Objective.We studied compliance with guidelines and prescriptions for six steps of the health care process to identify the step with the greatest need for improvement. Design.In a cross-sectional study we used hidden observation in health centres and counting of remaining drugs in home visits. We assessed provider compliance with guidelines for medical history, physical examination, drug choice, and explanation of drug dosing, and patient compliance for drug buying and drug taking. Setting.The study took place in six rural health centres in Burkina Faso. Main outcome measures.We measured unconditional (UPC), conditional (CPC) and accumulated proportions of compliant procedures (APC). UPC determined the proportion of compliant procedures independent from earlier steps. CPC was defined as the proportion of compliant procedures among those which were compliant in all previous steps. APC was the proportion of procedures compliant in all steps including the step concerned. Results.Twenty-three per cent UPC medical history, 27% UPC (CPC=39%) clinical examination, 59% (83%) drug choice, 22% (40%) explanation of dosing, 71% (75%) drug buying, and 63% (67%) drug taking compliance. Two per cent of the patients had compliant procedures for all steps of the process (APC). Conclusion.The majority of patients did not get treatment compliant with guidelines. Diagnosis had the largest need for improvement, UPC, CPC and APC were useful to identify steps with the greatest need for improvement and to assess quantitatively aspects of quality of care.