The decision-making process

The Decision-Making Process


You now have some understanding of the policy, political and legal processes in your region. However knowing the processes and accessing them to influence decision-making are very different activities. In the previous topic you developed a policy intervention plan, now you will be given an understanding of the decision-making processes themselves.

Decision can be defined as a choice made from two or more alternatives. Decision-making process is a set of steps that include identifying the problem, selecting an alternative and evaluating the decision's effectiveness Individuals at all levels of an organization make decisions. That is they make choices from two or more alternatives. Although decision-making is typically described as "choosing between alternatives" that view is overly simplistic. If we go back to the previous session we are reminded that we operate within a system and that the system is a set of interrelated and interdependent parts arranged in a manner that produces a unified whole.

If we apply this thinking to decision-making we understand that there will be many economic, political, social and environmental factors both formal and informal which can have an impact on any decision-making process.

Decision-Making Models

It is useful to have some understanding of the various models of decision-making. This will assist you when determining how you should engage the relevant decision-making process to achieve your intentions. These intentions may be to advocate for change as an external change agent or by establishing yourself in a decision-making position. Some of the decision-making models are presented below.

  • Rational Model: This is the classical, scientific approach to decision-making which views the process as essentially orderly and rational. A problem is defined and isolated, information is gathered, alternatives identified, and an end is established.
  • Garbage Can Model: This describes decision-making processes in organizations which are characterized by ambiguity, where objectives are ill-defined or inconsistent for individual decision-makers. The model applies when resource constraints are high and it encapsulates the complex environment which surrounds organizational decision-making. This is often found in the public health system and is very hard to affect.
  • Contingency Model: The contingency approach considers organizational goals and structures as dependent (contingent) upon technological and environmental forces rather than as properties to be manipulated at will by management. This is often used as an excuse for not proceeding with change.
  • Organizational Process Model: This model recognizes a real difference between an individual decision-maker and an organization, emphasizing the centrality of routines and procedures in reducing the effects of uncertainty. It is important to understand the difference between individual and organizational decision-making.
  • Incremental Model: This approach suggests that there are interrelated decision-making processes which may be depicted as a sequence of steps, or series, comprising:

  1. An identification phase;
  2. An alternatives development phase, and
  3. A selection phase.

This model is often used when introducing a new specifically funded program, Technology or capital works.

  • Political bargaining model: Underlying this model is the view that individuals, groups and organizations have self defined interests to protect. When faced with a decision, participants in the process focus on those aspects which they perceive as affecting their own interests and, consequently, a range of linked issues compete for attention, rather than a single strategic problem requiring a solution. Again this model is often seen in the health system.

As previously stated, understanding the model of decision making you are involved with will assist you to determine how you should engage the decision-making process to achieve your intentions

Types of Decisions

Decisions can be located at points along a continuum from structured to unstructured. Unstructured decisions require managerial judgment and consideration of unquantifiable factors. They may also require consideration of qualitative factors, ethical judgments or simply personal taste; and may even be the result of a decision-makers inability to fully comprehend a structure in a complex situation. An unstructured decision may either be incapable of being structured or may not yet have been examined in depth, so may appear to the organization as unstructured.

Unstructured decisions can be characterized as:

  • Involving trial and error approaches,
  • Intuition and common sense
  • Tending to be ad hoc; and
  • Are usually made at the middle and top levels of management.

It is also appropriate to mention the widespread existence of non-rational decision-making, often involving hidden agendas and objectives.

Structured decisions are often those which can be automated, and where often a single "best" solution can be identified. Many problems are difficult to structure without ignoring important qualitative features.

Decision levels can also be seen as existing on a spectrum from strategic to operational. Strategic decisions can be defined as those concerned with deciding the objectives of an organization, the resources used to attain the objectives and policies governing acquisition, use and disposition of those resources. Operational decisions, on the other hand, are concerned with ensuring that resources are used efficiently in the accomplishment of the organizational


For example, in health services, strategic decisions may include:

  • Allocating funds among program areas,
  • Assessing program performance with respect to strategic objectives (evaluation), and
  • Setting standards for operations.

Operational control decisions ensure that specific tasks are performed in an effective and efficient manner: monitoring daily operations and activities with respect to standards, corrective actions, and scheduling. It is useful to determine what type of decision-making process you are entering. Your response to the decision-making process may depend on the type you are confronted with.

Having determined the model of decision-making, the types of decisions and the decision-making stages, you should be in a position to decide how and where you need to have some influence. This will very much depend on the nature of the influence or intervention you wish to make. For example, if you want to influence policy it will be the policy making process; if you what to influence decisions regarding resource allocation it may be the policy making and/or budget process. If you want to bring about lasting and mandated change then it may be the legislative process.

You need to maximize your effort and resources (because they are likely to be limited) so assess carefully what resources you do have and when best to enter the relevant process. Timing is important.


Before you enter into decision making process you have to identify the resources available, that is; the relevant support groups who can support you and maximize your effort. Your support groups could be:

  • anesthesia nursing staff
  • local general practitioners
  • professional association
  • staff of similar health facility
  • local member of parliament
  • Local media

Then after identifying your support group you should try to figure out their skills or interests to the issue you want to advocate. The following table will give you an example of how you can involve your support groups towards your agenda based on their respective skills and/or interests.

Table 12.2 Support groups and skills for decision making process

Person/ Group Skills Comments
Nursing staff Passion, knowledge of consequences of current situation but do not have the political skills and "know how" Preferably get them to work through professional association.
Local general
Have an interest but no time and have other priorities. Provide them with a letter to sign to the Minister and the Department Head listing the medium to long-term financial consequences
Professional association Have an interest and have indicate they want to use this situation as a benchmark case, therefore they are prepared to put resources into it. Develop plan of action with the professional association and a time table. Will be available when the time is right.
Staff of similar health centers Have an interest, can provide additional supporting information; are prepared to speak out through the media; and to put a case to their local politician, the minister and Department Head Need to work together on the issue.
Local member of Parliament Has taken an interest; has other priorities but if given the right information can be a political "in house" supporter. Need to provide with relevant evidence based consequences of current action and way forward
Local media Have indicated they will publish an article if given the details. appropriate time Provide material for article at appropriate time

Entering the Decision Making Process

As indicated before, the timing for a just a couple of colleagues you may need a long term plan with entry at the beginning of the process so as to build up credibility and ability to influence. If you have an organization's support, you may enter at any stage in the process, but often the "big bang" approach can be successful. What is meant here is that all resources are put into impacting on a particular stage in the decision-making process.

You are now well on the way. You are armed with a clearly defined issue; you have the evidence to support your case; you have some understanding of the policy, political and legal.

Processes in your region; you have an understanding of the context in which decisions are made and you know how and when to access the appropriate step in the process of decision making.

Last modified: Tuesday, 21 March 2017, 2:31 PM