Marchal et al. BMC Public Health 2010, 10:787 http://www.biomedcentral.com/1471-2458/10/787 The study we report on here is part of a longitudinal series of case studies in Ghana and Tanzania examining the links between management and the performance of hospitals. The findings of our previous case studies are generally in line with the bundle approach to manage- ment of performance. Our research has found that balanced bundles of health workforce management prac- tices are more likely to increase organisational perfor- mance than singular or linear interventions [28]. This paper presents the findings of a study that focused on an ailing urban district hospital in Ghana. We chose Ho Municipal Hospital (HMH) as a case, because it is an interesting positive deviant case: its management team succeeded in improving the perfor- mance over a relatively short period of time. The research questions were as follows: (1) Which strategies were implemented to improve the performance? (2) What were the results in terms of health service provision? (3) How do staff members perceive these practices (the organisational climate) and what were the HRM outcomes in terms of staff commitment? (4) What made this intervention work? The paper is structured as follows. We present in the Methods section the realist evaluation methodology and the middle range theory that formed the initial hypoth- esis of this study. We then present the results and the analysis. In the discussion, we frame our findings in the larger picture of the management literature and compare them with the findings of our previous case studies. We end with a revision of our initial middle range theory. Methods A realist evaluation case study Realist evaluation is an approach within theory-driven evaluation [29]. Theory-driven evaluation was an impor- tant dimension of the discipline of evaluation during the 1980 s. Chen & Rossi developed it as a response to policy and programme evaluation approaches that remain lim- ited to before-after and input-output designs or that focused too narrowly on methodological issues (method- driven evaluation) [30]. Realist evaluation proposes conceptual tools to apply the principles of theory-based evaluation and specifically aims at understanding the underlying mechanism between intervention and outcome. It aims at answering the question: ‘Why does this work in this context and for whom?’ rather than merely the question ‘Does it work?’. The starting point of realist evaluation studies is a middle range theory (MRT) that is tested empirically and modified in accordance with the findings of Page 3 of 16 each case. Middle-range theories should be understood as part of the theories of the middle range, defined by Merton as [31]: the “theories that lie between the minor but necessary working hypotheses (...) and the all- inclusive systematic efforts to develop a unified theory that will explain all the observed uniformities of social behavior, social organization and social change“. In practice, realist evaluators seek to analyse the case in terms of context-mechanism-outcome configurations, which offer an explanation of how the intervention led to the observed outcomes by describing the underlying mechanisms of change and the influence of the context on implementation and outcome. A realist study ends by adapting the initial middle range theory accordingly. This modified MRT then serves as a new hypothesis of the next study. This cycle refines the MRT and leads to better insights of how particular interventions work, in which conditions and how. Both qualitative and quanti- tative methods are used in the framework of case stu- dies, which are linked to each other through the middle-range theory. We previously described the devel- opment and results of a realist case study of the influ- ence of management on performance elsewhere [28]. The middle range theory that was tested in this case is the result of a literature review of the effect of high commitment management on health care performance [27] and of the concept of commitment, combined with previous empirical work in Ghana [28]. It may be sum- marised as follows: In well-performing hospitals, the managers are dri- ven by a strong vision and are capable of sharing this vision with their team and the staff at large. Managers also work within the institutional arrange- ments that spell out their responsibilities and pro- vide (access to) resources, but tend to utilise their decision spaces optimally. In the management of the workforce, effective man- agement teams combine administrative and commit- ment-eliciting management practices and adapt the mix according to the cadre, problem and task. They have a contingency view on HRM: they balance the configuration of management vision, management practices, the organisational tasks and staff, and orga- nisational climate and culture. A balanced HRM strategy consists of a combination of personnel administration (administrative HRM) and commitment-eliciting management. Such balanced bundles of management practices include goal setting, role distribution and task monitoring (structure) on one hand, and training, support and recognition (eliciting commitment) on the other. Such a balanced bundle (through triggering per- ceived organisational support and reciprocity) leads