Are Client Satisfaction Surveys Useful? Evidence from Matched Facility and Household Data in Madagascar

Client satisfaction surveys in developing countries are increasingly being promoted as a means of understanding health care quality and the demand for these services. However, concerns have been raised about the reliability of responses in such surveys: for example, 'courtesy bias' may lead clients, especially if interviewed upon exiting clinics, to provide misleadingly favorable responses. This study uses unique data from Madagascar to investigate these and other issues. Identical questions about satisfaction with local health care centers were asked in user exit surveys and in a population based household survey; the latter would be less contaminated by courtesy bias as well as changes in provider behavior in response to being observed. We find strong evidence that reported satisfaction is biased upward in exit surveys for subjective questions regarding (for example) treatment by staff and consultation quality, but is not biased for relatively objective questions about facility condition and supplies. The surveys do provide useful information on the determinants of consumer satisfaction with various dimensions of provider quality. Still, to obtain reliable estimates of consumer perceptions of health service quality, household based sampling appears to be far superior to the simpler exit survey method