Marchal et al. BMC Public Health 2010, 10:787 http://www.biomedcentral.com/1471-2458/10/787 R E S E A R C H A R T I C L E Open Access Turning around an ailing district hospital: a realist evaluation of strategic changes at Ho Municipal Hospital (Ghana) Bruno Marchal1*, McDamien Dedzo2, Guy Kegels1 Abstract Background: There is a growing consensus that linear approaches to improving the performance of health workers and health care organisations may only obtain short-term results. An alternative approach premised on the principle of human resource management described as a form of ‘High commitment management’, builds upon a bundles of balanced practices. This has been shown to contribute to better organisational performance. This paper illustrates an intervention and outcome of high commitment management (HiCom) at an urban hospital in Ghana. Few studies have shown how HiCom management might contribute to better performance of health services and in particular of hospitals in low and middle-income settings. Methods: A realist case study design was used to analyse how specific management practices might contribute to improving the performance of an urban district hospital in Ho, Volta Region, in Ghana. Mixed methods were used to collect data, including document review, in-depth interviews, group discussions, observations and a review of routine health information. Results: At Ho Municipal Hospital, the management team dealt with the crisis engulfing the ailing urban district hospital by building an alliance between hospital staff to generate a sense of ownership with a focus around participative problem analysis. The creation of an alliance led to improving staff morale and attitude, and contributed also to improvements in the infrastructure and equipment. This in turn had a positive impact on the revenue generating capacity of the hospital. The quick turn around in the state of this hospital showed that change was indeed possible, a factor that greatly motivated the staff. In a second step, the management team initiated the development of a strategic plan for the hospital to maintain the dynamics of change. This was undertaken through participative methods and sustained earlier staff involve- ment, empowerment and feelings of reciprocity. We found that these factors acted as the core mechanisms under- lying the changes taking place at Ho Municipal Hospital. Conclusions: This study shows how a hospital management team in Ghana succeeded in resuscitating an ailing hospital. Their high commitment management approach led to the active involvement and empowerment of staff. It also showed how a realist evaluation approach such as this, could be used in the research of the management of health care organisations to explain how management interventions may or may not work. Background Over the last 20 years, a number of strategies aimed at improving the performance of health services have been implemented in low- and middle-income countries (LMIC). Each strategy has had its specific perspective * Correspondence: bmarchal@itg.be 1Department of Public Health, Institute of Tropical Medicine-Antwerp, Nationalestraat 155, B-2000 Antwerp (Belgium Full list of author information is available at the end of the article and focused on one particular issue: quality improve- ment, performance management, building learning orga- nisations, innovation diffusion, etc. [1]. While success has been reported in some cases, there is increasing acknowl- edgement that to improve performance of health workers and health care organisations, approaches that deal with one problem, mostly fall short or obtain only short-term results. © 2010 Marchal et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.