The quality of the health care process in developing countries has been assessed by many studies using the following methods: direct observation of patient--provider encounters, review of records, exit interviews with clients, interviews with providers, and inventories of facilities, drugs and supplies (1-7). Assessing the quality of case management of sexually transmitted diseases (STD) is now receiving more attention because the treatment of STDs has become an important component of acquired immunodeficiency syndrome (AIDS) control programmes. WHO has included proper case management and counselling of STD patients among the proposed AIDS prevention indicators (8), and also developed a facility-based quality assessment protocol for STD case management (9). This protocol, which incorporates observation, provider interviews, simulated patients, and inventories of facilities, drugs and supplies, is similar in concept to other facility-based assessment surveys developed by WHO for other diseases (7).
One difficulty in quality assessment is judging the process of care. There are many untested assumptions about the validity of observation data (5), and nothing has been published on the comparison of reliability and validity of data-collection methods for quality assessment in developing and developed countries. One unpublished study (10), conducted in Peru, compared direct observation of case management of childhood diarrhoea with simulation using a doll. This study found that health workers performed similarly, both in simulated circumstances and when carrying out the same activities under observation in normal clinical conditions. Published studies are needed on the reliability and validity of the various methods so that quality assurance programmes can determine how best to assess quality, and supervisors can select appropriate methods.
Quality assessment methods differ in their ability to obtain reliable data about what takes place during a normal provider--patient encounter. Summarized below are the known or presumed advantages and disadvantages for the most frequently used methods.
* Review of patients' records. The information provided in such records is easy to extract and readily available at the convenience of the compiler, and can be assessed objectively using explicit criteria (11). This information can be collected on a large sample, which allows assessment of the health care process for rare conditions. However, the information present in patients' records is often incomplete, particularly as regards counselling, and it is not possible to recover missing information. In addition, in outpatient settings in developing countries, facility-based patients' records are often scanty or not used at all.
* Direct observation of Provider--patient encounters. A more complete picture of what providers do during case management can be ascertained by direct observation, but the diagnostic thought process of the provider is difficult to observe without discussion (8). Furthermore, the presence of an observer could alter a provider's behaviour for better or worse.(a) Finally, direct observation would generally be able to provide information about the most common types of cases only; it would be difficult to generate an adequate sample size for rare conditions.
* Interviews with providers. These interviews yield information about the person's knowledge, but may not reflect his/her actual performance. Such information can be incomplete if the providers have difficulty in visualizing abstractly what they do with an actual patient. However, interviews can provide information about knowledge related to more serious and less common conditions, as well as the provider's considerations in the diagnostic process.
* Exit interviews with patients. Interviewing patients after they have received health care can supply information about what the provider did and what the patient learned during the encounter. …