RESEARCH ARTICLE Open Access A realist evaluation of the management of a well- performing regional hospital in Ghana Bruno Marchal 1* , McDamien Dedzo 2 , Guy Kegels 3 Abstract Background: Realist evaluation offers an interesting approach to evaluation of interventions in complex settings, but has been little applied in health care. We report on a realist case study of a well performing hospital in Ghana and show how such a realist evaluation design can help to overcome the limited external validity of a traditional case study. Methods: We developed a realist evaluation framework for hypothesis formulation, data collection, data analysis and synthesis of the findings. Focusing on the role of human resource management in hospital performance, we formulated our hypothesis around the high commitment management concept. Mixed methods were used in data collection, including individual and group interviews, observations and document reviews. Results: We found that the human resource management approach (the actual intervention) included induction of new staff, training and personal development, good communication and information sharing, and decentralised decision-making. We identified 3 additional practices: ensuring optimal physical working conditions, access to top managers and managers’ involvement on the work floor. Teamwork, recognition and trust emerged as key elements of the organisational climate. Interviewees reported high levels of organisational commitment. The analysis unearthed perceived organisational support and reciprocity as underlying mechanisms that link the management practices with commitment. Methodologically, we found that realist evaluation can be fruitfully used to develop detailed case studies that ana- lyse how management interventions work and in which conditions. Analysing the links between intervention, mechanism and outcome increases the explaining power, while identification of essential context elements improves the usefulness of the findings for decision-makers in other settings (external validity). We also identified a number of practical difficulties and priorities for further methodological development. Conclusion: This case suggests that a well-balanced HRM bundle can stimulate organisational commitment of health workers. Such practices can be implemented even with narrow decision spaces. Realist evaluation provides an appropriate approach to increase the usefulness of case studies to managers and policymakers. Background In the wake of the numerous global health initiatives, the health workforce of low and middle-income coun- tries is once again receiving a lot of attention [1-3]. While the key role of health workers in improving health care quality and implementing disease control programmes is widely recognised [4,5] operational aspects of health workforce management at service pro- vision level remain poorly studied. Indeed, the focus has been mostly on macro-level aspects, such as brain drain, the impact of human resource deficits on global health initiatives and planning and training capacity issues. This relative neglect of studies of health workforce management explains why the current evidence base on the effectiveness of HRM policies and strategies is rather weak. More specifically, there are a number of weak- nesses that limit their potential to inform decisions of policymakers or health service managers. First, the determinants of health worker performance in poor resource settings have not been studied well. Second, the HRM policies and strategies, too, are under- researched [6]. Third, systematic reviews indicate that most of the studies are methodologically flawed. A * Correspondence: bmarchal@itg.be 1 Department of Public Health, Institute of Tropical Medicine-Antwerp, Nationalestraat 155, B-2000 Antwerp, Belgium Marchal et al. BMC Health Services Research 2010, 10:24 http://www.biomedcentral.com/1472-6963/10/24 © 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.