Marchal et al. BMC Public Health 2010, 10:787 http://www.biomedcentral.com/1471-2458/10/787 to HRM outcomes like a positive organisational climate that stresses recognition, respect, commit- ment and trust. Enduring effects of such practices can be expected if the organisational culture stresses the latter out- comes and professional values. To be an important determinant of performance, organisational culture requires an appropriate formal organisational structure. Such balanced approaches assume a capacity for self- regulation, based on professionalism and public ser- vice ethos. Such balanced approaches demand time and a reasonable management capacity in terms of staff and competences. Study design We used the case study design, as it allows exploring a “phenomenon within its real-life context, especially when the boundaries between phenomenon and context are not clearly evident” [32]. Furthermore, this design allows a holistic in-depth investigation of these issues as they happen in their natural setting, whereby different sources of information and data collection methods can be used concurrently [33]. A realist evaluation examines the generative mechanisms that underlie an intervention at micro- and macro-level, and explores how actors’ choices and use of their resources led to the outcome. It also focuses on the embeddedness of the intervention in the social reality [29]. The case study design fits this bill nicely. Ethics We assessed the ethical issues on the basis of the work- ing paper “Notes regarding ethical guidelines for health services research” of the Department of Public Health, Institute of Tropical Medicine, Antwerp. This covered the following issues: Minimal risk to participants; Invita- tion, information and informed consent; Feedback to interviewees and staff. The protocol stipulated how potential interviewees would be (1) invited by letter, (2) given all relevant information about the study, (3) speci- fically informed before and after the interview of the possibility to opt out at any time, and (4) informed of the measures taken to protect anonymity and confiden- tiality. This study was presented for clearance by the hospital administration of the hospital and subsequently permission was granted. The case We define the case as Ho Municipal Hospital (HMH), a Ghana Health Service Hospital (public hospital) that was commissioned in 1927. It is located in Ho, the capital town of Volta Region. In time, it became the regional Page 4 of 16 hospital for the Volta Region. No major infrastructural works had been carried out since the 1950 s. Since the 1990 s, chronic under-funding of maintenance and repairs resulted in gradual deterioration of the infra- structure. In 1999, a new Volta Regional Hospital was commissioned and half of the staff of HMH was trans- ferred to the new hospital. The old hospital was re- designated as the district hospital for Ho Municipality and Adaklu-Anyigbe District, with 150 beds serving an estimated population of 265,046 inhabitants (estimation on basis of census of 2000 [34]). In 2000, the outpatient clinics recorded 35.865 consultations per year and 7.034 patients were hospitalised. At this time, the hospital would have on average 2 Ghanaian general doctors, 1 Cuban specialist and 1 Cuban generalist and around 70 professional nurses for a bed capacity of 150. Of the remaining staff, only a third had post-secondary school qualifications. The Ministry of Health funding provided on average 25% of the hospital’s recurrent budget, besides covering the wage bill. The remainder came from user fees for drugs, outpatient visits and hospitali- sations [35]. The opening of the new regional hospital led to a drop in patient attendance at the municipal hospital and the staff’s morale reportedly also plummeted. One ward was closed while major equipment fell into a state of disrepair [36]. The OPD attendance and the hospitalisa- tions dropped continuously reaching their lowest point in 2004-2005. In 2006, multiple transfers led to the con- stitution of a virtually new management team. A new medical superintendent (the hospital director) was posted in April 2006. The accountant and the pharma- cist were replaced, too. Finally, a new health services administrator took up his position in September 2006. Of the old team, only the nursing manager remained at post. After 2006, OPD attendance an admission rates increased steadily, despite a strike that paralysed services in June 2006. In addition, the volume of deliveries and of minor as well as some major operations increased. Following years of serious difficulties, Ho Municipal Hospital seemed finally to be on a rebound. Data collection The quantitative part focused on data needed to describe the performance of the hospital. We drew data from the routine information system’s records to produce over- views of trends in service production, revenue generation, expenditure, and staffing. The qualitative data was col- lected through document reviews, interviews and obser- vations. First, a document review was undertaken of hospital records (annual reports and staffing reports), government documents (policy papers, HR statistics and reports), and publications. Second, the daily activities of certain wards, departments, and management meetings