psychological interaction between the health care provider and the patient. This can include the general attitude and courtesy of the health worker, but also communication of information about treatment regimes, medication, return visits, etc. On the other hand, direct observation of patient-provider interactions may suffer from bias due to the behavioral response of the health worker to being observed. In addition, differences in case mix across providers can confound the assessment of quality. Observation of case management has been a feature in surveys such as the WHO multi-country evaluation of IMCI, SPAs, and Situation Analysis.

What is the best approach-clinical vignettes or consultation observation? Either approach has its advantages. Clinical vignettes are easy to administer, and do not necessarily require enumerators with sophisticated medical training. Consultation observation, on the other hand, provides more direct evidence from a clinical setting and permits observation of non-clinical aspects of the provider-client interaction. That said, the presence of an observer may lead the provider to adjust his or her behavior. Assuming that the provider effectively applies clinical knowledge in case management, and that observation bias is not significant, we would expect a close correspondence between quality measures from vignettes and clinical observations. There is indeed some evidence from the US that this is the case. Peabody and others (2000) report evidence that vignette scores in an outpatient setting appeared to reflect physician practice as recorded in observation episodes. On the other hand, it is not clear that these findings can be generalized. As noted by Peabody and others, the costs-in terms of time and effort-of complying with diagnostic and treatment procedures in a clinical vignette are negligible. This is not the case in a clinical setting. As a result, we would expect vignettes to be biased in favor of high quality in a context where external and/or internal incentives for compliance are low. Reflecting this concern, Leonard et al (2000) report evidence from Tanzania that while most clinicians knew how to deal with certain tracer conditions (on the basis written examination), many did not actually do the right thing when observed in a clinical setting.

QualIty measurement througdh beneflciiry perceptonM The assessment of quality through structural and process characteristics is premised on a set of established norms for clinical effectiveness. An alternative approach to assessing quality of care is to ask beneficiaries about their perceptions. Patient satisfaction is important in its own right as an objective of health care, but also as an indicator of the structure, process and outcome of health care, and through the effect of satisfaction on client behavior. Patient satisfaction is typically assessed through interviews with actual or potential patients. Data on actual patients can be collected through exit polls, whereas a sample of households or individuals in the community must be surveyed in order to capture the views of non-users.<sup>32</sup> Multi-topic household surveys with added facility modules, such as the LSMS and CWIQ surveys, have typically not collected detailed data on patient perceptions, whereas exit polls with sections on patient perceptions have often been a feature of more focused health surveys (e.g., WHO MCE, SPAs, and Situation Analysis surveys).

There is some evidence to suggest that observations and client exit interviews provide similar results for many (family planning) quality indicators (Bertrand, Sullivan, and Rice

> 32 Data can also be collected through focus group discussions. This option is not discussed here.

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