Facility standards and the quality of public sector primary care: Evidence from South Africa's “Ideal Clinics” program

Nicholas Stacey*, Andrew Mirelman, Noemi Kreif, Marc Suhrcke, Karen Hofman, Ijeoma Edoka

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review


Primary healthcare systems are central to achieving universal healthcare coverage. However, in many low- and middle-income country settings, primary care quality is challenged by inadequate facility infrastructure and equipment, limited human resources, and poor provider process. We study the effects of a recent large-scale quality improvement policy in South Africa, the Ideal Clinics Realization and Maintenance Program (ICRMP). The ICRMP introduced a set of standards for facilities and a quality improvement process involving manuals, district-based support, and external assessment. Exploiting differential prioritization of facilities for the ICRMP's quality improvement process, we apply differences-in-differences methods to identify the effects of the program's efforts on standards scores and primary care quality indicators over the first 12 months of implementation. We find large and statistically significant increases in standards scores, but mixed effects on care outcomes—a small magnitude improvement in early antenatal care usage, null effects on childhood immunization and cervical cancer screening, and small negative effect of human immunodeficiency virus (HIV) care. While the ICRMP process has led to significant improvements in facilities' satisfaction of the program's standards, we were unable to detect meaningful change in care quality indicators.

Original languageEnglish
Number of pages16
JournalHealth Economics (United Kingdom)
Early online date17 Mar 2021
Publication statusE-pub ahead of print - 17 Mar 2021

Bibliographical note

Funding Information:
This research was funded by the National Institute for Health Research (NIHR) (16/137/90) using UK aid from the UK Government to support global health research. The views expressed in this publication are those of the author(s) and not necessarily those of the NIHR or the UK Department of Health and Social Care. Additional financial support was provided by the South African Medical Research Council (grant no: 23108). The work benefited from helpful suggestions from the Global Health Economics and Econometrics group members and advisors Anna Heard, Mead Over, and Olusoji Adeyi. The authors would like to thank Jeanette Hunter and colleagues at the National Department of Health for their time and assistance in undertaking this work. Finally, we would like to thank two anonymous referees for substantive comments that strengthened the paper significantly. All views, errors, and omissions are our own.

© 2021 The Authors. Health Economics published by John Wiley & Sons Ltd.


  • policy
  • primary healthcare
  • quality
  • regulation
  • South Africa

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