immediate closure. Facilities scoring 11%-40% are considered “minimally compliant” and receive a 3-month notice for improvement and re-inspection, while facilities with scores between 41%-60% are classified as “partially compliant” and receive a 6-month notice for improvement and re-inspection. For these two categories, facilities are supposed to be closed if they do not improve to a higher category by the third inspection. Facilities that score above 60% do not face any risk of closure. Those classified as “substantially compliant” (61%-75% of maximum score) are re-inspected every 12 months and facilities in the “fully compliant” category (above 75%) face inspections every 24 months (Table A1). These standards are very ambitious and in multiple pilots over 2 years, we documented that almost all facilities would fall in the “minimally compliant” category with very few scoring above 60%. The boards and councils nevertheless insisted on maintaining these high standards, which therefore departs quite strikingly from the focus in economic theory on marginal changes.

**Implementation** : The new regulation was implemented by full-time inspectors nominated and seconded by the Boards and Councils and County Governments for one year. Candidates went through a standardized training course developed as part of the intervention with classroom and field assessments and the top 12 candidates were selected. Our results should be viewed in the light of this stringent selection and training process, which is known to affect performance (Ashraf et al., 2020). There were very few instances of corruption and/or rude behavior and inspectors were able to frame the inspections as an exercise carried out together with the facility in the face of considerable challenges to improve healthcare for Kenyans.<sup>14</sup> Inspections were carried out on a tablet and the inspection protocol and scoring system was publicly available, allowing facilities to evaluate themselves as required, even prior to the inspection. A monitoring system, including real-time reports, was also put in place to facilitate planning and follow-up visits according to the regulation schedule.

# **III.2 Experimental Design, Timing and Data, Design Integrity**

We discuss three components of the experimental design: The construction of markets, the allocation of treatment and control arms and the timing of inspections. Section 4 of the Supplemental Material documents IRB approvals of the trial and a discussion of the ethical issues.

**Construction of Markets** : We started with a census of 1,258 facilities that we could locate in the 3 counties between January and September 2015 and a census update conducted between October and November 2016 (see Section 1 of the Supplemental Material). We defined a market using a “z-center” clustering algorithm that assigned facilities to markets such that no facility was

> 14In the endline survey, 76% of facility in-charges commented on their experience with inspections and of these, only 2% of the comments were related to corruption. In addition, random inspection quality checks performed during the implementation showed minor discrepancies with inspectors’ results. Finally, a third-party qualitative assessment, separate from our team, similarly found few facility complaints with the inspection process (Tama et al., 2021).

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