The Strategic Facility Improvement (SFI) initiative, has resulted in the replacement of 44 outpatient clinics and 28 clinic renovation capital improvement projects across Louisiana's 64 parishes. A total of $67.3 million has been invested in this effort to date. The goal of the SFI is to improve the health status of medically underserved patient populations. It remains the sole capital improvement effort of its kind and has been in continuous implementation since 1991. The SFI consists of predesign needs assessment, analysis of alternate site planning options, historic preservation options in the adaptation of noteworthy community civic resources to healthcare uses, and the postoccupancy assessment of completed capital improvements with the aim of learning positive lessons that can be carried into future efforts. It is based on advocacy and guided by a statewide public health agency. The discussion is centered on a status report on a 21-year period and is examined critically from the perspective of key stakeholders.