policy framework.<sup>12</sup> The premise of these initiatives is that sustainable development impact requires local governance capacity, and an effective public expenditure process. In practical terms, this means that governments now face new pressures to demonstrate that resources are being channeled into increased and improved delivery of public services.

On other occasions, the motivation has been to better understand the influence that governments have-through the various policy instruments-over provider performance. There are few examples of surveys specifically addressed to these questions. A recent case is a survey implemented in Paraguay, carried out with support from MEASURE Evaluation, to identify and quantify the effect of transferring management control for basic health services provision from central to municipal government in Paraguay on costs, efficiency, basic health service quality, and patterns of health service use and equity (Angeles and others 1999).

# **III. What Data to Collect and How to Do It**

As is clear from the previous section, health facility surveys have served widely differing purposes. The choice of approach, as well as the scope and precise content of the survey instruments, reflect these differences. Depending on the survey, data have been collected on inputs, costs, outputs, quality, staff behavior and perceptions, and the institutional and organizational environment. Different approaches have been used to collect the data, including facility questionnaires; health worker questionnaires, sometimes including tests of clinical skills; direct observation of facilities or facility "audits"; direct observation of patientclient interactions; record reviews (e.g., stock cards, material requisitions, patient registers); and, exit polls, possibly including a re-examinations. In addition, some facility surveys have also collected data from administrative units "upstream" from the facility. This section will review the types of data that have been collected in facility surveys, and the different approaches that have been applied.

## **_Inputs_**

Data on facility inputs are a standard feature of most facility surveys. There are three primary reasons for collecting these data. First, information about the availability and quantity of inputs can be used to assess the adequacy of resources at facility level. Second, and related to resource adequacy, the availability and characteristics of inputs at facility level affects the range, quality, and effectiveness of services provided. Finally, in combination with price information, data on inputs are required for the analysis of costs. Data on some facility inputs are, of course, often available from administrative records at national or sub-national level. However, a survey approach is motivated by a lack of confidence in these records, or by insufficient richness and detail.

> 12 In large part, this shift **in** the approach to aid has resulted from increased appreciation of the fungibility issue and from finding that lack of government control over projects and the budget process more generally have senously undermined long-term impact of aid. The World Bank (1998, p. 12) notes: "Aid agencies have a long history of trying to 'cocoon' their projects using free-standing technical assistance, independent project implementation units, and foreign experts - rather than trying to improve the institutional environment for service provision. ..They have neither improved services m the short run nor led to institutional changes in the long run."

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