more representative information that data collected routinely at facility level in<sup>contexts</sup> where access to health care is limited.

Similarly to surveys carried out at household level, semi-standardized surveys of health care providers - for example, Service Provision Assessments (SPAs)<sup>or Situation</sup> Analysis (SA) - have provided valuable assessments of health care quality, infrastructure, utilization and availability. For example, a recent survey in Kenya (Macro International<sup>2000)</sup> found that although contraceptive services, drugs and materials are widely available, compliance with infection control procedures, including sterilization of<sup>equipment and</sup> sterilization of needles was often poor. Moreover, consultation observations revealed<sup>that the</sup> diagnostic process was often unsatisfactory, and that clients were frequently provided<sup>with</sup> incomplete or insufficient information to chose between interventions and<sup>to ensure</sup> compliance with treatment regimes. Aside from providing data for research on the determinants of health outcomes and health-related behavior, this type of<sup>informationis</sup> valuable in the design of health sector strategies and interventions. Moreover, repeat<sup>surveys</sup> permit the monitoring of changes in quality over time.

In other cases, household and/or facility surveys are implemented as components of the monitoring and evaluation of specific projects or programs. As noted by<sup>Mills (1997),a</sup> broad array of health sector reforms have been proposed in recent years, notwithstanding<sup>the</sup> fact that there is currently little empirical evidence to vouch for their effectiveness.<sup>In this</sup> context, efforts aimed at continuous assessment and ex post evaluation are of particular importance. Under ideal circumstances, this will entail (i) a baseline survey; (ii) subsequent policy change in a random sub-sample of units; and (iii) a follow-up survey of<sup>both treatment</sup> and control facilities. However, in many cases evaluations have to be carried<sup>out under less</sup> than perfect conditions.

There are several examples of surveys that have been implemented in the context of project or program evaluation. For example, two household and facility surveys have been carried out in Uganda (1995 and 1997) as components of the ongoing DISH project (reproductive health). The surveys have been implemented to measure changes in reproductive, maternal and child health knowledge and behavior (Kantende and others 1999). An ongoing Multi-Country Evaluation (MCE) of the Integrated Management of Childhood Illnesses (IMCI) comprises another example of the role that facility surveys can play in the monitoring and evaluation of health sector interventions. Worldwide there are 30 countries<sup>at</sup> different stages of implementation of IMCI, among which Uganda, Peru, Bangladesh and Tanzania will participate in the MCE. The purpose of the MCE is to document<sup>theeffects of</sup> IMCI interventions on health workers performance, health systems and family behaviors; determine the extent of measurable impact on health outcomes; and, describe costs of implementation (WHO 2001). Health facility surveys also formed part of the evaluation strategy for the Bolivian Social Investment Fund (SIF), which was established in<sup>1991to</sup> direct public service investments to poor communities. Surveys were collected in 1993 and 1997, and included households, communities, and service delivery units. The surveys demonstrated clear improvements in infrastructure and equipment, as well as<sup>increased</sup>

> 48 In many cases these efforts are ongoing. It is therefore difficult to determine how successful this approach has been in analyzing the determinants of facility performance. Many of these surveys are discussed in greater detail in the appendix.

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