allocation of resources within the sector. In practice, however, surveys may not be the most appropriate tool for costing basic service packages.<sup>43</sup> However, survey information on the availability of human and material resources at facility level can point at egregious imbalances in how resources are allocated across inputs.

Second, it should be noted that while resource inadequacy at the level of health care facility is likely to be the consequence of a general shortage of resources in the sector, these problems may be aggravated by weaknesses in the budget execution system, including systems of procurement and distribution of in-kind resources. For example, Public Expenditure Tracking Surveys have shown how delays and leakage in budget execution can result in budget outturns that depart considerably from intended allocations.44 In general, surveys can offer a perspective on support systems and administrative routines and procedures that is not otherwise available.

# _Monitoring, evaluation, and accountability_

A number of survey initiatives have for many years served as bases for continuous assessment of health status and living standards more generally. These include household surveys such as the Demographic and Health Surveys (DHS), the Multi-Indicator Cluster Surveys (MICS), and the Living Standards Measurement Study (LSMS). Data from these surveys have proved a useful supplement to data gathered from surveillance sites, such as the ICDDRB Centre for Health and Population Research in Bangladesh<sup>4 5</sup> and the Indepth Network<sup>46</sup> , as well as from more traditional sources, such as censuses and vital registration systems. The attraction of household surveys is that they can be stratified by, for example, gender, location, ethnicity, and household living standards.<sup>47</sup> In addition, surveys provide

> 42 Most facility surveys have taken a "checklist approach" to assessing resource availability, focusing on the availability of certain types of equipment, staff, drugs and other inputs. However, in the analysis of input data, the availability and quantity of inputs are often not related to output vanables, making it difficult to make any statements about the _adequacy_ of resources. There are only few examples of surveys that have used tracer conditions. One example is a survey of rural health facilities in Papua New Guinea, aimed at assessing the "potential quality" of each unit (Gamer, et al. 1990). In this case, a range of items on a checklist was scored to construct a "quality indices", reflecting the capability of each facility to perform certain common clinical tasks. The study analyzed differences in resource adequacy across, _inter alia,_ agency types and regions.

43 Comprehensive costing is typically beyond the scope of most surveys. In addition, survey based costing is likely to result in considerable variation in unit cost across unit. This variation may have many explanations, including differences in efficiency, quality, case mLx, and input prices.

44 Results from these surveys are discussed in greater detail below.

45 htto://www.icddrb.org 46 htto:H/www.indenth-network.or2/ 47 See htto://www.worldbank.org/novertv/health/data/index.htm for a 42-country study that disaggregates various key MCH outcomes by poverty status.

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