Marchal et al. BMC Public Health 2010, 10:787 http://www.biomedcentral.com/1471-2458/10/787 in Ho town), the OPD attendance has been decreasing since 2005. Here, it could be argued that the gate- keeping system may have contributed to this decrease: regional hospitals were not supposed to accept patients who could be dealt with at lower-tier health facilities. In practice, it may have done so, but only in 2006 and in the first half of 2007. Since then, non-referred patients have been admitted to the regional hospital’s OPD, and it even set up a primary care service to attract patients. Management of clinical care quality is reflected by hospital mortality rates. While the mortality increased in absolute numbers, in line with the higher number of admissions, the crude mortality rate (N of deaths/1,000 admissions) remained around 45/1,000 admissions since 2004. Tracer drug availability has increased steadily since 2005, despite the increasing number of out- and in- patients. However, regarding the availability of consum- ables, interviewees indicate that disinfectants, gloves, needles and syringes are regularly out of stock. Revenue generation at HMH has dramatically increased over the last 4 years. Actual expenditure has kept up well with the revenue generated and mobilised, with expenditure rates above 90% except in 2006, when only 82% of the actual revenue was spent (Table 2). Summary We found that the management team combined a crisis management plan with the development of a long-term strategy (the intervention). On the basis of their shared vision of what the hospital should become and on what good leadership should be, it set out to mobilise and moti- vate their workforce (intended proximal outcome) by involving staff in both the diagnosis and the search for solutions (expected mechanism). At the same time, they strengthened the management structures (ensuring a con- ducive work environment and streamlining the internal administrative organisation and procedures) (expected mechanism). This combination was intended to lead to better performance of the hospital (intended distant outcome). We saw that the first initiatives taken by the core man- agement team - investing in staff, communication, revenue generating capacity and infrastructure - lifted the spirits of staff and that this led to a change in attitudes of staff towards patients (observed actual proximal outcome). Page 12 of 16 We also found that participation and inclusion, improved information sharing and communication between director, management team and staff, in addi- tion to the visible improvements, led to a strong sense of being supported amongst most staff (perceived orga- nisational support), and to a positive organisational cli- mate (mechanisms). For some cadres, however, the change and support is not sufficient (failure of mechan- ism for some staff cadres) and they feel clearly frustrated (unequal distribution of intermediate outcome). We also note an increase in most performance indica- tors. The volume of patients (OPD, hospitalisations, maternity) improved, as well as the revenue (measured actual distant outcomes). However, this cannot solely be attributed to the management changes, since utilisation of health care services increased all over Ghana since the start of the NHIS (implementation context). How- ever, HMH improved its utilisation more than the other facilities in Ho, which all can draw on NHIS reimburse- ments. This may indicate that other factors besides the NHIS funding contributed to increased utilisation at HMH - plausibly the management approach. Analysis In a realist case study, the analysis consists of searching for patterns in the form of context-mechanism-outcome (CMO) configurations, whereby the analyst is guided but not constrained by the key elements of the initial middle range theory. In our case, the initial key ele- ments included: leadership, creation of a shared vision, the choice of management practices, mechanisms of reciprocity and outcomes at levels of HRM and hospital performance (see Methods). We found during the analysis that the patterns centred on the themes of participation, empowerment and reciprocity. The first theme is ‘participation’, reflected by the joint problem analysis, construction of the mission and strate- gic plan for the hospital, and in the organisation of workshops and ward conferences. Increased participa- tion of operational staff resulted in reconnecting a frag- mented organisation. By reviving the regular committees and initiating the ward conferences, the CMT recon- nected the operational staff to their unit heads, and the unit heads to the CMT. The system of inclusive work- shops gave all staff the possibility to engage in hospital Table 2 Revenue generation and expenditure at HMH, 2000-09 (Source annual reports and accounting records HMH) Total revenue generated (Ghana Cedi) 166,654 Total expenditure (Ghana Cedi) 148,491 % of revenue spent 89.1 Note: Exchange rate: 100 Ghana Cedis = approximately US$ 70 2000 2001 158,581 140,738 88.7 2002 195,497 200,509 102.6 2003 249,748 228,597 91.5 2004 298,853 276,615 92.6 2005 317,709 309,531 97.4 2006 377,973 310,469 82.1 2007 730,670 656,643 89.9 2008 1,316,638 1,186,927 90.1 2009 1,387,883 1,389,009 100.1