Marchal et al. BMC Public Health 2010, 10:787 http://www.biomedcentral.com/1471-2458/10/787 These singular approaches stand in sharp contrast with the concept of high commitment management, an approach that is well developed in the domain of Human Resource Management (HRM). High commit- ment management holds that implementing balanced bundles of HRM practices leads to higher staff attraction and retention, and often to higher organisational perfor- mance. Such approaches are described under different names: high involvement work practices [2,3], high per- formance work systems [4], high commitment manage- ment [5] and high performance management [6]. These labels cover approaches based on similar basic assump- tions [4]. For reasons of simplicity, we will use the term high commitment management (HiCom) practices throughout this text. The key elements of HiCom may be summarised as follows: (1) Bundles of management practices are more effec- tive than singular practices [7]. (2) Key practices in HiCom include: selective staff- ing, self-managed teams, decentralised decision- making, attention for training and job flexibility, open communication and performance-contingent remuneration [4]. Pfeffer and Veiga add participative decision-making and efforts at the reduction of sta- tus differentials to the list [5]. (3) Effective bundles are balanced. They display good internal coherence (internal fit): bundles of manage- ment practices are synergistic, i.e. they reinforce each other and do not cancel each other out. They display good external coherence (external fit): good fit between the practices and the type of staff, the organisational mission/task and the type of organisa- tion [8,9]. Well-balanced management approaches combine tight rules and procedures (command-and- control features) with loose, autonomy facilitating practices (empowerment of professionals). The mechanisms that underlie such practices, or in other words the ways in which such bundles work, have not been studied well in LMIC. However, the literature from industrialised countries has identified leadership style, the internal social structure, the organisational cli- mate and culture as important mechanisms. Since HiCom maintains that it is not only the number of practices, but also how they are implemented that counts, leadership style may play an important role in the effect of high commitment management. In this respect, the concept of engaging leadership is an inter- esting one. It makes an explicit link between leadership and staff commitment. Alimo-Metcalfe and colleagues for example define engagement as “a positive attitude held by the employee towards the organisation and its Page 2 of 16 values”. Distributed or nearby-leadership stimulates such engagement: “It is a model that is characterized by a strong sense of inclusiveness, in which leadership is seen as being ‘distributed’ throughout all levels of the organi- zation“ [10]. Engaged leadership has shown to have a positive impact on motivation, commitment, absentee- ism, staff turn-over and organisational performance in the private sector. Bradley & Alimo-Metcalfe obtained similar results in a study of leadership in multi-disciplin- ary mental health teams in the UK [11]. In HiCom, the elements of open communication and participative decision-making are in line with this perspective on leadership. A second mechanism is the internal social structure, or the nature of relations between managers and work- ers. This has an impact on staff attitudes and behaviour in terms of task behaviour, absenteeism, staff turn-over and organisational citizenship behaviour [4,12]. HiCom’s characteristics of reducing status differentials and decen- tralising decision-making power has an influence on the internal social structure of the organisation. A third mechanism includes organisational climate and organisational culture. These could be considered as pathways through which HiCom may have a long-lasting effect. The organisational climate is defined as “the atmosphere that employees perceive is created in their organisation, by practices, procedures and rewards” [13]. HiCom practices have been shown to lead to a positive organisational climate in which reciprocity is central [14,15]. If leaders can translate their vision into practices that inspire others, their values and principles may be taken up by other staff, which may lead to shared ways of thinking and commitment that supports a strong organisational culture [16,17]. Despite the body of knowledge developed in indus- trialised countries, few studies have been carried out in LMIC settings on how good management of a health workforce can contribute to better performance and accountability of health services [18]. Only a handful of studies describe some of the challenges faced by health service managers or health workers,) and their (management) interventions from their perspective [19-24]. Even fewer studies explicitly explore the link between organisational management and performance. Couper and colleagues for example, compare differ- ences in management style and organisational culture to explain varied performances of two first line services [25], while Puoane et al. examine why 4 hospitals differ in their nutritional programme outcomes by analysing organisational support and management [26]. Our pre- vious work shows how HiCom practices may be well suited to the management of health workers [27] and that such approaches have been applied with positive results in Ghana [28].