Unravelling the role of leadership in motivation of health workers in four Moroccan hospitals: a realist multiple embedded case study

In LMIC, health system leadership is often characterised by hierarchical exercise of power, which contributes to poor motivation, dysfunctional patient-provider interaction and patient dissatisfaction. While effective leadership is recognised as a critical lever of health system strengthening in low- and middle-income countries, little is known about the mechanisms and contextual conditions underlying the relationship between leadership and “public service” motivation of health workers in LMIC. In Morocco, this relationship has not yet been examined. I set out to unravel the processes linking leadership to health worker motivation and to identify the organisational characteristics and contextual conditions within which these processes are enabled or hindered.

Methodology
I adopted the realist evaluation approach. I developed the initial programme theory on the basis of a scoping review and tested it in four hospitals using a multiple embedded case study design. The data collection included 68 individual interviews, 8 focus group discussions and 11 group discussions with different professional cadres, and non-participant observations, carried out between January and June 2018. I analysed the qualitative data using thematic analysis and adopting the Intervention-Context-Actors-Mechanisms-Outcome (ICAMO) configuration as a heuristic tool to identify plausible causal configurations. Conjectural ICAMOs were compared within cases (across time spans and professional profiles) and across cases. We finally translated the confirmed ICAMOs into a refined programme theory.

Results
I found that in high-performing hospitals, effective leaders foster distributed leadership and facilitate the creation of a supportive environment, which enables open communication, improves relations between staff and allows for effective problem-solving but that this requires a conducive organisational culture and the absence of perceived organisational politics.

Discussion
My study showed that effective leaders can foster health worker motivation by distributing leadership and facilitating the creation of an enabling environment. By adding an explicit analysis of the time dimension (ICAMO (t)), I was able to track the sequencing, timing and dynamic processes of leadership, overcoming the traditional “snapshot” analysis.

Conclusion
Our study leads us to recommend that the development of leadership capacity in Morocco would benefit from focusing on reinforcing individuals’ cognitive, functional and social capabilities, distributed leadership and enabling a positive organisational climate.