7Making Progress and Making Decisions: 


Structure and Decisionmaking Issues
 

This	chapter	focuses	on	the	role	that	TB	prevention	and	control	program	staff	and	 

partnership	leaders	can	play	to	ensure	that	TB	partnerships	identify	and	use	appropriate	 

structures	and	decisionmaking	styles—ones	that	create	a	sense	of	commitment	while	 

significantly	improving	TB	prevention	and	 Elements of Making Progress and control	outcomes.	 Making Decisions 

Partnership Structure: An Overview • Partnership structure 

Research Suggests	 • Creating partnership structures that fit your 

needs A	TB	prevention	and	control	program	 • Creating decisionmaking processes that fit should	offer	guidance	and	technical	 your needs 

advice	to	those	with	whom	it	is	 • Anticipating and managing differences 

partnering.	However,	partnerships	 

addressing	complex	issues	must	be	able	to	operate	autonomously	if	they	are	to	succeed.	 

Each	partnership	is	different	and	must	develop	the	structures	and	decisionmaking	styles	 

that	best	fit	its	unique	circumstances.	There	is	no	one	best	way	to	forge	partnerships.	 

However,	the	following	conditions	appear	critical	to	developing	effective	partnership	 

structures	and	processes	for	joint	decisionmaking	among	diverse	stakeholders:45 

•	 Stakeholders	see	themselves	as	interdependent,	believing	that	their	goals	cannot	 

be	reached	by	any	one	group	or	partner	working	alone. 

•	 Stakeholders	assume	collective	responsibility	for	the	direction	of	the	partnership. 

•	 Decisions	emerge	by	dealing	constructively	with	differences. 

•	 Joint	ownership	of	decisions	exists. 

•	 Partnering	is	viewed	as	an	emergent	process. 

Effective	leadership	is	key	to	creating	these	conditions.	Whether	acting	through	 

formal	or	informal	partnership	structures,	effective	leadership	exhibits	the	following	 

competencies	when	working	with	TB	stakeholders: 

•	 Communication,	including	respect	for,	engagement	with,	and	mutual	influence	 

among	people	of	different	ethnic,	racial,	and	economic	backgrounds	 

•	 The	ability	to	effectively	frame	and	communicate	the	vision	and	mission	of	a	 

partnership	to	a	broad	range	of	stakeholders46	 

45Lewicki,R	J,	ed.	1999.	Negotiation: Readings, exercises, and eases,	117. 2nd	ed.	Irwin	McGraw-Hill;	Roussos	ST,	
 

Fawcett	SB.	2000.	A	review	of	collaborative	partnerships	as	a	strategy	for	improving	community	health.	Annual 


Review of Public Health 21,	370.
 46Ibid.,	385.
 

Forging Partnerships to Eliminate Tuberculosis: A Guide and Toolkit  

Chapter : Making Progress and Making Decisions: Structure and Decisionmaking Issues 
•	 The	ability	to	listen	actively	to	partners	and	then	repeat,	in	the	listener=s	own	 

words,	what	he	or	she	thinks	the	partner	has	said 

•	 Encouragement	of	a	team	building	process	by	which	the	partnership	clarifies	its	 

goals,	identifies	barriers	to	achieving	the	goals,	and	develops	strategies	to	remove	 

the	identified	barriers 

•	 The	ability	to	resolve	conflict	and	manage	differences	in	a	way	that	views	conflict	 

and	differences	as	opportunities	to	expand	the	partnership’s	common	vision 

•	 Flexibility	as	changes	in	the	partnership’s	needs	and	composition	occur 

Things to Keep in Mind 

•	 Do	not	underestimate	the	leadership	skills	and	abilities	of	TB	partners	and	 

key	stakeholders.	It	is	important	to	accurately	assess	their	leadership	skills	and	 

abilities,	as	well	as	your	own,	and	to	encourage	all	partners	to	effectively	use	their	 

leadership	capabilities. 

•	 Partnering	is	an	emergent	process,	which	means	that	partnerships	are	not	static;	 

they	grow	and	develop	over	time.	At	their	best,	TB	partnerships	are	co-learning	 

experiences	where	all	participants	learn	and	grow. 

•	 The	skills	and	talents	required	for	partnerships	to	operate	effectively	may	 

change	over	time.	Productive	partnerships	accurately	evaluate	and	monitor	their	 

competencies,	talents,	skills,	and	limitations.	They	build	on	their	strengths	and	 

seek	new	recruits	and/or	training	to	overcome	their	limitations.	 

Creating Partnership Structures That Fit Your Needs 

Some	partners	will	prefer	establishing	traditional	formal	structures,	such	as	standing	 

committees	and	elected	officers;	others	will	prefer	allowing	structures	and	leadership	to	 

emerge	over	time.	As	noted	in	Chapter	3:	What Successful Health-Related Community 

Partnerships Have in Common,	what	leaders	do	is	more	important	than	how	they	 

are	designated.	(Specific	leadership	competencies	and	actions	associated	with	high	 

performance	partnerships	are	addressed	in	that	chapter.)	 

However,	when	diverse	partners	do	not	have	a	history	of	positive	working	relationships,	 

it	is	often	better	not	to	choose	formal	leadership	through	majority	vote	early	in	the	 

partnership’s	development.	Instead,	a	good	facilitator	can	work	with	the	partnership	and	 

help	it	to	adopt	operating	principles,	share	information,	develop	a	vision,	and	develop	 

governing	processes	over	time.	 

Several	structural	approaches	that	partnerships	might	wish	to	consider:	 

•	 Project approach—The	partnership	decides	to	undertake	clearly	defined	projects	that	 

are	consistent	with	the	vision.	Those	most	involved	with	implementing	the	projects	 

 Forging Partnerships to Eliminate Tuberculosis: A Guide and Toolkit 

Chapter : Making Progress and Making Decisions: Structure and Decisionmaking Issues 
have	decisionmaking	responsibility	for	them.	They	regularly	share	their	progress	at	 

partnership	meetings,	seeking	others’	feedback	and	guidance.	 

•	 Stakeholder approach—Partners	from	specific	stakeholder	groups	provide	leadership	 

to	the	group	on	how	to	effectively	develop	TB	prevention	and	control	efforts	within	 

their	communities	that	are	consistent	with	the	vision.	Partners	jointly	identify	the	 

steps	they	will	take	to	accomplish	this.	 

•	 Area of responsibility approach—The	partnership	is	organized	by	committees	 

associated	with	ongoing	areas	of	responsibility,	such	as	overall	partnership	 

recruitment,	media	relations,	community	outreach,	fundraising,	and	program	 

evaluation.	Partners	join	one	or	more	committees	charged	with	carrying	out	their	 

areas	of	responsibility	in	accordance	with	the	vision.	The	work	of	the	committees	 

may	be	coordinated	through	a	steering	committee.		 

These	structural	approaches	are	not	mutually	exclusive.	TB	partnerships	addressing	 

complex	issues	may	find	that	a	combination	of	structural	approaches	works	best	for	 

them.	 

Creating Decisionmaking Processes that Fit Your Needs 

A	variety	of	decisionmaking	styles	is	available	to	partnerships.	Some	partners	may	 

be	accustomed	to	making	decisions	on	individual	issues	using	either	majority	vote	 

or	consensus	frameworks.	However,	both	of	these	decisionmaking	styles	will	present	 

problems	for	multicultural	partnerships	dealing	with	complex	issues	if	partners	try	to	use	 

these	decisionmaking	styles	to	adopt	“one	size	fits	all”	approaches	that	fail	to	consider	 

cultural	differences. 

Partnerships	need	to	create	decisionmaking	processes	and	styles	that	allow	partners	to	 

customize	projects,	decisions,	and	activities	to	achieve	maximum	fit	and	productivity	for	 

the	diverse	groups	they	are	trying	to	serve.	A	collaborative	decisionmaking	style	can	help	 

to	achieve	these	goals.	With	collaborative	decisionmaking 

•	 Partners	maintain	concern	for	their	own	interests	as	well	as	those	of	others 

•	 Open	sharing	of	partners’	needs,	interests,	and	objectives	is	encouraged 

•	 Partners	seek	win-win	options	agreeable	to	all	partners47 

47Ibid.,	89. 

Forging Partnerships to Eliminate Tuberculosis: A Guide and Toolkit  

Chapter : Making Progress and Making Decisions: Structure and Decisionmaking Issues 
A Step-by-Step Approach for Collaborative Decisionmaking48 

•	 Step One:	Identify	and	define	the	issue.	 

Identifying	an	issue	may	not	be	as	straightforward	as	it	seems.	Diverse	partners	 

may	have	very	distinct	perceptions	of	the	issue	being	addressed.	Their	perceptions	 

may	be	rooted	in	strongly	held	preconceived	views	on	the	best	way	to	address	the	 

issue.	However,	at	this	stage	of	the	decisionmaking	process,	it	is	inappropriate	to	 

discuss	solutions.	For	collaborative	decisionmaking	to	occur,	partners	must	first	 

be	able	to	create	a	mutually	agreed-upon	 Collaborative Decisionmaking definition	of	the	issue.	A	facilitator	helps	 

identify	objective	language	that	all	partners	 1. Identify and define the issue

2. Identify and understand concerns find	agreeable.	Ideally,	the	issue	or	problem	 3. Create options can	be	framed	as	a	goal	that	partners	will	 4. Evaluate alternatives and select an work	toward,	with	any	barriers	that	might	 approach

need	to	be	overcome	clearly	identified.	 

•	 Step Two:	Identify	and	understand	concerns.	 

Collaborative	decisionmaking	is	more	successful	when	partners	understand	 

the	interests,	uncertainties,	worries,	concerns,	and	suspicions	that	partners	 

may	associate	with	the	issue	being	discussed.49	Partners	can	then	use	this	 

understanding	to	craft	decisions	that	minimize	concerns,	while	maximizing	 

progress	toward	the	group’s	common	vision.	 

Some	partners	will	prefer	to	discuss	concerns	one-on-one	with	a	trusted	 

partnership	leader,	rather	than	in	a	group	setting.	It	is	important	for	them	to	have	 

this	option.	As	trust	among	partners	increases,	suspicions	and	worries	will	tend	to	 

decrease. 

Concerns	your	TB	partnership	may	encounter: 

-	 Material	concerns involve	tangible	issues,	such	as	protecting	one’s	job	or	the	 

way	in	which	a	budget	is	distributed.	 

-	 Process	concerns refer	to	how	decisions	are	made.	A	partner	may	believe	that	 

because	he	or	she	has	more	knowledge	about	a	situation	than	others	do,	his	or	 

her	perspective	must	be	given	more	weight.	 

-	 Relational	concerns come	into	play	when	partners	believe	that	powerful	 

partners	may	retaliate	against	them,	or	they	are	concerned	about	damaging	a	 

valued	relationship.	 

48Ibid.,	18–52,	111–126. 

49Ibid. 

4 Forging Partnerships to Eliminate Tuberculosis: A Guide and Toolkit 

Chapter : Making Progress and Making Decisions: Structure and Decisionmaking Issues 
-	 Matters	of	principle	occur	when	a	partner	feels	strongly	that	there	is	only	one	 

right	way	to	proceed,	which	cannot	be	compromised.	When	differences	are	 

framed	as	matters	of	principle,	they	are	almost	impossible	to	resolve.	 

•	 Step Three:	Create	options. 

One	or	more	of	the	following	approaches	may	be	helpful	when	creating	options: 

-	 When	partners	can	agree	that	the	main	barrier	to	coming	to	agreement	is	a	 

lack	of	resources,	deciding	to	look	for	additional	resources	may	be	a	simple	 

way	to	move	partners	forward. 

-	 When	an	issue	is	complex,	it	is	often	helpful	to	identify	and	subdivide	the	 

issue	into	its	component	parts.	Partners	can	then	discuss	which	parts	matter	 

most	to	them	and	why.	This	process	often	results	in	partners	being	able	to	 

craft	an	option	that	encompasses	the	outcomes	of	greatest	importance	to	each	 

partner,	while	minimizing	concerns	associated	with	the	issue.	 

-	 A	trade-off	approach	may	be	helpful	when	trying	to	decide	between	two	 

valuable	options	that	cannot	be	completed	at	once.	An	agreement	may	be	 

made	to	complete	them	sequentially,	establishing	timelines	and	assigning	 

responsibilities	for	each.	 

•	 Step Four: Evaluate	alternatives	and	select	an	approach. 

At	this	stage,	all	options	are	weighed	against	the	vision	and	the	partners	discuss	 

the	potential	benefits	of	each	option,	as	well	as	possible	pitfalls.	Options	that	are	 

not	strongly	supported	are	removed	from	consideration.	The	approaches	used	to	 

create	options	can	be	used	to	help	with	final	selection.	 

Anticipating and Managing Differences 

Differences	that	result	in	conflict	are	a	natural	part	of	diverse	groups	partnering	to	 

address	complex	issues.	Rather	than	seeing	differences	as	a	problem,	it	is	helpful	to	view	 

them	as	opportunities	to	expand	the	partnership’s	common	vision	and	understanding	 

of	TB	prevention	and	control.	When	partners	are	unable	to	view	differences	in	this	 

way,	their	differences	can	escalate	into	conflict.	Unfortunately,	perceiving	differences	as	 

a	problem	appears	to	be	a	common	occurrence	in	multisector	partnerships	addressing	 

complex	issues.	Partners	often	try	to	avoid	conflict	by	ignoring	it	or	employ	conflict	 

resolution	methods	that	are	not	helpful.	 

Conflicts	are	accompanied	by	tension.	Consequently,	recognizing	the	early	signs	of	 

tension	(body	language,	mild	verbal	expressions	of	frustration)	and	being	prepared	to	 

address	them	before	they	escalate	is	a	valuable	skill.	However,	even	the	most	contentious	 

discussions	can	be	effectively	managed.	 

Forging Partnerships to Eliminate Tuberculosis: A Guide and Toolkit  

Chapter : Making Progress and Making Decisions: Structure and Decisionmaking Issues 
What	follows	are	descriptions	of	common	conflict	resolution	methods	and	the	 

circumstances	under	which	they	are	most	helpful:50	 

Conflict Resolution Methods 

Compromise 

High level of 


concern for 


other party 


Low level of 


concern for
 

other party
 

Low level of 

Compliance Collaboration 

Avoidance Competition 

Compromise 

High level of 

concern for self concern for self 

Adapted from Essentials of Negotiation (2nd ed.) by Lewicki, Saunders, and Minton. 

•	 Avoidance—Avoiding	or	ignoring	conflict	appears	to	be	the	most	common	approach	 

used	by	partnerships.	However,	its	effectiveness	is	very	limited.	It	may	be	popular	 

because	partners	are	uncomfortable	or	unskilled	in	dealing	with	conflict,	or	because	 

they	feel	intimidated	by	another	partner.	 

When	the	issue	being	avoided	is	important	to	one	or	more	partners,	it	cannot	really	 

be	avoided—only	postponed.	Often,	postponement	allows	a	difference	to	fester	 

and	become	a	full-blown	conflict	that	threatens	the	partnerships	ability	to	function.	 

Avoiding	conflict	is	only	appropriate	when	the	issue	at	the	center	of	the	conflict	 

is	of	minimal	importance	to	all	partners.	However,	a	partnership	might	choose	 

to	temporarily	postpone	addressing	a	conflict	when	partners	need	time	to	calm	 

down.	When	this	occurs,	it	is	important	to	set	a	specific	time	when	the	issue	will	be	 

addressed.	 

	50Ibid. 

 Forging Partnerships to Eliminate Tuberculosis: A Guide and Toolkit 

Chapter : Making Progress and Making Decisions: Structure and Decisionmaking Issues 
•	 Compromise—This is	one	of	the	more	common	conflict	resolution	styles	used	 

by	health	related	partnerships.	In	fact,	the	term	compromise	is	often	viewed	as	 

synonymous	with	conflict	resolution.	However,	this	conflict	resolution	approach	has	 

limitations.	It	often	results	in	mediocre	solutions	that	are	unsatisfying	to	the	parties	 

in	conflict.	The	root	of	its	limited	effectiveness	with	partnerships	may	lie	in	an	 

emphasis	on	seeking	solutions	before	a	conflict	is	fully	understood 

•	 Compliance—Partners	more	interested	in	helping	the	other	party	to	arrive	at	a	 

satisfactory	outcome	than	in	pursuing	their	own	goals	adopt	this	strategy.	This	 

approach	is	suitable	when: 

-	 The	issue	is	much	more	important	to	other	partners	than	it	is	to	you. 

-	 You	could	be	wrong	about	the	consequences	or	outcomes	associated	with	your	 

position. 

-	 The	relationship	with	partners	holding	a	distinct	view	is	more	important	to	the	 

vision. 

•	 Collaboration—As	noted	earlier	in	this	section,	partners	using	a	collaborative	 

approach	maintain	a	high	concern	for	their	own	interests	as	well	as	those	of	other	 

partners.	This	approach	is	appropriate	when	the	issue	is	important	to	the	parties	 

involved	and	input	is	required	from	multiple	partners	to	solve	a	shared	problem.	 

•	 Competition—By definition,	partners	who	compete	are	most	concerned	with	 

their	own	outcomes.	This	is	a	contentious	approach	to	conflict	management	 

and	may	involve	intimidating	other	partners.	It	is	the	conflict	resolution	strategy	 

most	often	used	when	a	win-lose	outcome	is	desired	or	expected.	It	tends	to	be	 

counterproductive	in	partnerships	seeking	to	establish	trusting	relationships.	 

Tips and Strategies 

Sometimes	conflict	escalates	to	the	point	where	 When Differences Escalate 

partners	or	stakeholders	have	become	angry	and	 into Conflict 

unshakable	in	their	differing	perceptions	of	a	 • Diffuse tension and hostility 

situation.	This	can	happen	when	partners	or	 • Find similarities 

stakeholders:	 • Divide the conflict into 


manageable parts
 •	 Fail	to	deal	with	the	conflict	in	a	timely	fashion	 

•	 Have	incompatible	conflict	resolution	styles	 

•	 Communicate	ineffectively	and	use	accusatory	language 

•	 Lack	confidence	and	respect	for	each	other 

Forging Partnerships to Eliminate Tuberculosis: A Guide and Toolkit  

Chapter : Making Progress and Making Decisions: Structure and Decisionmaking Issues 
However,	even	the	most	contentious	partnership	differences	can	be	managed	
 

effectively.	The	following	are	some	approaches	that	may	help51:
 

•	 Diffuse tension and hostility—Active	listening	can	help	to	diffuse	strong	 

feelings.	This	type	of	listening	requires	acknowledging	how	the	partners	feel	 

and	sincerely	showing	that	you	empathize	with	them.	By	paraphrasing	what	the	 

partner	is	saying,	you	communicate	your	understanding	of	the	partner’s	points	 

of	view	without	expressing	agreement	with	them.	Depersonalize	the	conflict	by	 

helping	partners	separate	the	issues	from	the	parties	who	hold	them.	Frame	the	 

conflict	to	make	it	clear	that	the	issues	are	at	stake,	not	the	relationships.	 

•	 Find similarities—Parties	in	conflict	may	fail	to	remember	they	have	anything	in	 

common.	Acknowledging	commonalties	can	help	to	de-escalate	a	conflict.	The	 

following	approaches	may	help: 

-	 Mention	goals	and	viewpoints	that	the	partners	share,	including	the	 

partnership	vision.	 

-	 Have	partners	work	with	you	to	identify	a	conflict	resolution	process	that	 

is	mutually	agreeable	and	is	in	keeping	with	the	partnership’s	operating	 

principles.	 

•	 Divide the conflict into manageable parts—Addressing	complex	conflicts	 

involving	a	number	of	issues	can	be	cumbersome	and	frustrating.	The	following	 

suggestions	may	help:	 

-	 Acknowledge	that	the	problem	is	complex	and	may	not	be	able	to	be	resolved	 

in	one	meeting.	 

-	 Have	partners	agree	on	a	time	limit	for	the	discussions.	 

-	 Work	with	partners	to	separate	the	problem	into	its	component	parts	 

and	discuss	each	separately.	Start	with	the	parts	that	seem	to	be	the	least	 

contentious. 

-	 Help	partners	to	frame	differences	in	ways	that	minimize	perceived	matters	 

of	principle.	When	an	issue	is	framed	as	a	matter	of	principle,	it	is	extremely	 

difficult	to	resolve. 

-	 If	partners	fear	that	a	solution	will	set	an	unacceptable	precedent,	help	 

partners	clarify	whether	they	are	willing	to	view	the	solution	as	an	isolated	 

agreement,	rather	than	as	a	matter	of	precedent.	 

When	you	effectively	manage	the	differences	that	exist	within	your	partnership,	you	 

allow	partners	to	develop	higher	levels	of	trust,	commitment,	and	productivity.	 

51Ibid. 

8 Forging Partnerships to Eliminate Tuberculosis: A Guide and Toolkit 

Chapter : Making Progress and Making Decisions: Structure and Decisionmaking Issues 
Related Resources 

•	 National Public Health Leadership Development Network 

The	CDC,	with	the	Association	of	Schools	of	Public	Health	and	Saint	Louis	 

University,	created	this	network.	It	provides	a	variety	of	resources	and	information	 

designed	to	develop	state	and	regional	health	care	leadership	dedicated	to	meeting	 

local	grassroots	needs.	The	network’s	goals	are	accomplished	by	developing	and	 

enhancing	individual	and	organizational	leadership	and	management.	Additional	 

information	on	the	network	can	be	obtained	from	www.heartlandcenters.slu.edu/nln. 

Forging Partnerships to Eliminate Tuberculosis: A Guide and Toolkit  

Chapter : Making Progress and Making Decisions: Structure and Decisionmaking Issues