Table 1 Steps in the simulated client (SC) method in a health facility (HF) survey in Benin

1.

The SC and the co-surveyor drove to within 10-minutes walking distance from the HF.

2.

The SC walked to the HF and observed the consultation for her child. The SC did not choose the health worker (HW); she went to whichever consultation room she was told to by the HF staff and seen by the HW there.

3.

During the consultation, the following steps were taken.

a. At the beginning of consultation, the SC gave the child’s health booklet to the HW.

b. The SC spontaneously offered a chief complaint that the child had fever for 1 day.

c. If the HW asked, the SC said the child had diarrhea for 1 day and vomited once. All other signs and symptoms denied.

d. When the time came to purchase medicines, if the HW prescribed an injection, the SC said she had little money and could not buy injections and she asked the HW to write which injections the child needed. All non-injectable medicines were purchased.

e. If the HW tried to give the first dose of a medicine to the child, the SC said she could not give medicines to the child until she showed them to her husband.

f. If the HW ordered a blood test, the SC said she would not agree to have the child’s blood taken because she had to ask her husband first. (During training, SCs were repeatedly instructed to never allow her child to be given a medicine or a blood test.)

4.

The SC walked back to the survey vehicle and began completing the questionnaire.

5.

The co-surveyor walked or drove to the HF and told the HW that he was there to collect information on the children seen that day. This story gave the co-surveyor an excuse to examine HF records. The HW’s identity was confirmed when the name of the SC child was found.

6.

The co-surveyor returned to the survey vehicle and recorded on the questionnaire the HW’s name and whether the register was completely filled-in (correctness not assessed).