Marchal et al. BMC Public Health 2010, 10:787 http://www.biomedcentral.com/1471-2458/10/787 CMT did not aim at simply imposing their analysis and solutions to the middle-level cadre and operational staff, but adopted a participative and enabling style of leader- ship. This management vision had a positive influence on the implementation of their set of practices and on how the staff perceived these practices. This led in turn to a positive organisational climate in most departments and wards. Staff felt supported and in return were will- ing to go the extra mile for the hospital. However, the CMT also initiated structural changes in the sense of strengthening the administrative, financial and procurement procedures and management systems. In that sense, they adopted rather a contingency approach to leadership and management, combining a hard and soft approach. This is in tune with research on high performance in primary health care organisations. Ohman-Strickland and colleagues show how a number of similar organisational attributes lead to better organi- sational performance [42]: Leadership: a focus on effective problem solving through engagement of stakeholders and sharing of information Organizational culture: stimulating openness, con- nectedness and learning Relationships: fostering collaboration and communication Management functions: clear structures and role distribution in the domains of financial management, logistics and infrastructure, healthcare provision, HRM and strategic planning Information mastery: access to and use of informa- tion for learning and problem solving Finally, if the findings are framed in the change manage- ment perspective, they reflect many of the key conditions of success identified by Kotter: establishing a sense of urgency, setting up a coalition, developing a shared vision, strong communication, removing obstacles to change, planning systematically, creating short-term success and anchoring change in the organisational culture [43]. Conclusions Few studies on hospital management in LMIC have been published, despite a well-developed body of knowl- edge of how management can influence performance in the disciplines of human resource management and strategic management. This study shows that HiCom management is being implemented in a Ghanaian dis- trict hospital and that such an approach contributed to better performance. The hospital management team at Ho incorporated a balanced administrative and commit- ment-eliciting HR strategy within an overall change strategy. By triggering mechanisms of staff participation, Page 15 of 16 empowerment and reciprocity, it instigated a U-turn in hospital performance. This case also shows how a realist evaluation approach can be used to study management interventions in complex settings such as a hospital. However, additional work is needed to explore the spe- cific contextual factors that enable such balanced HRM practices to work, and how the dynamics of change could be institutionalised for sustained improvement in hospital management practice. Acknowledgements We would like to thank all the staff of Ho Municipal Hospital (Ghana) for their warm welcome and collaboration during this study and Kasturi Sen for the proofreading of the manuscript. Author details 1Department of Public Health, Institute of Tropical Medicine-Antwerp, Nationalestraat 155, B-2000 Antwerp (Belgium. 2Human Resources Directorate, Ghana Health Service, Accra, Ghana. Authors’ contributions All three authors contributed to the original design of the study. BM carried out the data collection. BM and MD analysed the data. BM, MD and GK contributed to the discussion section and to the writing of the manuscript. BM edited the final draft. All authors read and approved the final manuscript. 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