Marchal et al. BMC Public Health 2010, 10:787 http://www.biomedcentral.com/1471-2458/10/787 affairs. As we’ve described, major efforts were made to delegate decision making to the operational units and a number of committees. This cascade of interlocking committees channels up and enables information and concerns from the operational units to the central levels of decision-making. The striking feature of the unit meeting is that before the Unit Heads come for Unit Heads meeting, they must have held in-house unit meeting at the unit level to equip the unit manager with the problems militating against his unit before he even appears at the Unit Heads meeting. So he comes armed with the collective decision from the Unit. So that whatever he says there he speaks for the unit. (HMH IM 1-1) Another example of how participation works is the ‘ward conference’, whereby the situation of a particular unit is analysed by its staff, supported by a few CMT members. We found these conferences to be an effective way of decentralising decision-making power to the operational level. They are perceived as useful by opera- tional staff members, not only because they allow infor- mation to be passed up and down the hierarchy, but also because staff problems are discussed and solutions sought. Others point out how these meetings involve and engage staff at the operational level. What they do is organizing these seminars and the rest. It is one way of doing that; if you bring the workers closer to you, then you are going to tap their ideas/views and it makes people feel good because there are people who may equally contribute to the progress of the hospital but if given the chance. So, these seminars and workshops have really given them the platform to really make their point and it is a way of bringing out our grievances. You know, deal- ing with grievances is one aspect, which is so dear to workers. If you as a manager don’t know the in and out of your workers, solving such grievances becomes difficult; you get to know the why and how things happen; and since they are closer to us it is easier for them to correct you where you are going astray. (HMH IO 1-8) By stressing participation, the CMT stimulated the sense of self-capacity of many interviewees (empower- ment). As one of the staff actively involved in the orga- nisation of the workshops mentions: Most of the time, if the M/Supt. realises that you have the potential to work, he tries to delegate some of his responsibilities. [...] How he is doing it is that he doesn’t just look within the core management, but Page 13 of 16 he looks beyond the core management. Those who have the capacity and those who share his vision, he tries to bring them in. Some of us have been doing that for him. (HMH IO 1-13) Indeed, for a significant number of staff, the call of the CMT for their involvement was a sign of recognition. This resulted in feelings of reciprocity, but not among all: expectations may have been too high for some. To some extent, the orderlies are up against a difficult task: given the poor infrastructure, the needs for cleaning are great and the resources still too limited. The theatre staff is clearly frustrated despite the improvements made in infrastructure and supplies. It may well be that there are deeper underlying conflicts that may explain these staff’s unease with the CMT. It should be noted, however, that this commitment- eliciting approach was combined with a strategy to strengthen the administrative management systems and operational support in terms of supplies and facilitating working environment (for instance in outpatient depart- ment, laboratory, radiology and the health information unit). The negative reactions of some cadres indicate that the initial change of climate, from poor staff attitudes to a sense of being capable and of being proud to work at HMH, may prove difficult to maintain, if it is not fol- lowed by permanent reinforcing mechanisms and by induction procedures for new staff. Conditions that enabled this approach at HMH include the bad condition in which the hospital was - there were few options other than to change dramatically - and the strong support from the Regional Health Directorate. Also, the NHIS came at the right moment and the oppor- tunities it provided were quickly grasped by the CMT. Discussion It could be argued that the limits of this study include the traditional limitations of the case study design in terms of internal and external validity, whereby the find- ings reflect to some extent the researchers’ perspective and may only be relevant for the local context of the study site. We would argue that the theory-driven approach however addresses both issues by forcing the researcher to make explicit the initial hypothesis in the form of a MRT that describes the assumed mechanisms and the influence of the context. This explicit MRT is the framework that guides the analysis, with the explicit aim to refine it by confirming or refuting its elements on the basis of the analysis of empirical findings. It also forces the researchers to identify the key conditions for this intervention to work in this context. In Pawson and Tilley’s view, a realist evaluator does not strive nor pretends to provide the ultimate evidence