to 25.27 Even after this considerable simplification, the recommended approach requires data collection through consultation observation, a facility audit, and interviews with clients. More generally, facility surveys have measured quality through a combination of three different approaches: inputs, the consultation process, and beneficiary or client perceptions. Although it is not possible to reach full agreement on how to best measure quality, findings from research to date can provide some guidance.

# **Quality measurement through inputs**

The most common approach to measuring the structural dimension of quality is to collect data on the availability and quantity of inputs considered important for the delivery of services. Quality can then be proxied by focusing on particular inputs, for example drugs. Alternatively, composite quality indices can be constructed.<sup>28</sup> Quality data of this kind permit an analysis of the relationship between quality and health outcomes and behavior.<sup>2 9</sup> Observed variation in "structural quality" also raises the question of what explains these differences. While some of these indicators are important and have the benefit of being easy to measure, they are likely to be inadequate as measures of quality.<sup>30</sup>

# **Quality measurement through clinical vignettes**

Good health care quality, as pertaining to the overall management of a health problem, clearly requires more than material inputs. In this regard, clinical skills are of obvious importance, and many surveys have tried to collect data concerning the process of care. Here, the general principle is to assess case management against established diagnostic and treatment norms. The most common ways of assessing "process quality" is through clinical vignettes and consultation observations.<sup>31</sup> In addition, some surveys (e.g., DHS SPA) have asked questions about general facility procedures, for example in respect of sterilization, disposal of needles, etc.

I Clinical vignettes assess clinical skills by presenting health workers with hypothetical cases, and seek to elicit information about the way in which they would handle such a case. This approach has the advantage of permitting a considerable degree of structure in the survey instruments, thus limiting the need for technical skills in the enumerators. It has been used in a number of surveys, including the Jamaica LSMS, the IFLS, and DHS SPAs. A more ambitious approach entails using medically qualified enumerators, who observe the case management of health workers in the respective facilities. While the skill requirements for this type of survey can be prohibitive in many contexts, the approach has the advantage of permitting a more comprehensive assessment of the process of care. For example, beyond the strictly clinical aspects of the case management, the enumerator can assess the social-

> 2 7 The "Quick Investigation of Quality" (QIQ) approach is described **in** Bertrand et al. (Bertrand, et al. 2001).

**28** See, e.g., Gamer et al. (1990).

**29** Evidence from this literature is discussed below.

**30** One reason for this is that we may expect only a weak link between structural dimensions of quality and health outcomes. As noted by Gilson et al. (1993), process quality **is** more likely to be validated in terms of effectiveness than structure.

**31** Consultation observation is often combined with re-examination of the client. It is also possible to carry out ex post reviews of patient records, or chart abstractions. This approach however relies on records that are often inadequate in the case of outpatient care and/or unavailable **in** developmg countries (Peabody, et al. 2000).

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