Marchal et al. BMC Public Health 2010, 10:787 http://www.biomedcentral.com/1471-2458/10/787 2007-08. In parallel, the main thrust of phase 5 (rebuild- ing the management systems) occurred in 2007-09. Phase 1 - Team building and the crafting of a shared vision The first step consisted of constituting the core manage- ment team and the development of a shared vision on leadership and management. In April 2006, the M/Supt. was posted to the hospital. By September 2006, the arri- val of the health services administrator made the team complete. In addition to the M/Supt., the team consisted of the nursing manager, the finance manager, the administrator and the pharmacist. This team initially met daily, and later on twice weekly. Our interviews indicate that this core management team held regular meetings and brainstorming sessions, during which an initial plan to deal with the problems emerged. This consisted of re-launching the hospital through improving the motivation of the staff, rehabili- tating the basic infrastructure and increasing the rev- enue of the hospital. The interviews indicate that the values and principles upon which this plan was based include: “excellence through self-reliance”, “enhance- ment of problem solving capacity of staff”, “best prac- tices”, “involvement and participation of staff and external stakeholders” and “delegation to the middle cadre”. Key elements of this leadership view include the cen- tral role of the staff themselves in shaping and maintain- ing change and in the subsequent choice of participative processes to induce change. Indeed, the team believed that the health workers at the hospital were key to their success. The implicit aim was to build upon the internal capacity and action of the staff: So, you want to let [the staff] feel part of the circle, that everybody is within the circle, that you are neces- sary for whatever we are doing here. And that nobody from outside is coming to do this for us. So, when you look at our strategic plan, you realise that the theme is ‘Rising internal strength’. In fact, this thing, we sat down and I could just do whatever and write the entire thing, but you make sure that everybody who came to the meeting contributes. So, everybody went through in participation so that you buy into whatever we are trying to put in place. (HMH IM 1-4) The CMT felt that the development of the strategies to achieve this vision needed to be participative in nat- ure and that workshops being held with all cadres were a good tool. You see, everybody had to come on board, so work- shops were held to really appeal to the people to Page 6 of 16 change their attitude, depart from the old ways of doing things, because management was on the war- path. We requested to turn things around because management alone could not do that. Everybody had to come on board to make the hospital be at where it should be. (HMH IM 1-1) Phase 2 - A participative situation analysis One of the first actions of the new management team was a situation analysis by means of a SWOT question- naire distributed among all staff. The interviews show that this staff survey helped the management team members to know better their staff and their concerns. They picked up the general sense of frustration and were struck by the high number of elderly nurses and by the relatively high degree of illiteracy among lower cadres. The survey was followed by individual interviews with staff members of all cadres. The team arrived at the following analysis: poor staff attitudes led to low quality of care and services, which was not accepted by the community. People stayed away and the subsequent weak revenue generation tied the hands of the management team. Inadequate mainte- nance further strained the already poor infrastructure. This all resulted in an organisational culture of fatalism, not countered by the previous management team. The results of this initial ‘diagnosis’ were presented and dis- cussed during general staff meetings (durbars) at the end of 2006. This assessment was widely shared by the staff at that time. Yes, this hospital was dying, almost dying, because it came to a point we even had to close down the thea- tre. We could not operate. That time, the attitude of staff towards the patients was not good. Doctors too were not there. So, for OPD, you will see less than 50 patients a day. [...] It came to a point, because patients were not happy with our services here, they decided to go to the Regional Hospital and Korle Bu, where they think they can be treated better. So, attendance here fell drastically before the new man- agement came. (HMH GO 1-1a) Phase 3 - Tackling the crises The CMT quickly initiated action to deal with the most urgent needs: the poor staff attitude, the low revenue generation, the low engagement of the mid-level cadre and the weak core administrative functions. Improving the staff attitude and communication towards the patients was at the top of the agenda. The CMT carried out 2 patient satisfaction surveys in 2006, the results of which were used to sensitize the staff to