Marchal et al. BMC Public Health 2010, 10:787 http://www.biomedcentral.com/1471-2458/10/787 Second, the interviewed health care providers express the feeling that this delegation is effectively accompanied by a better information flow through staff durbars, the monthly bulletin, posters and reports. Especially the management meetings and the follow-up of issues are perceived as positive. The ward conferences are appre- ciated because they are oriented towards problem analy- sis and effective solutions. The participative nature of the strategy development and implementation seems to have led to a sense of involvement. The strategic plan was developed in consultation of some experts from outside. They came and consulted with a lot of the units, deliberated, took our recom- mendations and they made their findings to the management. Then, later on, they came back to the various units, spelled out the findings, whether it’s really good for the various units. Then we made our adjustments and input to those ones. Then, finally, they send it to the experts to refine it until it became a document. So, there was interaction until the final document came out. (HMH IO 1-7) Third, the diversity of interacting committees, from the unit meeting, over the head of units meeting and the hospital management team to the core management meeting all contributed to a positive sharing of informa- tion between ‘bottom’ and ‘top’ of the hospital, but also to a sense of being part of the team (inclusion) and a perception of sharing values among staff. This management has really brought that much. They have always done this to show that we are part of the process. We are in one car moving in one direction. Very often they bring some forms for us to fill: how do you feel about the hospital, how do you feel about your leader, how do you feel about this worker. We always have such interactions. So, I think we have very positive mind of the management so far. (HMH IO 1-8) Finally, the broad involvement of staff in the work- shops and ward conferences has led to better teamwork and collaboration between staff of various units, and strengthened the sharing of the values of the hospital, especially that of ‘working for the patient’. I feel there is a change. And I think in terms of com- munication too, the patient and workers relationship has improved and that was as a result of seminars that were organised. (HMH GO 1-4) Love. We have been told by the authorities to really do it for love and that thing has been preached so many times, to do it for love. That is what is Page 10 of 16 keeping most of us moving with the hope that one day it would be better. [...] People are now working with their heart. They are working not because of what they are getting, but they are working because of a certain satisfaction. Like one nurse said, when I nurse my patient from a very bad situation of sickness to a better one, then it’s a joy. (HMH IO 1-2) Perception of positive change: some mixed feelings The interviews show that the workshops and initial wave of improvements of the hospital infrastructure lifted the spirits of many staff members. As for now, things are improving. Look at our Mater- nity Wards over there, and the new signboards we are having here. The mortuary was broken down for so many years. Now the mortuary is working and it is bringing more money. And so now, we all feel proud and we hope very soon, they will rehabilitate the whole hospital. (HMH IO 1-6) They state that the hospital gained again the trust of the population of Ho and that this explains the increase in the volume of patients. I have seen a lot of change. Initially, client atten- dance was less when I came. People normally talk about the hospital, that if you go there the human relations are poor. That was one big problem. For instance the nurses, they insulted and they talked to you anyhow. There was no confidentiality, they shouted and people heard whatever was going on. (HMH IO 1-8) However, the hospital personnel is in a sense, also the victim of its own success: the higher volumes of patients increase the workload and staff start claiming additional incentives. In general, the initial promises and successes seem to have raised high expectations, which cannot all be met given the resource constraints. Now the pressure of work has increased, and now everyone wants motivation and when motivation is not coming... (HMH IO 1-5) Perception of support Regarding the perception of support by management, some staff remained sceptical. In the group discussions, theatre staff expressed their dissatisfaction despite the repairs made in the theatre. Orderlies complained about poor supplies of cleaning equipment and consumables.