Marchal et al. BMC Public Health 2010, 10:787 http://www.biomedcentral.com/1471-2458/10/787 that the intervention works, but rather to enlighten the decision-maker by providing plausible explanations. The structured description of intervention, outcomes at dif- ferent levels, context conditions and mechanisms allows the reader to judge whether this explanation is plausible and whether such intervention, by triggering specific mechanisms, may have similar effects in other environ- ments. We refer to an earlier publication for a more detailed discussion on the methodological issues of doing a realist evaluation [28]. A difficult question is the attribution of the increased utilisation and revenue of the hospital. Without doubt, the rapid expansion of the National Health Insurance Scheme contributed to a substantial increase in utilisa- tion rates at HMH, as it did in the whole of Ghana. However, the revenue generated from providing services to non-NHIS members also increased. Furthermore, HMH did noticeably better than other health facilities in the town of Ho, including the regional hospital. We argue therefore that the introduction of new manage- ment practices by the new CMT plausibly explain the U turn. Adapting the MRT Our initial MRT - the result of previous case studies and literature reviews - states that “in the management of health workers, effective management teams com- bine administrative and commitment-eliciting manage- ment practices and adapt the mix in function of 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 organisational climate and culture.” It also stipulates that both a commitment-eliciting approach and a structuring approach need to be com- bined. We found that this indeed mattered in HMH. The results of our case study at Ho confirm the main lines of this initial MRT, even if the setting was one of a crisis. There are, however, new elements. Regarding the mechanisms, this case points to the influence of leader- ship vision on the effect of HiCom practices. Inclusion, participation, involvement and empowerment were key attributes of the management intervention and led to a positive organisational climate and to the perception of organisational support. Indeed, the strategy of trying to include all staff in the dynamics of change, through mobilising a critical mass of close collaborators and through workshops for all operational staff, has contrib- uted to a feeling among most staff of being effectively supported by management. This perceived organisa- tional support has been shown to lead to higher organi- sational commitment through the mechanism of reciprocity [40,41]. We would argue that a leadership Page 14 of 16 style that facilitates inclusion and participation triggers commitment and reciprocity through the mechanism of perceived organisational support. In summary, the results of this case allow us to modify the initial MRT as follows (see text in italics) 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 provide (access to) resources, but tend to utilise their decision spaces optimally. In the management of health workers, 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 organisational 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. These practices need, however, to be responsive to the different cadres. This adaptation requires permanent good communication with all staff. Triggering perceived organisational support and reci- procity, a balanced bundle leads to HRM outcomes like a positive organisational climate that features inclusion, recognition, respect, commitment and trust. Enduring effects of such practices can be expected if the organisational culture stresses the importance of participation, commitment and empowerment, and professional values. To be an important determinant of performance, organisational culture requires structure. Such balanced approaches assume a capacity for self- regulation, for instance based on professionalism and public service ethos. Such balanced approaches demand time and thus a reasonable management capacity in terms of staff and competences. Putting the findings in perspective Our findings correspond with the views of Alimo-Met- calfe and colleagues about engaging leadership. The style of leadership at Ho was decidedly aimed at increas- ing the engagement of staff (commitment-eliciting): the