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Original research
Unravelling the role of leadership in motivation of health workers in a Moroccan public hospital: a realist evaluation
  1. Zakaria Belrhiti1,2,3,
  2. Wim Van Damme2,3,
  3. Abdelmounim Belalia1,
  4. Bruno Marchal2
  1. 1 Ecole Nationale de Santé Publique, Rabat, Morocco
  2. 2 Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
  3. 3 Department of Gerontology, Vrije Universiteit Brussel, Brussel, Belgium
  1. Correspondence to Dr Zakaria Belrhiti; drbelrhiti{at}


Objectives This study aimed at opening the black box of the relationship between leadership and motivation of health workers by focusing on a high-performance hospital in Morocco.

Design We adopted the realist evaluation approach and used the case study design to test the initial programme theory we formulated on the basis of a scoping review on complex leadership. We used the Intervention-Context-Actors-Mechanism-Outcome Configuration as a heuristic tool to identify plausible causal configurations.

Settings Since 2000, the Ministry of Health in Morocco initiated many reforms in the frame of the governmental deconcentration process called ‘advanced regionalisation’. The implementation of these reforms is hampered by inadequate human resource management capacities of local health system managers. Yet, the National ‘Concours Qualité’, a national quality assurance programme implemented since 2007, demonstrated that there are many islands of excellence. We explore how leadership may play a role in explaining these islands of excellence.

Participants We carried out a document review, 18 individual interviews and 3 group discussions (with doctors, administrators and nurses), and non-participant observations during a 2-week field visit in January–February 2018.

Results We confirmed that effective leaders adopt an appropriate mix of transactional, transformational and distributed leadership styles that fits the mission, goals, organisational culture and nature of tasks of the organisation and the individual characteristics of the personnel when organisational culture is conducive. Leadership effectiveness is conditioned by the degree of responsiveness to the basic psychological needs of autonomy, competence and relatedness, perceived organisational support and perceived supervisor support. Transactional and overcontrolling leadership behaviour decreased the satisfaction of the need for autonomy and mutual respect. By distributing leadership responsibilities, complex leaders create an enabling environment for collective efficacy and creative problem solving.

Conclusions We found indications that in the Moroccan context, well-performing hospitals could be characterised by a good fit between leadership styles, organisational characteristics and individual staff attributes.

  • human resource management
  • complex leadership
  • motivation
  • leadership
  • low middle income countries
  • Morocco

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  • Contributors All the four authors (ZB, BM, WVD, AB) contributed significantly to the original design, analysis and interpretation of data, and writing of the manuscript. ZB carried out the data collection. AB and BM cross-checked the transcripts. Initial coding was done by ZB and discussed between the research team members (ZB, AB, BM, WVD). ZB and BM edited the final draft. All authors read and approved the final manuscript

  • Funding This work was funded through a PhD framework agreement between the Belgian Directorate-General for Development Cooperation and the Institute of Tropical Medicine, Antwerp.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval The research protocol was approved by the Moroccan Institutional Review Board (No. 90/16) and the Institutional Review Board of the Institute of Tropical Medicine, Antwerp (No. 1204/17). All research participants were informed before the start of the data collection about the study’s objectives, the topics and type of questions, and their right to refuse being interviewed, to interrupt the interview at any time and to withdraw any given information during or after the interview. This information was provided through an information sheet and was explained before the start of the interview and focus group discussion. All respondents were presented an informed consent form, which was signed by them and countersigned by the first author. Respondents had the possibility to opt out at any time during the whole process and were given a copy of the signed informed consent form.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data sharing not applicable as no datasets generated and/or analysed for this study.

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