Marchal et al. BMC Public Health 2010, 10:787 http://www.biomedcentral.com/1471-2458/10/787 Casual workers complained about receiving fewer bene- fits than staff on permanent contract. Since I came here, the changes, in particular at thea- tre, have been negative, because things continue to deteriorate. When you enter the theatre now, the wall tiles are all falling down. The roofs are leaking. The windows of the theatre, which are supposed to be closed or airtight because of the theatre, are open. They cannot close well. [...] Our equipments are obso- lete and we are not using them. So in short, things have been going negative. There is not much improvement. (HMH GO 1-1) However, most of the operational staff members we interviewed feel that their problems are recognised and effectively solved by the management team. This sup- port is felt through a number of actions of the CMT: the relationship between management team members and the staff, their work floor presence, the meetings and easy informal access to the CMT members. They express this support by the management team as ‘keep- ing promises’. Interviewees say that the good cordial relationship between management team members and the staff is important to them. This relationship is felt to be fair and supportive. It is also a factor that improves the motivation and retention of health workers at Ho Muni- cipal Hospital. Because I have established a nice relationship with management, I will feel better working here than going elsewhere with the same condition. Upon that, just because their facilities are better, no, no, I don’t see it like that. I prefer working here, because the people you are working with have a good relationship with you and that makes you going and staying stronger. That is keeping us here, otherwise most of us here would have gone. The spirit of the people, our leaders, our colleagues around, they are suppor- tive. (HMH IO 1-8) Although the work floor presence of CMT members is variable - some turn round everyday, others rarely - it is perceived as a strong signal of interest and support. As I have already said, they come round to see what you are doing and give you support appropriately. In that aspect, we are one. (HMH IO 1-5) Also unit meetings were in general perceived as effec- tively channelling concerns, problems and information to the core management team about the operational Page 11 of 16 units, facilitating effective support by the CMT. Besides these formal channels of interaction, several interviewees indicated that access to the CMT members is good: they could easily go and see management team members in case of problems that could not be solved with their supervisor. They perceive especially the M/Supt. as “really listening to us“. Hospital performance As already mentioned in the introduction, the OPD attendance doubled to more than 62,000 consultations in 2009, from around 30,000 consultations per year dur- ing the period 2002-05. Also, the number of admissions increased, but less dramatically than the OPD atten- dance, from 6,882 admissions in 2004 to 8,512 admis- sions in 2008, dropping slightly in 2009. The admission rate gradually declined, from 37% in 2004 to 14% in 2008, a sign of more selective hospitalisation. However, since we could not assess the evolution of the case mix, firm conclusions cannot be drawn from these figures. The total number of deliveries at HMH almost doubled in 5 years’ increasing from 1,163 in 2003 to more than 2,000 deliveries in 2009. Data on Caesarean sections however could not be fully retrieved (see Figure 3). An important change in the context was the start of the National Health Insurance Scheme in 2006, which stimulated the utilisation of health services in Ghana. In Ho Municipal District, the OPD attendance at all facilities combined has increased from 0.45 new cases/ inhabitant/year in 2005 to 0.8 in 2008. This supports the idea that the NHIS increased access to virtually all health facilities in the district. However, this increase of utilisation was not uniform for all facilities. Indeed, the Ho Policlinic (a Ghana Health Service facility) saw a decrease in utilisation between 2004 and 2007. Only in 2008 was there an increased attendance. At the Volta Regional Hospital (another Ghana Health Service facility Figure 3 Volume of services (OPD, admissions, maternity and theatre for Ho Municipal Hospital, 2000-2009).