Do health care quality improvement policies work for all? Distributional effects by baseline quality in South Africa

Health care quality improvement (QI) initiatives are being implemented by a number of low‐ and middle‐income countries. However, there is concern that these policies may not reduce, or may even worsen, inequities in access to high‐quality care. Few studies have examined the distributional impact of QI programmes. We study the Ideal Clinic Realization and Maintenance program implemented in health facilities in South Africa, assessing whether the effects of the program are sensitive to previous quality performance. Implementing difference‐in‐difference‐in‐difference and changes‐in‐changes approaches we estimate the effect of the program on quality across the distribution of past facility quality performance. We find that the largest gains are realized by facilities with higher baseline quality, meaning this policy may have led to a worsening of pre‐existing inequity in health care quality. Our study highlights that the full consequences of QI programmes cannot be gauged solely from examination of the mean impact.