> practice? Will it be possible to design simple ways of collecting meaningful and consistent data on quality? Is it even reasonable to view health care quality as a facility characteristic? Actual client experience may be endogenous to client characteristics and previous client

> behavior. For example, both structural (e.g., attending staff, access to equipment and drugs) and process (e.g., staff attitudes, time spent with the patient) characteristics of care may depend on client characteristics such as income, social standing, education, assertiveness of the client, or on how much was paid. This would mean that different individuals do not only perceive their visit to the health care provider differently, but also receive different treatment. Progress in the measurement of quality is not only important for the purpose of monitoring, but also for increasing the value of research on health outcome and health related behavior. To date, the disparate approaches to measuring health care quality, and the sometimes inconsistent findings, largely reflect differences in data availability and quality. Similar methodological concerns exist in respect of the measurement of costs and outputs.

Surveys have been better at documenting variation in facility performance-both in terms of quality and efficiency-than in explaining differences across facilities and countries. We still do not know enough about the possible merits of private and NGO providers, or about whether general prescriptions can be made in respect of the institutional context in which public providers operate. There are a number of instructive examples of surveys that have focused on detailed performance measurement, including concerning staff perceptions and behavior. Some of these surveys have also made some progress in trying to systematically capture important aspects of the institutional and organizational environment that may be important determinants of performance. However, this is very much an open research agenda, and we are still far from a consensus about what features of the facility and its environment matter for performance, and about how we should go about measuring these features. Notwithstanding the inherent difficulties involved in researching this area, the widespread and well-documented problems of quality and efficiency in health care provision suggest that the potential payoffs from progress in this area are considerable.

Finally, what has been the impact of health facility surveys? This is very difficult to assess, not least because of the considerable differences in focus and motivation of surveys. Yet, it is probably safe to say that the impact has not been as great as it could have been. In many cases, data have been under-utilized and survey finding have not found their way into the policy process. Although this problem is by no means universal, it raises some important challenges for the future. Ultimately, impact requires a degree of involvement by policymakers in the design and implementation of surveys, as well as in the dissemination and use of survey findings. In part, this depends on the survey approach being attuned to the needs and requirements of a particular context. However, survey findings generally gain force if they can be generalized and compared with findings from other surveys. An important challenge is therefore to improve consistency across surveys - both over time and across countries. This would require agreement about some core methodological issues, possibly in the form of some core facility modules that will permit international analyses of health system performance.

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