iGlobal University Healthcare Supply Chain Discussion

Describe what it means to have a resilient healthcare supply chain. What factors should be considered when assessing the health of a supply chain network? If a healthcare organization’s supply chain fails, what possible implications could there be? What could a healthcare organization do to strengthen their supply chain?

https://ijhpm.com
Int J Health Policy Manag 2022, 11(8), 1316–1324
doi 10.34172/ijhpm.2021.26
Original Article
Seeking Healthcare During Lockdown: Challenges,
Opportunities and Lessons for the Future
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Fiona Imlach1 , Eileen McKinlay2 , Jonathan Kennedy2 , Megan Pledger1 , Lesley Middleton1 ,
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Jacqueline Cumming1 , Karen McBride-Henry3* ID
Abstract
Background: In Aotearoa/New Zealand, the first nation-wide coronavirus disease 2019 (COVID-19) lockdown
occurred from March 23, 2020 to May 13, 2020, requiring most people to stay at home. Health services had to suddenly
change how they delivered healthcare and some services were limited or postponed. This study investigated access
to healthcare during this lockdown period, whether patients delayed seeking healthcare and reasons for these delays,
focusing on the accessibility of primary care services.
Methods: Adults (aged 18 years or older) who had contact with primary care services were invited through social media
and email lists to participate in an online survey (n = 1010) and 38 people were recruited for in-depth interviews. We
thematically analysed qualitative data from the survey and interviews, reported alongside relevant descriptive survey
results.
Results: More than half (55%) of survey respondents delayed seeking healthcare during lockdown. Factors at a national
or health system-level that could influence delay were changing public service messages, an excessive focus on COVID-19
and urgent issues, and poor service integration. Influential factors at a primary care-level were communication and
outreach, use of technology, gatekeeping, staff manner and the safety of the clinical practice environment. Factors that
influenced patients’ individual decisions to seek healthcare were the ability to self-manage and self-triage, consciousness
of perceived pressure on health services and fear of infection.
Conclusion: In future pandemic lockdowns or crises, appropriate access to primary care services can be improved by
unambiguous national messages and better integration of services. Primary care practices should adopt rapid proactive
outreach to patients, fostering a calm but safe clinical practice environment. More support for patients to self-manage
and self-triage appropriately could benefit over-burdened health systems during lockdowns and as part of business as
usual in less extraordinary times.
Keywords: Primary Healthcare, Pandemic, COVID-19, Access, Health Services, New Zealand
Copyright: © 2022 The Author(s); Published by Kerman University of Medical Sciences. This is an open-access
article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/
licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the
original work is properly cited.
Citation: Imlach F, McKinlay E, Kennedy J, et al. Seeking healthcare during lockdown: challenges, opportunities and
lessons for the future. Int J Health Policy Manag. 2022;11(8):1316–1324. doi:10.34172/ijhpm.2021.26
Article History:
Received: 16 December 2020
Accepted: 13 March 2021
ePublished: 13 April 2021
*Correspondence to:
Karen McBride-Henry
Email:
karen.mcbride-henry@vuw.ac.nz
Key Messages
Implications for policy makers
•
Those who delayed seeking care were more likely to be struggling financially, be concerned about the impact of coronavirus disease 2019
(COVID-19), have poorer health, a disability or more difficulties in managing their health in the pandemic.
•
Individuals considered the risk of COVID-19 exposure to themselves and others and managed non-urgent problems by watching and waiting
and self-care.
•
Proactive, up-to-date communication from practices about what services were available, how to get in touch and expected changes to service
delivery could encourage access to services but needed to reach those most at risk.
•
Practices with systems already in place to undertake electronic, patient-focused communication were better able to provide care during
lockdown.
•
Outreach by non-digital methods can ensure that patients without online capability are not excluded.
Implications for the public
This study offers insights into how people experienced accessing healthcare during the pandemic. It highlights that people did delay, or did not,
access healthcare if they believed their need for healthcare was not urgent, or if the risk of being coming ill because of the pandemic was deemed too
great. The study also reflects the people’s views on how primary care should operate during a pandemic; this information can support future health
service planning.
Full list of authors’ affiliations is available at the end of the article.
Imlach et al
Background
The novel coronavirus disease 2019 (COVID-19) has spread
rapidly throughout the globe since its emergence in December
2019, infecting millions of people and causing over a million
deaths as of September 30, 2020.1 Different countries have
taken a range of approaches to constrain the impact of the
virus, including intensive community testing and tracing
of contacts, travel restrictions, mask-wearing and partial to
complete ‘lockdowns,’ where all non-essential workers are
instructed to stay at home.2
Aotearoa/New Zealand responded to the COVID-19 threat
with a nationwide lockdown from March 23, 2020, until May
13, 2020. During the complete lockdown period, from March
25 to April 27, 2020 (level four of a four-level alert level system
introduced to manage the pandemic response),3 only essential
services remained open (including supermarkets, pharmacies,
general practices and public hospitals), with much routine
healthcare put on hold, and many consultations performed
remotely by telephone or video (telehealth). People were
expected to keep within their neighbourhoods, limit contact
to household members, and maintain physical distance from
others. During level three, the partial lockdown period that
ended on May 13, 2020, early childhood centres, schools and
takeaway food services could open with restrictions. Health
services were still advised to operate remotely as much as
possible, to avoid them becoming the focus of virus spread, as
had happened elsewhere.4
During lockdown, televised daily briefings from the Prime
Minister and Director-General of Health updated the nation
on the number of new COVID-19 cases, hospitalisations and
deaths, and provided messages about accessing healthcare and
COVID-19 testing. These messages were repeated via regular
advertising on television, social media and news channels. In
the early stages of lockdown, there was a high level of concern
that both primary and secondary healthcare services could be
overwhelmed by the pandemic.5 However, it quickly became
apparent that demand for primary care declined during
lockdown (apart from an initial surge for repeat prescriptions
and flu vaccinations as the winter flu session approached),6
with concomitant reduced hospital emergency department
(ED) presentations and acute hospital admissions.7,8 This led
to a new concern, that delays in seeking healthcare could lead
to serious problems being missed or an unmanageable deluge
of demand once lockdown ended.6,7
Declines in healthcare utilisation during COVID-19
lockdowns have also been reported internationally.9 In the
United Kingdom, general practitioner appointments in AprilMay 2020 were down by a third compared to the same period
the year before.10 Cancer screening appointments decreased
in the United States and cancer diagnoses decreased in
the Netherlands.11 Delays in seeking paediatric healthcare
contributed to avoidable harm and even death for children
during the 2020 lockdown in Italy, attributed to parental fear
of COVID-19.12 An inability to access care or delays in seeking
care were likely explanations for a significant reduction in ED
presentations for heart attacks and strokes in the United States
during March to May 2020.13
It is worth noting that prior to the 2020 lockdown,
inequities were evident in relation to accessing primary
healthcare within New Zealand,14 an issue that has been
exacerbated by COVID-19.9 In particular, inequities related
to access to primary healthcare existed for the indigenous
population Māori,15 those with mental health challenges,16
multimorbidity17 and those with lower socioeconomic status18
prior to COVID-19 lockdown. There is little research being
published about the impact of lockdown on access to primary
healthcare for vulnerable groups in Aotearoa/New Zealand.
This study aimed to obtain a patient perspective on
accessing healthcare during the first COVID-19 lockdown
in Aotearoa/New Zealand, with a particular focus on general
practice, as the front-line health service for the pandemic.19
For the purposes of this research, ‘access’ to healthcare refers to
health service utilisation and help seeking by the participants.
Research questions included:
• What contact did patients have with health services
during lockdown?
• Did patients delay seeking healthcare and for what
reasons?
• What changes would improve access to general practice
in a future crisis?
This is one of a series of papers about patient experiences
of healthcare during lockdown; others report on telehealth20
and pharmacy/prescribing.21 This paper reports on barriers
to healthcare during lockdown highlighting negative
experiences, however in another analysis we found that
those who accessed healthcare had predominantly positive
experiences.20
For context, the health system in Aotearoa/New Zealand
is set up to provide free emergency and hospital services but
general practices operate as private organisations, using a wide
range of business models.22 Most of these involve patient copayments for services, subsidised by a Government capitation
fee, based on the characteristics of the patients enrolled in
the general practice (higher capitation funding applies to
practices that serve populations with higher health needs).
Services are free for children less than 14 years old.
Methods
A mixed method approach was used, with an anonymous
online survey of adults (18 years and older) who had, or
wanted to have, contact with health services during lockdown,
supplemented by semi-structured interviews. Given the
constraints of lockdown, the survey and interview schedule
were developed by experienced health researchers within the
research team, informally reviewed by external experts, and
consumer pilot testing was done with household contacts of
the research team.
Online Survey
The survey was online from April 20 to May 13, 2020 (within
lockdown levels four and then level three) and asked about
contact with health services and if people had delayed seeking
healthcare during lockdown (questionnaire in Supplementary
file 1). Eight possible reasons for delay were presented, based
on previous surveys (eg, cost and transport)23 and likely
reasons in the context of lockdown (eg, fear of infection,
International Journal of Health Policy and Management, 2022, 11(8), 1316–1324
1317
Imlach et al
services unavailable). Socio-demographic questions included
age, gender, ethnicity, postcode and work status. Health status
was assessed with questions on self-rated health, disability
status and existing long-term conditions. Other questions
asked whether the pandemic made it easier or more difficult
to manage health, and level of concern about the impact of
the pandemic on health. Responses to open-ended questions
were included in the qualitative data analysis.
Recruitment was through snowballing using social media
and email lists, sent through personal and professional
networks, including the Universities affiliated with the
research and other organisations. Only responses from those
who lived in Aotearoa/New Zealand, who completed >70%
of the survey and provided >20 responses were included in
the final analysis (n = 1010). Descriptive survey statistics
only are presented, with missing values dropped from the
analysis, assuming that respondents with missing values were
similar to those without. The sampling errors in a snowball
sample are not meaningful so judgements have to be made
pragmatically. However, as a guide, the maximum margin
of error of a simple random sample of equivalent size to the
groups we analyse here are 3.1% (n = 1010), 4.2% (n = 542)
and 4.7% (n = 444).
Interviews
Interviewees were recruited from the online survey. Four
hundred and thirty-six survey respondents provided name and
contact details (collected separately from survey responses)
for follow-up. From these, we purposefully sampled by gender
and invited 75 people for an in-depth interview, of whom 41
agreed to and 38 completed an interview within the project
timeframe (others did not respond). Interviewees were sent
information about the research, provided oral or written
consent prior to the interview, and were given a gift-voucher
for their time. Interviews were done via Zoom or telephone,
audio-recorded, transcribed, checked and could be reviewed
by the interviewee on request.
Interviewees were asked in more detail about their
experiences of accessing healthcare and reasons for delaying
seeking care. Interviews were conducted by EM, FI, LR, MC,
JK, JM and took on average 33 minutes.
Qualitative Data Analysis
We used thematic analysis and a mixture of deductive and
inductive coding to analyse the 38 interview transcripts and
open-ended survey questions. The coding of the transcripts
was managed using NVivo 11 Pro (QSR International).
We applied Levesque’s framework of access to healthcare24
as an initial coding frame. This framework describes the
intersection of patients’ abilities, and demand for services,
with supply features of health services (all of which may be
disrupted by lockdowns and pandemics). From this initial
analysis, we developed more nuanced themes25 around what
could enable or hinder access to healthcare. Themes from
interviews were checked against the analysis of open-ended
questions to confirm the completeness of the analysis. Quotes
are inserted verbatim, with identifiers including age range,
gender and whether from survey (S) or interview (I).
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Results
Sample Characteristics
Characteristics of survey respondents and interviewees are
shown in Supplementary file 2. There was a predominance of
females and those from the lower North Island of Aotearoa/
New Zealand. Interviewees were more likely to be older and
not in employment than survey respondents.
Quantitative Results
Contact With Health Services
Most respondents (86%) reported contact with general
practice during lockdown, either for themselves or someone
else. (More details about the types of contacts with general
practices and experiences of telehealth are published
elsewhere20). Contact with community pharmacy was also
common (56%); 15% had contacted Healthline (free national
telephone health information service); 11% had experience
of a community-based COVID-19 testing centre and 8% had
contacted another health professional (eg, mental health,
physiotherapy, maternity care). Respondents also reported
contact with a variety of other health services: 9% attended
a hospital outpatient or specialist appointment; 6% attended
a public hospital ED and another 6% visited a private afterhours clinic; 3% had imaging or lab testing; and another 3%
had a hospital admission. (Multiple responses were possible;
hence these totals add to more than 100%).
Delay in Seeking Healthcare
Over half (55%) of survey respondents delayed seeking
healthcare during lockdown, and were more likely to be
younger, have a disability, have poorer self-rated health
and struggle to pay for living costs, find it more difficult
to manage their health during the pandemic and be more
concerned about the impact of the pandemic on their health
(see Table 1).
Most common reasons for delay were a concern that health
services were busy (52%); that services were postponed or
delayed (37%) or not available (27%); fear of being infected
with COVID-19 (31%), or infecting others (8%). Cost (9%)
and transport (4%) were less often reported as reasons for
delay. Six percent of respondents specified in the open-ended
response option that they delayed because their problem was
not urgent enough, usually from their own judgment of what
was urgent.
Qualitative Results
Respondents described their experiences mainly in relation
to general practice but also mentioned other health services.
They reported influences on accessing health services at
three levels: (1) National/health system; (2) General practice;
and (3) Individual. These influences could either enable or
hinder access across four of Levesque’s dimensions of access
to healthcare24 (see Table 2): the patient’s ability to perceive
their health need, aligned with the approachability of services;
the ability to seek healthcare that was acceptable; the ability to
reach services that were available and accommodating; and
the ability to engage in appropriate healthcare services. We did
not find influences for all dimensions and levels. Responses
International Journal of Health Policy and Management, 2022, 11(8), 1316–1324
Imlach et al
Table 1. Characteristics of People Who Delayed or Did Not Delay Seeking
Healthcare
Characteristics
Delayed Seeking Did Not Delay
Healthcarea,b
Seeking Carea,b
(n = 542)
(n = 444)
No. (%)
No. (%)
Age
18-34
139 (26)
79 (18)
35-44
120 (22)
78 (18)
45-54
139 (26)
105 (24)
55-64
82 (15)
89 (20)
65+
56 (10)
89 (20)
Female
464 (86)
366 (83)
Male
68 (13)
71 (16)
Other
8 (1)
5 (1)
Māori
51 (10)
45 (10)
Pacific peoples
13 (2)
5 (1)
Asian
22 (4)
11 (3)
New Zealand European/other
448 (84)
379 (86)
303 (57)
270 (61)
61 (11)
47 (11)
In paid employment not being paid
18 (3)
8 (2)
Unemployed looking for work
22 (4)
8 (2)
Not in paid employment, not looking
for work
130 (24)
108 (24)
Agree/strongly agree
57 (11)
16 (4)
Neither
68 (13)
34 (8)
Disagree/strongly disagree
414 (77)
391 (89)
Excellent
51 (9)
67 (15)
Very good
194 (36)
184 (42)
Good
176 (33)
144 (33)
Fair
93 (17)
44 (10)
Poor
26 (5)
4 (1)
Presence of long term health
condition
336 (62)
268 (61)
Presence of disability
78 (14)
43 (10)
Concerned about impact of
COVID-19 on their own health
284 (52)
184 (41)
More difficultd to manage health
during pandemic
306 (57)
88 (20)
Gender
Prioritised ethnicity
Current work status
In paid employment as before
COVID-19
In paid employment with reduced
pay
Struggle to pay for living costs in last 7 days
Self-rated health
c
Abbreviation: COVID-19, coronavirus disease 2019.
a
Missing values were excluded from the analyses.
b
The maximum margin of error for a simple random samples of size 542 and
444 are 4.2% and 4.7%, respectively.
c
Extremely, very or moderately concerned (other question responses were
slightly or not at all concerned).
d
A little or much more difficult (other question responses were a little
easier, much easier or neither).
about ability to pay and affordability of services related almost
exclusively to telehealth, which is discussed elsewhere.20
1. National/Health System Influences on Healthcare Access
1.1. Public Service Messages
During lockdown, people reported relying on national news
outlets for health information, especially the televised daily
updates. On the whole, people found these reassuring and
informative. However, at the start of lockdown, people noted
that messages emphasised being alert for signs of COVID-19,
were focused on containing the virus and directed people to
telephone Healthline. As time went on, it was recognised that
people were not accessing care for non-COVID-19 conditions,
and messages encouraged access to general practices for any
health concerns. This change in messaging introduced some
confusion about how to access healthcare services, and for
what, and was perceived to conflict with the general stay-athome advice. People were also unclear about whether they
were allowed to travel for healthcare that was not local (eg,
for those in rural settings or who attended a general practice
outside of their home suburb).
“I think there have been mixed messages about seeking GP
help. Initially we were asked to stay away, only go in extreme
circumstances, call the 0800 number … and then we’re told
people aren’t going and to remember to go when you need
help. For me it did delay in getting my … asthma dealt with”
(Survey response: Female, aged 45-54).
1.2. Focus on COVID-19 and Urgent Issues
In some instances, respondents felt their non-COVID-19 health
issues were not taken seriously or given proper consideration,
particularly at the start of lockdown when concerns about
COVID-19 were dominant. Respondents reported staff
spending more time on screening for COVID-19 symptoms
than attending to their presenting complaint. People who had
health issues that were not deemed sufficiently urgent were
deferred or denied care, even if this could have been delivered
through telehealth (eg, support for smoking cessation (S: F,
45-54)), or should have been a priority (eg, flu vaccinations (S:
F, 35-44)). Elective surgery and specialist appointments were
postponed or cancelled, sometimes without any indication
about rescheduling. Concerns were also expressed about
the long-term consequences of delaying healthcare for nonCOVID-19 issues (eg, cancer screening), and missing out on
imaging and laboratory testing.
“The lockdown meant I couldn’t get see my GP for
examination, couldn’t get a mammogram or ultrasound for
a breast lump for 6 weeks even though I am [in] a high-risk
group… It put my health at risk when the testing could have
been managed safely” (S: F, 45-54).
People with respiratory symptoms from pre-existing
problems sometimes had care delayed until a COVID-19 test
was done. Lab tests were sometimes unavailable or unable to
be processed due to overload from COVID-19 testing.
1.3. Service Integration
Although people were usually positive about their interactions
with individual service providers, integration of services
International Journal of Health Policy and Management, 2022, 11(8), 1316–1324
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Imlach et al
Table 2. Influences on Access to Primary Care During Lockdown by System, Practice and Individual-Level Factors
Influences on Access
Dimensions of Access24
National/Health System-Level
General Practice-Level
Individual-Level
Ability to perceive/approachability
1.1 Public service messages
2.1 Communication and outreach
3.1 Self-management and self-triage
Ability to seek/acceptability
2.2 Use of technology
3.2 Conscious of health services pressure
Ability to reach/availability and
accommodation
1.2 Focus on COVID-19 and
urgent issues
2.3 Gatekeeping
3.3 OK/not OK to seek routine healthcare
Ability to engage/appropriateness
1.3 Service integration
2.4 Staff manner
2.5 Safety of the health service
environment
3.3 Fear of infection
Abbreviation: COVID-19, coronavirus disease 2019.
between general practice and other organisations was
variable. A commonly reported example was the interface
between general practices and pharmacies. Although
the Ministry of Health quickly enabled more widespread
electronic prescribing,26 this took time for some practices
and pharmacies to adopt effectively, and led to delays in
patients getting medicines they needed, particularly early in
lockdown. Similarly, poor co-ordination between Healthline
and other health services could cause difficulties in arranging
COVID-19 tests or getting advice for non-COVID-19 issues.
The sense of being bounced from one service to another and
getting inadequate help was compounded by long wait times
or an inability to get through on the phone.
“The different departments gave different advice on
whether I should take my elderly relative for urgent
assessment … I rang the ED who said I should ring Healthline,
Healthline said I should ring GP. GP had said I should take
them to ED. When we got to ED I was unable to advocate
for my relative [due to visitor restrictions], so the diagnosis
appeared to neglect several aspects of medical history that
had been forgotten by my relative. Five days later treatment
has been ineffective, and I am left in limbo as to where to go”
(S: F, 65-74).
For some patients who required support from multiple
agencies, including provision of care in the home, the
terminally ill, and those waiting for specialist review or
recovering post-surgery, inadequate care coordination and
having no-one taking the lead for their care during lockdown
caused more distress.
“[My sister] got a phone call from the oncologist on the
Friday which would have been about the 27th of March to say
that no, there was no more treatment they could offer her, no
more chemo [because the cancer was too extensive] … They
had to chase everyone up. Nobody contacted them … My
sister felt abandoned. That’s her words, totally abandoned”
(Interview response: F, 45-54).
2. General Practice Influences on Healthcare Access
2.1. Communication and Outreach
Communication between practices and patients was perceived
to vary from excellent to poor. It ranged from general practice
staff in a deprived area standing outside the practice building
in personal protective equipment (PPE) to assure those
driving past that health services were available; to practices
that sent messages by email, text or through patient portals;
1320
through to practices that sent no information to patients
about how to access care.
“I honestly would have really appreciated an email or
something; some sort of contact about what my GP clinic was
doing or expecting from their patients” (I: F, 18-24).
Respondents valued up-to-date websites and social media
platforms such as Facebook. These, coupled with voice
messages on practice telephones, were often the first line of
information about whether/when the practice was open and
for what, and needed to be updated quickly. This was especially
important early on, when people received a deluge of emails
from different companies and groups, leading to ‘alert fatigue’
(a phrase coined by one respondent (I: M, 25-34)).
Proactive outreach from practices was highly valued but far
from universal. One respondent reported how this worked
well, receiving an email from her practice to warn her of
being at ‘high risk’ of complications from COVID-19, which
was then followed up by phone to make plans to prevent
infection (S: F, 18-24). Another reported how practices were
ringing patients to check on their welfare and make sure they
had enough medication and reflected on how that felt: ‘they
took the time to call me, they reached into my world instead
of me reaching into theirs and running a gauntlet to get the
information’ (I: F, 45-54).
2.2. Use of Technology
Usual methods of contacting general practices changed
during lockdown. Respondents praised practices that made
use of existing or new digital technologies from the start
of lockdown or soon after, both for communication and
service delivery. Patient portals and email communication
were popular as they greatly enhanced access to care in the
lockdown context, but ineffective use of these tools created
barriers, particularly when useful functions were disabled
or ignored. For example, general practices that withdrew the
option for online appointment bookings to prioritise triaging
of all appointments by telephone caused frustration with long
waiting times to get through on the phone. Practices that
already had well set-up systems were able to quickly provide
services appropriate for lockdown such as telehealth and
online prescriptions whereas practices without pre-existing
systems did not function as well.
“I’ve been booking appointments and asking for repeats
through [the online portal] for a long time but now … I can
actually just email my doctor” (I: F, 35-44).
International Journal of Health Policy and Management, 2022, 11(8), 1316–1324
Imlach et al
2.3. Administrative Gatekeeping
Administrative gatekeeping within primary care is a known
barrier,27,28 where access to care is denied or delayed at
reception or administrative stages. In lockdown, this most
often occurred when patients phoned for appointments, or at
the time of triage, but occurred on occasion in-person with
acute issues (eg, an elderly man reportedly bleeding from a
head injury, being told he needed an appointment through a
closed glass door that he couldn’t hear through (S: M, 65+)).
People did not like being triaged by reception, were reluctant
to discuss private health concerns with a non-healthprofessional, and were not confident in advice transmitted
through receptionists.
“Did not appreciate being questioned by the receptionist as
to why I needed to see the nurse, from a two metre distance
in an area with other people” (S: F, 55-64).
you’ve got this makeshift tent and … these weird fences,’ with
rows of cars filled with people who may be infectious (‘all you
can hear them doing is coughing’). Health professionals in PPE
asked questions without considering privacy (‘they’re yelling
at them [in the cars] so you know what everyone’s temperature
is’), forbade eye contact (“every time I went to look at them,
they would say ‘don’t look at us!’”) and minimised any sense
of personal connection (‘I couldn’t see their faces, I couldn’t
see who they were so I had no idea, or no relationship with
them’). Finally, the detritus from the swab was discarded into
the car (‘instead of them passing you things, they just throw
them into the car because they’re not wanting to touch you,
because they’re not wanting to waste their PPE or whatever’)
(I: F, 45-54). Although the interviewee understood the need
for precautions, she was unprepared for how de-personalising
and disrespectful the experience would feel.
2.4. Staff Manner
The approach taken by practice staff (whether by phone,
online or in-person) exacerbated or attenuated patient anxiety
during lockdown, with a flow-on impact on healthcare access.
Patients described how the way they were spoken to, and
overall demeanour, of reception staff and clinicians could
either calm or reinforce their fear, and directly influence their
decision about whether to seek care. People understood why
health professionals might be alarmed by COVID-19 and
want to limit contact with patients, but could be put off when
this alarm was overly apparent.
“When I visited my medical centre, I felt very much at ease
and calm. I didn’t know what to expect going in, but the staff
I saw all appeared happy and were friendly. No one seemed
stressed or overworked” (S: F, 25-34).
“They [general practice clinic staff] were sending out a lot
of mixed messages about … the whole COVID thing … they
were really, really scared, and that came across to us, as
patients, that they were unsure of what to do” (I: F, 45-54).
3. Individual Influences on Healthcare Access
Respondents’ decisions around seeking healthcare also
reflected their own resources and ability to weigh up risks and
benefits.
2.5. Safety of the Health Service Environment
For those who had an in-person consultation, changes to safety
procedures (eg, PPE, hand sanitising, physical distancing)
were noticed by patients immediately. Changes included
having consultations, vaccinations or COVID-19 testing
through a car window by staff wearing PPE; waiting outside
the practice before being called in; or not being physically
examined. These could have a positive impact on patients,
by increasing their confidence in accessing healthcare safely,
or a negative impact, if the experience was overly onerous or
frightening.
“The car park flu shot [and wait a short while after in the
car park] made me feel safer than if I had to enter the clinic
building” (S: F, 45-54).
Safety procedures could be insufficient to allay concerns if
not well-executed; for example, if patients had to wait in what
they perceived as confined areas alongside other patients.
Although people accepted the need for safety, changes could
be disconcerting. One interviewee’s experience of having a
COVID-19 swab exemplified the worst aspects of this. She
described driving into ‘an army-type environment, where
3.1. Self-management and Self-triage
Many people chose to self-manage their health concerns
when they were able to, particularly for health conditions
that they were familiar with, either pre-existing, recurrent,
or common. For new conditions, they considered what the
condition might be, the severity of the symptoms and the
consequences of not being immediately assessed. They made
judgments about whether the condition might improve on its
own and whether they could use over-the-counter medicines
or other available treatments. Some monitored the symptoms
and waited until later in lockdown before seeking treatment
if the condition had not resolved. People also put on hold
issues that they knew required a physical examination, and
avoided seeking help for non-urgent problems, in response to
perceptions related to public messages (see section 1.1) and
the health service focus on COVID-19 and urgent issues only
(see section 1.2).
“For the gastric issue I waited four weeks trying to figure
out what was going on, and going to the doctor was sort of
the last resort when the pain became quite unbearable … I
think under normal circumstances I would have definitely
gone and seen [doctor] partway through that” (I: F, 45-54).
3.2. Conscious of Pressure on Health Services
Respondents did not want to unnecessarily burden the
health system. The motivation to undertake self-triage (see
section 3.1) and delay seeking care was driven by concern
that the public health system may be overwhelmed. This was
particularly pressing in the first 2 weeks of lockdown when
COVID-19 cases were proliferating, and it was uncertain
whether lockdown would work. Patients worried that seeking
help might cause stress to what was initially perceived to be
a stretched health service. They also considered the needs of
others, imagining that more serious issues would take priority,
and acted on altruistic notions that other people’s problems,
or COVID-19 infections, were more important.
International Journal of Health Policy and Management, 2022, 11(8), 1316–1324
1321
Imlach et al
“I would’ve gone to the doctors if we weren’t in lockdown.
And yes, I heard Ashley Bloomfield [Director-General of
Health] say many times to seek help if you need it, but I
couldn’t convince myself that my issues were more important
than others” (S: F, 25-34).
When patients did seek healthcare, they recognised that
clinicians were under stress and conveyed tolerance, often
qualifying descriptions of mistakes with an explanation of why
this may have occurred or an expression of understanding.
“Given how stressed everyone is as humans and health
professionals … everyone has done amazing. Someone forgot
to ring me for my scheduled appointment but we are human”
(S: F, 45-54).
However, sometimes service disruptions meant that people
were put off trying to seek healthcare or they tried but were
discouraged and gave up.
3.3. OK/Not OK to Seek Routine Healthcare
The health services’ focus on COVID-19 and urgent care
(see section 1.2) directly affected patients who engaged with
services, but also influenced those who may have wanted
to seek healthcare. People felt the onus was on themselves
to determine whether their health need was sufficiently
important, which could lead to potentially urgent symptoms
being underplayed or unrecognised.
“A few times we’ll even have like Dr Bloomfield say, yeah,
you should go to your doctor if you think you need to. But it’s
that ‘if you think you need to’ … everyone feels that it’s a big
scary pandemic out there and so maybe the slight pain in my
heart doesn’t mean [it’s] serious” (I: F, 25-34).
3.4. Fear of Infection
Patient fears about catching COVID-19 in a healthcare
service could be allayed through a safe practice environment
(see section 2.5), but patients were still justifiably worried
about the risks of infection for themselves and others in their
household. Waiting areas at general practices and hospitals
were widely perceived to be one of the most likely places to be
exposed to COVID-19, supported by reports of outbreaks in
health settings in Europe.4
“I was worried about going to a clinic with sick people
there in case I picked up coronavirus” (S: F, 55-64).
Discussion
From this study of the first 2020 COVID-19 lockdown in
Aotearoa/New Zealand, just over half of respondents delayed
seeking healthcare. At a national level, Government advice
about accessing health services were perceived by some to
conflict with messages about COVID-19 and lockdown
restrictions, creating confusion about the appropriate
management of non-COVID health problems. Changes
in messaging were inevitable because of the uncertainty
and evolving nature of the pandemic. What was needed,
and what happened over time, was repeated clarifications
of these changes. Stronger involvement of consumer
groups in developing COVID-19 communications may
also help mitigate such confusion.29 Unnecessary delays in
seeking healthcare have been recognised as an unintended
1322
consequence of stay-at-home mandates and prioritisation of
urgent healthcare.13
Other health system factors were also at play. From a
patient’s perspective, lockdown highlighted when health
services functioned well, but also where services lacked
integration, which was problematic when they needed quickly
(eg, palliative care, some repeat prescriptions). Integration
of services throughout Aotearoa/New Zealand is variable
and difficult to assess,30 but improvements in the interfaces
between secondary care, general practices and community
pharmacies will be important for future extended lockdowns.
Some patients experienced delays because health services
were unavailable or inaccessible, not through their choice.
Early indicators from Aotearoa/New Zealand suggest that
total deaths during this lockdown were lower than the same
time period in previous years.31 However, the long-term
impact of delays in cancer screening, routine investigations,
and elective surgery are yet to be assessed. At a national
level, a clear framework for how to prioritise screening
and non-emergency procedures in lockdown situations
would help both patients and health professionals navigate
the uncertainty of postponing healthcare in a pandemic.32
This type of framework would have to contain guidance on
weighing up the risks and benefits for individuals depending
on how seriously the health system was affected, and how
much of the health system needed to be reserved in case of an
overwhelming outbreak.
At a practice level, barriers to access included administrative
gatekeeping and overtly stressed staff. Although patients
understood why staff would feel anxious, this, along with a
belief that services were stretched or would not deal with nonurgent issues, led to delays in seeking care. In a pandemic,
fear and uncertainty predominate and affect both the general
public and health professionals,33,34 but fear of infection
could be reduced by obvious hygiene procedures and a calm,
reassuring manner. Gatekeeping could be minimised with
upskilling of reception staff and ensuring that clinicians
answer health-related queries.
From this research, those who delayed seeking care were
more likely to be struggling financially, be concerned about
the impact of COVID-19, have poorer health, a disability or
more difficulties in managing their health in the pandemic.
Proactive, up-to-date communication from practices about
what services were available, how to get in touch and expected
changes to service delivery could encourage access to services
but needed to reach those most at risk. Practices with systems
already in place to undertake electronic (website/portal/
messaging), patient-focused communication were better
able to provide care during lockdown, as has been found
elsewhere.35 Outreach by non-digital methods can ensure that
patients without online capability are not excluded.
As well as health system and practice-level influences,
individual patients weighed up the need to seek healthcare
through self-assessment of their own illnesses. They
considered the risk of COVID-19 exposure to themselves and
others, and managed non-urgent problems by watching and
waiting and self-care. Health systems, including Healthline
and general practices, could provide more support for self-
International Journal of Health Policy and Management, 2022, 11(8), 1316–1324
Imlach et al
triage36 and routinely promote trusted patient-information
sites, to help patients make appropriate decisions around how
and when to access healthcare.
Limitations of this research include that respondents were
not fully representative of the overall population, with more
female and European respondents. We cannot tell why people
did not respond to the survey; perhaps they were unaware of
they it, they did not think that the survey applied to them or
they were unwilling to complete it. However, it could be the case
that some groups had much lower access to healthcare than
others; for example, the extreme disparity between genders
suggests some level of inequity at play. Future research needs
to be conducted to explore how pandemic lockdowns further
exacerbate inequities in accessing to primary healthcare.
The online nature of the survey meant that those without
internet access or digital skills were less able to participate, and
respondents were likely to be more comfortable with digital
technology. As a result, we may not have identified how those
in disadvantaged communities experienced delays in seeking
healthcare, particularly those not enrolled in general practice.
However, the online survey approach was the only practicable
method during lockdown, given that in-person recruitment
was prohibited, and seeking assistance from stressed general
practices for recruitment was considered inappropriate.
with coding input and review by FI. FI led the analysis of the interview data, with
coding input and review by EM, LR, MC, and KMH. FI drafted the manuscript
and all authors read, revised and approved the final manuscript.
Conclusion
In future lockdowns or crises, appropriate access to primary
care could be improved with timely communication from
practices to patients, proactive outreach, maintaining
a physically safe and emotionally supportive practice
environment and improving the integration between primary
care and other health services. More support for patients to
self-manage could benefit over-burdened health systems both
in lockdown and in less extraordinary times.
5.
Acknowledgements
The authors would like to thank all survey respondents
and interviewees. Other members of the Primary Care
Programme team were involved in securing funding for and
the establishment of the programme.
We thank our wider team members, professional and
personal networks, colleagues known and unknown who
helped in the dissemination of the online survey. We also
want to acknowledge Dr. Lynne Russell’s (LR), Dr. Janet
McDonald’s (JM), and Dr. Marianna Churchward’s (MC)
assistance with interviews.
Funding
This research was funded by the New Zealand Health Research Council (ref
# 18/667).
Authors’ affiliations
Health Services Research Centre, Victoria University of Wellington, Wellington,
New Zealand. 2Department of Primary Health Care and General Practice,
University of Otago, Wellington, New Zealand. 3School of Nursing, Midwifery
and Health Practice, Victoria University of Wellington, Wellington, New Zealand.
1
Supplementary files
Supplementary file 1. Interview Schedule.
Supplementary file 2 contains Table S1.
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Competing interests
Authors declare that they have no competing interests.
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Healthcare supply chain resilience framework: antecedents, mediators,
consequents
Article in Production Planning and Control · August 2021
DOI: 10.1080/09537287.2021.1913525
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Healthcare supply chain resilience framework:
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Pedro Senna, Augusto Reis, Ana Dias, Ormeu Coelho, Julio Guimarães &
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PRODUCTION PLANNING & CONTROL
https://doi.org/10.1080/09537287.2021.1913525
Healthcare supply chain resilience framework: antecedents, mediators,
consequents
Pedro Sennaa , Augusto Reisa
Severo Elianab

, Ana Diasa
, Ormeu Coelhoa
, Julio Guimar~aesb

and
a
Production Engineering Department, Cefet/RJ, Rio de Janeiro, Brazil; bDepartment of Administrative Sciences (DCA/UFPE), Centre for
Applied Social Sciences (CCSA), Recife, Pernambuco, Brazi
ABSTRACT
ARTICLE HISTORY
Supply chain management literature provides several frameworks aiming to identify the constructs of
supply chain performance and supply chain resilience. Nevertheless, the literature lacks a framework
that encompasses healthcare supply chains and its idiosyncrasies. Therefore, the purpose of this paper
is to propose a framework for analysing the relationships between the antecedent factors, mediators,
and consequents of healthcare supply chain resilience (HCSCRes). The supply chain risk management
(SCRM) literature shows a significant gap concerning a framework that comprises the particularities of
SCRM applied to healthcare. In this sense, based on the importance of identifying the determinants of
HCSCRes, qualitative, and exploratory research was developed through an extensive literature review.
In this sense, we propose two research questions: (i) Which are the antecedents, mediators, consequents of a resilient Healthcare Supply Chain? (ii) Which are the variables that compose the constructs
of a resilient healthcare supply chain? The proposed framework of this research was designed to analyse healthcare organisations, including the healthcare supply chain. To use the proposed framework
in other industries (e.g. commerce, services), it is necessary to make adaptations and adjustments on
the observable variables and constructs. The main contributions of the paper are twofold: (i) Show an
essential theoretical value in proposing scales for the HCSCRes factors and can be useful for future
quantitative approach and surveys. (ii) The literature review reveals that the set of practices and technologies known as industry 4.0 plays a major role in the theoretical framework proposed by
this paper.
Received 18 December 2019
Accepted 2 April 2021
1. Introduction
Profit-oriented organisations tend to increase operational
efficiency, eliminating wastage to improve their position in
the market. Healthcare organisations find themselves in a
tough spot, mostly because they must focus on cost reduction and increasing revenues to provide continuously
improved healthcare services. Depending on the country,
Healthcare organisations can be either public or private.
Although public Healthcare organisations generally do not
have to worry about bankruptcy, they still have the compromise to serve the taxpayer with the utmost service level.
One way to succeed is to develop the ability to anticipate,
adapt, respond, and recover, making the supply chain less
susceptible to risks (Ali, Mahfouz, and Arisha 2017). In this
sense, healthcare supply chain risk management (HCSCRM) is
an essential building block of healthcare supply chain resilience (HCSCRes), which contributes to healthcare supply
chain performance (HCSCP). An increase in global scale disasters can generate disgraceful results and disruptions and
make researchers pay greater attention to SCRM (Chowdhury
et al. 2019). Recently, COVID-19 pandemic has generated
KEYWORDS
Supply chain resilience;
supply chain risk
management; healthcare
organisations
disruptions, reinforcing the urge of generating resilience for
healthcare supply chains.
Risk analysis should consider the whole supply chain to
provide satisfactory results (Juttner, Peck, and Christopher
2003; Waqas et al. 2019). A healthcare supply chain (HCSC) is
a supply chain where all the companies must be driven by
the objective of offering Healthcare and saving lives
(Abdulsalam et al. 2015; Rakovska and Stratieva 2018).
Figure 1 shows a healthcare supply chain.
HCSC has additional risks such as long waiting times for a
medical appointment, Labib et al. 2019). COVID-19 taught an
important lesson: if healthcare supply chains break, all other
supply chains break. In this sense, generating resilience in
healthcare supply chains mean reducing uncertainties with
fast decision-making, generating adaptability that allows the
system to reconfigure itself and improve availability of hospital beds, respirators, and life support drugs.
Supply chain risks happen due to several reasons like disruptions to material flows, information flows, knowledge
flows, and control and coordination flows (Ancarani and Di
Mauro 2011). Today’s globalised, leaner and Just-in-Time
CONTACT Pedro Senna
pedro.senna@cefet-rj.br
Production Engineering Department, Cefet/RJ, Avenida Maracan~a 229 – Maracan~a, Rio de Janeiro, 20271110, Brazil.

Department of Administrative Sciences (DCA/UFP E), Centre for Applied Social Sciences (CCSA), Recife, Pernambuco, Brazil.
ß 2021 Informa UK Limited, trading as Taylor & Francis Group
2
P. SENNA ET AL.
Figure 1. Healthcare supply chain design. Source: Landry and Beaulieu (2007).
Supply Chains are more vulnerable to natural and man-made
disasters (Soni and Jain 2011). The lack of supply chain
coordination during disruptions may cause the bullwhip and
ripple effects downstream in the SC (Dolgui, Ivanov, and
Rozhkov 2020). In addition, all mankind has been experiencing such disruptions, as the COVID-19 pandemic advances
and healthcare supply chains fail to fulfil the demand
for treatment.
To manage supply chain risks it is crucial to generate
supply chain resilience. In the supply chain context, a SC
must be resilient to disturbances to achieve competitiveness (Barroso, Machado, and Machado 2010). Barroso,
Machado, and Machado (2011) and Carvalho, Azevedo, and
Cruz Machado (2012) affirm that Supply Chain resilience is
a matter of survival. Moreover, SCRes constitutes a very
efficient way of dealing with the inevitable ruptures and
even predicting when the risks will occur (Mancheri
et al. 2019).
According to Riley et al. (2016), for hospitals, a shortage of
supply or unanticipated demand spike can lead to catastrophic
consequences beyond poor in stock metrics. When a hospital
experiences an unanticipated demand spike or supply shortage, supply managers must have the means to alter and/or
reconfigure the supply chain (Riley et al. 2016). Considering
supply chain risks, ruptures caused by epidemics/pandemics
have been neglected by SCRM literature. The COVID-19 pandemic, for example, led all countries to experience severe
shortages of respirators and beds. Due to the lack of sustainable practices and damage dealt to the environment, pandemics may become more frequent. In this sense, supply chains
should be more resilient to respond to healthcare demand
quickly. The development of vaccines generates additional supply chain challenges. The healthcare supply chains must deal
with an overwhelming demand for raw materials such as
syringes and needles meaning that managers must generate
resilience to increase production and distribution capacity. We
were able to find only 3 papers making brief comments about
pandemics. Oke and Gopalakrishnan (2009) identify the pandemic risk as a natural disaster mentioning the avian flu, while
Mavi, Goh, and Mavi (2016) classify as an exogenous social risk.
However, whether a pandemic is a natural disaster, or its
causes can be traced to human behaviour can be debated.
Vanvactor (2011) affirms that pandemics are unexpected
events that require preparedness and mitigation strategies,
which is a more proactive approach comparing to Oke and
Gopalakrishnan (2009). Ivanov and Dolgui (2020) is the only
SCRM study that proposes a digital supply chain to generate
resilience during the COVID-19 pandemic. Nevertheless, the literature lacks a framework that comprises the particularities of
SCRM applied to healthcare.
To identify some relevant factors that build HCSCRes, this
paper proposes a framework to analyse the relationships
between the antecedent factors, the mediators, and the consequents of HCSCRes. Consequently, we carried out a literature review from the studies indexed in the Scopus and ISI
Web of Science databases, and other articles relevant to the
development of the proposed framework.
2. Methodology
Our full research methodology is presented in the workflow
seen in Figure 2.
2.1. Formulation of research questions
The first step of our research is defining the study questions
that are in adherence to the objectives (Kilubi 2016a; Light
and Pillemer 1984) In this sense, we propose two
research questions:
RQ1) Which are the antecedents, mediators, consequents of a
resilient HCSC?
RQ2) Which are the variables that compose the constructs of a
resilient HCSC?
PRODUCTION PLANNING & CONTROL
3
Figure 2. Paper methodology.
2.2. Selection of databases
In this study we chose both Scopus and ISI Web of Science
databases. Scopus database is the largest searchable citation
and abstract source (Chadegani et al. 2013). WoS from
Thomson Reuters (ISI) was the only citation database and
publication that covers all domains of science for many years
(Chadegani et al. 2013). The advantage of one database over
another one depends on what explicitly will be analysed, the
scientific field and period of analysis (Chadegani et al. 2013).
WoS is the oldest citation database, therefore it has strong
coverage with citation data and bibliographic data going
back to 1900 (Boyle and Sherman 2006). Study of Vieira and
Gomes (2009) reveals that 2/3 of the studies can be found in
both databases and 1/3 only in one database. Another considerable advantage is that both databases provide“. bib”
files providing full search data (such as references, article
authors, etc.) that can be further analysed in bibliometric
packages. Moreover, using Scopus and ISI as search engines
allows locating papers of Science Direct, Taylor and Francis,
Emerald, Springer, and other important bases.
2.3. Definition of search terms
Our first research string (STR1) was “supply chain risk management” (and variations of this string such as SCRM) in the
period ranging from 2000 to 2019, which returned 775 documents, including Web of Science and Scopus. This period
was chosen because we want to make sure that all available
relevant literature were included. Both SCRM and industry
4.0 are new streams of research and there is not much relevant literature prior to the year 2000.
We broadened the search using the strings healthcare
AND procurement, “healthcare supply chain” AND risk,
“healthcare supply chain” healthcare AND warehouse, which
composed STR2.
After this search, there was still a significant body of knowledge that was not considered; therefore, we searched for
“clinical engineering” and high-reliability organisations (STR3)
Process automation is increasingly having a significant role in
all economic sectors, including healthcare. Business solutions
such as IoT (internet of things) are starting to be applied to
hospitals and clinics. In this sense, we conclude that “Industry
4.0” related concepts will play a major role and will revolution
the way supply chains are organised and will have a crucial
contribution in SCRM. Thus, we added the following search
strings (STR4): (“supply chain 4.0”) AND (“supply chain risk management); (IoT OR “internet of things”) AND (“supply chain risk
management”); (“supply chain 4.0”) AND healthcare.
2.4. Article selection process
Our selection process was based in Patel and Desai (2018),
Marques, Martins, and Araujo (2020) and the PRISMA protocol created by Moher et al. (2009). PRISMA is an acronym for
Preferred Reporting Items for Systematic Reviews and MetaAnalyses method. This protocol is mostly used in healthcare
SLR and meta-analysis; nevertheless, it is also used in industrial engineering segment, see for example Muhs, Karwowski,
and Kern (2018). In the filtering stage, we followed the criteria of Patel and Desai (2018) and Marques, Martins, and
Araujo (2020): (1) we excluded conference papers, short
notes, book chapters and editorial notes and (2) we considered only papers written in English language.
4
P. SENNA ET AL.
2.5. Paper analysis
We used a content analysis technique to analyse the data,
with a priori categories (Guimar~aes, Dorion, and Severo
2019), related to the antecedents’ factors, the mediators, and
the consequents of HCSCRes.
3. Antecedents, mediators and consequents of
healthcare supply chain resilience
The research strategy used the antecedent factors, mediators,
and consequents of HCSCRes to establish the observable and
latent variables that compose a new HCSCRes analysis framework for healthcare organisations. The factors that precede
HCSCRes are RID (supply chain risk identification) (Lu,
Koufteros, and Lucianetti 2017; Sinha, Whitman, and Malzahn
2004; Zsidisin et al. 2004; Manuj and Mentzer 2008;
Chaudhuri, Boer, and Taran 2018), the RAS (healthcare supply
chain risk assessment) (Soni and Jain 2011; Christopher and
Peck 2004; Ibey et al. 2015; Pate-Cornell and Cox 2014), RMI
(healthcare supply chain risk mitigation) (Juttner, Peck, and
Christopher 2003; Iakovou, Vlachos, and Xanthopoulos 2007;
Barroso, Machado, and Machado 2010; Sheffi and Rice 2005;
Chaudhuri, Boer, and Taran 2018; Norrman and Jansson
2004; Chaudhuri, Boer, and Taran 2018), SCI (healthcare supply chain integration) (Ellinger 2000; Thome et al. 2012;
Chaudhuri, Boer, and Taran 2018; Cagliano, Grimaldi, and
Rafele 2016; Flynn, Huo, and Zhao 2010; Chaudhuri, Boer,
and Taran 2018; Tang 2006; Barroso, Machado, and Machado
2010). Conceptual framework can be seen in Jasti and Kodali
(2015), Jasti and Kodali (2015), Agarwal et al. (2019), Raval
and Kant (2017). In SCRM context, there are only a few
papers that propose similar frameworks. In addition, none of
the frameworks propose a specific supply chain resilience
framework based in healthcare supply chain literature.
In this sense, aiming to fulfil these significant literature
gaps: (i) We conducted an exhaustive literature review.
Nevertheless, we could not find any similar frameworks; (ii)
The variables and constructs we identified are mentioned by
several studies. However, they are still not comprised by any
of the frameworks. In this sense, our framework provides a
significant contribution to the literature and fulfils these
research gaps.
The HCSCRM actions are planned to optimise the risk
management in a supply chain and increase the resilience,
making the SC less prone to errors, disturbances, and ripple
effects. Considering HCSC, besides these benefits, the possibility of saving lives can be added. Although the main
objective of HC organisations is saving lives, they still must
be economically viable. Therefore, managing healthcare supply chain risks increases the supply chain resilience, which
generates an improved healthcare supply chain performance.
A healthcare chain must plan the deployment of its resources to sustain their services even during disruptions.
Therefore, we extend the notion of resilience to medical SCs
and define it as the capability of medical SC entities to work
in a synchronised manner with an objective to provide
uninterrupted medical services to patients in the event of a
disruption. A robust and resilient SC or logistics network is
the goal of SC risk management (Colicchia and Strozzi 2012).
In this sense, HCSCRes can generate internal factors (mediators of HCSCRes), which contribute to HCSCP. Lack or poor
quality of data and lack of systems communication may be a
cause of disruptions in a SC. In healthcare organisations,
inaccurate data can result in wrong quantities of medicine
and medical supplies, resulting in broken processes that
impact in patient’s treatment. In this sense, Internet of
Things (IoT) devices can make a major difference, measuring
and make the data available in real-time, providing more
security and quality of data, accelerating processes that will
result in better treatment. Ivanov, Dolgui, and Sokolov (2019)
highlight the importance of digitalisation and industry 4.0 on
the ripple effect in SCs. In general, humans perform badly in
repetitive monotonous tasks and perform well in tasks that
require cognitive abilities, thinking and solution design. In
this sense, the automation of recurrent activities makes them
less prone to errors, therefore contributing to HCSCP.
3.1. Antecedents of healthcare supply chain resilience
The factors related to healthcare supply chain risk identification , healthcare supply chain risk assessment , healthcare
supply chain risk mitigation , and healthcare supply chain
integration (SCI) are considered as the antecedents of healthcare supply chain resilience.
The RID factor means that the companies must know
which risks are inherent to their business. An organisation
must periodically promote Risk identification practices to discover all the relevant risks (Kern et al. 2012; Fan and
Stevenson 2018). There is no risk mitigation methodology
that works for all kinds of threats. An efficient risk mitigation
strategy must be customised for the organisation’s needs;
therefore, the risks must be well-known to trigger the risk
assessment and risk mitigation (Kern et al. 2012; Fan and
Stevenson 2018). Lu, Koufteros, and Lucianetti (2017) focus
on supply chain security breaches and highlight security
issues such as terrorist attacks. In terms of healthcare risks,
can be highlighted seizures of substandard foods and drug
smuggling, drug recalls management, Excess of packaging
material, lack of provision of dressings to nurses.
Identification of risks and security breaches are features
closely related. In such cases, prevention is the key (Hinrichs,
Dickerson, and Clarkson 2013; Cochrane et al. 2017; Lu,
Koufteros, and Lucianetti 2017). Supply chain thinking
includes promoting risk identification practices also for
organisations that a company provides service for (Lu,
Koufteros, and Lucianetti 2017), which includes risk register
and documentation (Ibey et al. 2015) and holding all suppliers accountable for supply chain security (Lu, Koufteros, and
Lucianetti 2017). Organisations should work on detecting
operations risks, e.g. internal or supplier monitoring, inspection, and tracking (Sinha, Whitman, and Malzahn 2004;
Zsidisin et al. 2004; Manuj and Mentzer 2008; Chaudhuri,
Boer, and Taran 2018). Figure 3 represents the variables that
constitute the Supply Chain Risk Identification factor.
PRODUCTION PLANNING & CONTROL
Promote risk identiication
practices (Organization,
Suppliers and customers)
Buffer inventory
Multisourcing
Hold all suppliers
accountable for supply chain
security
Educate suppliers about
supply chain security
practices
5
Healthcare Supply Chain
Risk Identiication
Agility
Effective Comunication
Crisis respondent team
Figure 3. Healthcare supply chain risk identification factor.
Healthcare Supply Chain
Risk Mitigation
Employees cross-training
Employees cross-training
Create Key Process
Indicators
Extra capacity
Give SC visibility to the KPI
Supply Chain Risk register
and mapping
Healthcare Supply Chain
Risk Assessment
Monitor the changes in
Figure 4. Healthcare supply chain risk assessment factor.
Once the supply chain risks are identified, they must be
assessed (RAS). To prioritise and calculate the risk magnitude,
companies must have key process indicators (KPI) (Soni and
Jain 2011; Cruz, Rincon, and Haugan 2013; Nabelsi 2011) providing SC-level visibility to the indicators (Soni and Jain 2011;
Christopher and Peck 2004; Pate-Cornell and Cox 2014).
Examples of such KPI are hospital/clinics cancellation rates
(Meekings and Briault 2013), Inventory accuracy rate (Rajesh
2016), and Employees error rate (Gu and Itoh 2016; Reijula et
al. 2014).
A good risk assessment demands maintaining a supply
chain risk register, e.g. operational risks, technical risks, financial risks, legal risks, brand risk, environment risk, safety and
health risk (SCOR – BP.150 Maintain supply chain risk register;
Bektemur et al. 2018; Fukuda et al. 2008) and risk mapping
that can either map supply-related risks (medicines and
materials) as well as human-related risks like underperforming and absenteeism. After risk mapping, there should be a
team designed to monitor the changes in probability or
impact of risk events (SCOR – BP.173 supply chain risk monitoring; Ibey et al. 2015; Powell-Dunford et al. 2017). By following these steps, the SC can reach a clear understanding
of where the greatest risks may exist in order to prioritise
resources for risk mitigation and management (SCOR BP.174 supply chain risk assessment; Ibey et al. 2015). Figure
4 represents the variables that constitute the supply chain
risk assessment factor.
Risk mitigation (RMI) is a plan to reduce the probability of
occurrence or minimise the impact of the risk (SCOR – BP.002
risk management strategies). Risk mitigation strategies can
be increased stockpile for buffer inventory (Juttner, Peck, and
Christopher 2003; Iakovou, Vlachos, and Xanthopoulos 2007;
Supply Chain Risk Culture
Alternative transportation
Figure 5. Healthcare Supply Chain Risk Mitigation.
Barroso, Machado, and Machado 2010; Hyman 2008; Okoh
and Haugen 2015), multisourcing (Juttner, Peck, and
Christopher 2003; Iakovou, Vlachos, and Xanthopoulos 2007;
Barroso, Machado, and Machado 2010) and agility
(Christopher and Peck 2004). In order to quickly mitigate
risks, organisations should designate a group of employees
as first respondents in case of crisis like shortage of supplies
and human resources (Lu, Koufteros, and Lucianetti 2017;
Okoh and Haugen 2015). Effective communication across the
supply chain is essential when a crisis hits (Lu, Koufteros, and
Lucianetti 2017); therefore, managers and employees should
clearly communicate to avoid risks. In terms of preparedness,
it is crucial preventing operations risks, e.g. select a more
reliable supplier, use clear safety procedures, preventive,
maintenance, and employees cross-training (Lu, Koufteros,
and Lucianetti 2017; Tomlin 2006; Chaudhuri, Boer, and
Taran 2018), responding to operations risks, e.g. backup suppliers, extra capacity and alternative transportation modes
(Sheffi and Rice 2005; Chaudhuri, Boer, and Taran 2018) and
if prevention and response fail to recover from operations
risks is essential, e.g. task forces, contingency plans and clear
responsibility (Norrman and Jansson 2004; Chaudhuri, Boer,
and Taran 2018). A SC should proactively develop a risk mitigation strategy (Lu, Koufteros, and Lucianetti 2017), which is
supported by the creation of a supply chain risk culture that
extend beyond the boundaries of the organisation
(Christopher and Peck 2004; Barroso, Machado, and Machado
2010). Figure 5 represents the variables that constitute the
supply chain risk mitigation factor.
Supply chain integration has long been studied by scholars. Supply chain risk management should be Collaborative
to improve supply chain visibility and understanding (Friday
et al. 2018; Juttner, Peck, and Christopher 2003; Christopher
and Peck 2004; McCullough 2014; Arquilla and Cram 2005).
6
P. SENNA ET AL.
Collaborative Supply Chain
Risk Management
Continuous education
programs
Supply Chain Visibility
Multi-skilled workforce
Information Sharing
Healthcare Supply Chain
Integration
Joint decision-making
Strong collaboration with
government agencies
Healthcare Supply Chain
Risk Management
Quality management
systems
Figure 6. Healthcare supply chain risk integration.
Figure 7. Healthcare supply chain risk management.
Information sharing about sales forecast, production plans,
production progress and the stock level is the backbone of
SCI. The information must be shared with the purchasing
department (Ellinger 2000; Thome et al. 2012; Chaudhuri,
Boer, and Taran 2018; Chen, Jing, and Xi 2016; McCullough
2014), with key suppliers (Cagliano, Grimaldi, and Rafele
2016; Flynn, Huo, and Zhao 2010; Chaudhuri, Boer, and Taran
2018; Tang 2006; Barroso, Machado, and Machado 2010;
Chen, Jing, and Xi 2016; McCullough 2014) and key customers (Zhao et al. 2008; Flynn, Huo, and Zhao 2010; Chaudhuri,
Boer, and Taran 2018; Tang 2006; Barroso, Machado, and
Machado 2010; Muriana et al. 2017). As the chain becomes
more integrated, companies should consider joint decisionmaking with the purchasing department about sales forecast,
production plans, and stock level (Thome et al. 2012;
Chaudhuri, Boer, and Taran 2018; McGowan 2012; Lin and
Ho 2014), key suppliers, about a product, process, quality
improvement and cost control (Narasimhan and Das 1999;
Koufteros, Vonderembse, and Jayaram 2005; Lin and Ho
2014; Turhan and Vayvay 2012) and key customers about
product design/modifications, process design/modifications,
quality improvement and cost control (Lengnick-Hall 1996;
Chaudhuri, Boer, and Taran 2018; Soni and Jain 2011). There
should be collaborative approaches with key customers and
Key suppliers, e.g. risk/revenue sharing, long-term agreements (Lambert, Emmelhainz, and Gardner 1999; Chaudhuri,
Boer, and Taran 2018; Iakovou, Vlachos, and Xanthopoulos
2007; Soni and Jain 2011; Ragatz, Handfield, and Petersen
€ge, Jayaram, and Vickery 2004). Another essential
2002; Dro
feature is system coupling with key customers and key suppliers, e.g. vendor managed inventory, just-in-time, Kanban,
continuous replenishment (Frohlich and Westbrook 2001;
Chaudhuri, Boer, and Taran 2018; Cagliano, Grimaldi, and
Rafele 2016; Vereecke and Muylle 2006; Chaudhuri, Boer, and
Taran 2018). Figure 6 represents the variables that constitute
the supply chain integration factor.
et al. 2008). Every Healthcare professional should commit to
life-long education, mostly because accumulation of experiences and knowledge is considered mandatory to performance improvement (David, Jaramillo, and Stiefel 2008).
Organisations should promote continuous education programs along with the SC (David, Jaramillo, and Stiefel 2008;
Oumlil and Williams 2011), forming a multi-skilled workforce
(Ali, Nagalingam, and Gurd 2018). Ali, Nagalingam, and Gurd
(2018) highlight the importance of having robust collaboration mechanisms with government agencies. Resilient SC
must develop good quality management systems (Ali,
Nagalingam, and Gurd 2018; Wang et al. 2013; Zapalac 2007;
Sullivan et al. 2016; Griffith 2015; Borelli, Orr
u, and Zedda
2015). In Healthcare organisations, robust quality management systems often include accreditation or other quality
certificates (Ali, Nagalingam, and Gurd 2018; Zapalac 2007;
Mobarek et al. 2006; Sullivan et al. 2016). Figure 7 represents
the variables that constitute the Supply Chain Risk
Management factor.
Technology has always been a mean of process improvement. In this sense, the 4.0 revolution is contributing in
terms of efficiency gain in a broad scope of industries and
business. Therefore, technologies such as blockchain and the
Internet of Things IoT are also being applied to healthcare
SC. In general lines, blockchain is a digital ledger or distributed database that records transactions of value using a
cryptographic hash function that is inherently resistant to
modification (Mylrea et al. 2018). Network-connected devices
are used in industrial machines, household devices, and
healthcare management systems in what has been called the
Internet of Things (Martınez-Caro et al. 2018). Industry 4.0 is
based on intelligent devices deployment and full process
automation (Kumari et al. 2018). Healthcare 4.0 can be considered as an evolution of Healthcare 3.0 (hospital-centric,
where patients had to undergo multiple hospital visits for
their checkups) and includes advancements such as fog and
cloud computing for data storage and IoT for data collection
(Kumari et al. 2018). IoT is increasingly becoming important
for Healthcare organisations. IoT in the Healthcare context is
defined by Rodrigues et al. (2018) as the Internet of Health
Things (IoHT). Baker, Xiang, and Atkinson (2017) affirm that
the Internet of Things healthcare (presenting different
nomenclature) can offer remote health monitoring and can
generate benefits in other contexts, for example, to monitor
3.2. Mediators of healthcare supply chain resilience
Based on the literature, the factors that express the HCSCRes
process use mediators that refer to HCSCRM and SC40. One
of the most relevant strategies to improve patient safety is
to develop systems that will reduce the probability of error
and improve the probability of safety to obtain RES (Fukuda
PRODUCTION PLANNING & CONTROL
Blockchain
Capable Leadership
IoT
Low levels of SC
Vulnerability
Process automation
Healthcare Supply Chain 4.0
Security
7
Low probability of cargo
misuse
Good capability of detecting
defects
Healthcare Supply Chain
Performance
Reduced theft/loss of
products
Figure 8. Healthcare supply chain 4.0.
non-critical patients at home rather than in hospital; therefore, reducing the use of hospital resources. Joyia et al.
(2017) present a literature review showing applications of IoT
in healthcare. The authors define IoT applied to Healthcare
as the Internet of Medical Things (IoMT). The implementation
of IoT has the potential to optimise processes (Roy, Abidi,
and Abidi 2017; Griggs et al. 2018; Laplante, Laplante, and
Voas 2018; Javdani and Ashanian 2018; Rodrigues et al. 2018;
Baker, Xiang, and Atkinson 2017; Park, Chang, and Lee 2017).
As examples of processes, Griggs et al. (2018) created a communication system with a smart device that calls smart contracts and writes records of all events on the blockchain.
Laplante, Laplante, and Voas (2018) described an approach
to begin eliciting requirements for an IoT system to support
ER activities. Due to better use of resources, patient data collection, among other features such as IoT devices can help
improve the quality of care (Martınez-Caro et al. 2018; Griggs
et al. 2018; Javdani and Ashanian 2018; Rodrigues et al.
2018; Joyia et al. 2017). HCSC Processes can have more compliance and security if they are supported by a blockchain
(Mylrea and Gourisetti 2018; Kumari et al. 2018; Griggs et al.
2018; Hiromoto, Haney, and Vakanski 2017) and IoT
(Kouicem, Bouabdallah, and Lakhlef 2018; Griggs et al. 2018;
Hiromoto, Haney, and Vakanski 2017). Figure 8 represents
the variables that constitute the Healthcare Supply Chain
4.0 factor.
3.3. Consequents of healthcare supply chain resilience
Supply chain risk management should be considered a strategic activity because of its impacts on operational, market
and financial performances of a firm (Narasimhan and Talluri
2009). Supply Chain Performance if often measured by financial KPIs like EBTIDA. Nevertheless, HCSC Performance must
profit (in order to survive), but its primary objective is to
save lives and provide good quality of care. In this sense,
capable leadership is essential to obtain HCSC performance
(Chiarini and Vagnoni 2016). HCSC should pursue low levels
of SC vulnerability, good security levels, have low probability
of cargo misuse, and good capability to detect defects in
parts/products (Lu, Koufteros, and Lucianetti 2017). The SC
must develop practices that reduce theft/loss of products
and the potential of drug smuggling (Lu, Koufteros, and
Lucianetti 2017). HCSC must develop a growingly patient
Low potential of drug
smuggling
Improved patient
Figure 9. Healthcare supply chain performance factor.
satisfaction throughout the years (Hyman 2008; Fukuda et al.
2008; Cochrane et al. 2017; Woodhouse et al. 2016; Van
Spall, Kassam, and Tollefson 2015). Figure 9 represents
Healthcare supply chain performance factor.
4. Framework for healthcare supply chain
management analysis
Based on the literature, the framework for the HCSCRs analysis includes antecedents of HCSCRM (RID, RAS, RMI and
SCI); mediators of HCSCRes (HCSCRM and HCSC 4.0); and
consequents of HCSCRes (HCSC Performance), which
expresses the theoretical propositions of influence between
among the constructs (Figure 10).
4.1. P1 – Healthcare supply chain risk
identification drivers
Risk identification is the first step in the SCRM process, it
involves the identification of risk types, factors or both (Ho
et al. 2015) and is fundamental to obtain SCRM (Kwak et al.
2018). Risk identification involves a comprehensive and structured determination of potential SC risks associated with the
given problem presented by Tummala and Schoenherr
(2011). To identify and classify risks according to their nature
is an essential task before performing risk analysis and developing control strategies (Narasimhan and Talluri 2009). Risks
must be previously identified and mitigated before these
issues worsen or potentially cause more harm (Vanvactor
2016). The identification step must occur before the disruption happens, allowing managers to proactively avoid the
impacts of the disruption (Craighead et al. 2007).
The initial stage of risk management is to identify risks
that can influence supply chain operations directly or indirectly (Waters 2011). Risk identification is the first step to deal
with SC risks and will trigger all other risk management
actions. HCSC have specific risks that have not yet been systematically mapped; therefore, RID applied to HCSC is crucial.
8
P. SENNA ET AL.
Healthcare Supply
Chain Risk
Identiication (RID)
P1a
P1b
Healthcare Supply
Chain Risk Assessment
(RAS)
P2a
P2b
Healthcare Supply
Chain Risk
Management
(HCSCRM)
P6
P3a
Healthcare Supply
Chain Risk Mitigation
(RMI)
P3b
P5
Healthcare Supply
Chain Performance
(SCP)
Healthcare Supply
Chain 4.0 (S40)
P4a
Healthcare Supply
Chain Integration (SCI)
P4b
Figure 10. Framework for healthcare supply chain resilience analysis.
Consequently, the first proposition suggests the existence of
a positive relationship between RID and the mediators
(HCSCRM and S40).
P1a. The RID positively influences HCSCRM
P1b. The RID positively influences S40
4.2. P2 – Healthcare supply chain risk
assessment drivers
Usually, most risk assessment processes are intangible, and
due to this subjectivity, evaluating multiple supply chain risks
becomes increasingly difficult (Dong and Cooper 2016). RAS
is concerned with the determination of the likelihood of
each risk factor. Uncertainties can be assessed by objective
information, and probability distributions for relevant SC risks
or consequents can be derived from Tummala and
Schoenherr (2011). Most researchers did not prioritise nor
quantify the negative impact of neither risk types nor risk
factors (Ho et al. 2015).
Risk assessment is an essential phase to decide which
risks to prioritise. It helps answering questions like: “Which
are the most relevant risks concerning SC automation? Initial
investment? Unqualified Workforce?”. Supply chain vulnerability identification and evaluation are extremely important
to mitigate the supply chain risk (Liu et al. 2016)
Understanding supply chain vulnerability allows a better
decision-making process regarding risk exposure (Wagner
and Bode 2008). Understanding correct risk assessment
implies understanding that overestimating information based
on laboratory data can result in a misguided, misdiagnosis of
supply chain risks (Vanvactor 2016). Risk assessment is the
probability of an event occurring and the significance of the
consequents (Ho et al. 2015). Blackhurst et al. (2008) affirm
that risk assessment must rely upon the categories’ selection
and definition to be weighted, compared, and quantified.
The prioritisation is a part of the Assessment and includes a
prioritisation process in which the risks with the greatest
potential loss (or impact) and the greatest probability of
occurring are handled first, and risks with a lower potential
loss and lower probability of occurrence are handled in
descending order (Ekwall and Lantz 2017).
Risk assessment is vital, seeing that organisations still
have problems in forming a holistic view, and clear overestimations as well as underestimations concerning the risk
impact of their processes (Vilko and Hallikas 2012). Therefore,
the second proposition suggests the existence of a positive
relationship between RAS and the mediators.
P2a. The RAS positively influences HCSCRM
P2b. The RAS positively influences S40
4.3. P3 – Healthcare supply chain risk mitigation drivers
The risk mitigation and contingency plans component
involves developing risk response action plans to contain
and control the risks presented by Tummala and Schoenherr
(2011). Supply chain professionals must try to avoid a uniform response for every crisis (Vanvactor 2016). Since it is
not feasible and practical to develop mitigation and prevention strategies for every risk identified, risk-planning begins
with examining the costs required to implement each preventive action to contain and manage the identified SC risks
(Tummala and Schoenherr 2011). Resilience is an outcome
related to how people consider mitigating risks versus
attempting to prevent them from ever occurring
(Vanvactor 2016).
Prior to risk mitigation, it is essential that risks are identified and properly assessed, given that supply chain risk can
be affected by multiple different sources and a firm’s supply
chain risk mitigation strategy should be tailored to deal with
the characteristics of risk contexts (Chang, Ellinger, and
PRODUCTION PLANNING & CONTROL
Blackhurst 2015). Evaluating risk probability and severity is
important for assessing appropriate supply chain risk mitigation and strategy risk contexts to determine appropriate mitigation approaches (Chang, Ellinger, and Blackhurst 2015). To
manage the forms of risk that a SC is exposed to, companies
are increasingly investing in risk management tools such as
mitigation practices and contingency planning (Ellis,
Shockley, and Henry 2011; Wiengarten et al. 2016). In this
sense, the third proposition implies in a positive relation
between RMI and the mediators.
P3a. The RMI positively influences HCSCRM
P3b. The RMI positively influences S40
4.4. P4 – Healthcare supply chain integration drivers
Supply Chain Integration includes processes that allow firms
to achieve efficiency through collaborative information
exchange and coordination between internal activities and
external partners (Ellinger et al. 2015). The limited information sharing and collaboration limit the visibility of risks to
some practitioners generating the need to provide a more
holistic view by studying the processes involved as an integrated system (Vilko and Hallikas 2012). Tang (2006) defines
SCRM as the management of supply chain risks through
coordination or collaboration among the supply chain partners to ensure profitability and continuity; nevertheless, the
author understands that collaboration and coordination are
outset premises for SCRM. Supply chain integration is a
response that companies develop to manage an increased
level of complexity (Wiengarten et al. 2016).
A lot has been discussed concerning risk identification,
assessment and mitigation at SC-level. Nevertheless, if the SC
is supposed to function as one unique body, there is an
unequivocal need of supply chain integration, given that the
risks impact each tier in a very different way, making the risk
prioritisation and mitigation plans very different in each tier.
Supply chain integration has been identified as a critical
practice to manage supply chains and achieve superior performance (Wiengarten et al. 2016). The tighter the supply
chain integration, the better the performance (Kim 2009;
Wiengarten et al. 2016). The integration of internal and external processes with suppliers, customers, and functional areas
generates a competitive advantage (Ellinger et al. 2015). An
essential premise of SCI is that cross-functional and interorganizational knowledge and information sharing improves
performance (Ellinger et al. 2015). Prior to process automation, it is crucial that the processes are already clearly
mapped, or the automation will accelerate low value-added
processes that could even be discontinued.
SCRM requires supply chain members to work to a single
plan (Christopher and Lee 2004). Thus, SCRM is strongly supported by intra-firm and inter-firm processes to mitigate the
effects of SC disruptions (Ellinger et al. 2015). In this sense,
proposition 4 implies that there is a positive relationship
between SCI and the mediators.
P4a. The SCI positively influences HCSCRM
P4b. The SCI positively influences S40
9
4.5. P5 – Healthcare supply chain resilience drivers
Literature provides many different definitions of Supply
Chain Resilience. Nevertheless, they converge in one concept:
Resilience is the capability that a SC has of going through a
disturbance and return to the former performance level or
even an improved level (Carvalho, Azevedo, and Cruz
Machado 2012). Supply chain risks often lead to supply chain
disruptions. Developing resilience, through SCRM is a way of
protecting the SC or to help the SC to regain a performance
level as quickly as possible (Blackhurst et al. 2008).
Given the increase of global competition and supply
chains complexity, the likelihood of not achieving the desired
supply chain (SC) performance increases, mainly due to the
risk of SC failures (Tummala and Schoenherr 2011). Given the
level of connections that a SC has, it is implausible that a SC
can sustain competitively at high performance if it lacks
resilience. There evidence attesting the dreadful effects of
supply chain disruptions and ripple effects (Ivanov, Dolgui,
and Sokolov 2019) on operational and financial performance
with both immediate and long-term effects (Deane,
Craighead, and Ragsdale 2009; Blackhurst et al. 2011).
Lack of supply chain risk management may result in economic and financial losses, reductions in product quality,
delivery delays, and loss of reputation in the eyes of customers and suppliers, making risk management a core issue in
the planning and control of any organisation (Hendricks and
Singhal 2003; Finch 2004). Therefore, proposition 5 implies
that there is a positive relationship between HCSCRM and
SCP. SCRM effectively influences Supply Chain Performance
(Wagner and Bode 2008)
P5. The HCSCRM positively influences SCP
4.6. P6 – Healthcare supply chain 4.0
Disruptive innovations such as digitalisation and Industry 4.0
influence the development of new paradigms, principles, and
models in supply chain management (SCM) (Ivanov, Dolgui,
and Sokolov 2019). Since digital technology influences SCM
and SCM is influenced by disruption risks, it is logical to
expect interrelations between digital technology and SC disruption risk management (Ivanov, Dolgui, and Sokolov 2019).
Industry 4.0 and SC 4.0 are concepts that still require
more formal definition and are becoming a Panacea.
Although a Fully automated SC can generate efficiency and
minimise several risks, it may as well create others. For
example, it is charging the devices (battery autonomy).
Additionally, it requires a considerable amount of initial
investment, high-qualified workforce, among other features.
As a clear example of 4.0 technology applied to HCSC,
Tseng et al. (2018) suggest a blockchain as the base of the
data flow of drugs to create transparent drug transaction
data and improve the SC performance. Software, hardware
and Radio Frequency Identification (RFID) technology to
strengthen the track and trace of drugs in the supply chain
and are considered relatively mature and easy to adopt
(Mackey and Nayyar 2017).
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P. SENNA ET AL.
Blockchain technology could create an encrypted, distributed, and immutable data ledger with the possibility of
being applied in the healthcare sector, including sharing of
information with stakeholders while ensuring data integrity
and protecting patient privacy (Tseng et al. 2018). Literature
still lacks studies concerning more 4.0 technologies applied
in HCSC although there is some evidence. In this sense,
Proposition 6 suggests a positive relationship between SC40
and SCP.
P6. The S40 positively influences SCP
5. Discussion
5.1. Social implications
In the next ten years, businesses will have to adapt, reaching
new quality levels, while reducing costs to provide healthcare
to an increasingly elderly population, providing mass healthcare. Human resources will have to adapt to these changes and
training programs will have to update their syllabus to include
at least the basics of technologies such as industry 4.0. Supply
chain integration will increasingly become a mandatory feature.
If an OEM is fully automated, but the systems do not couple
with the wholesaler or the retailer, the benefits of such automation will be reduced or in a final analysis, it will not even be
noted. To fully reach SCRM, it is essential on the one hand, to
identify, assess, and mitigate risks and, on the other, to increase
supply chain resilience. However, Industry 4.0 is still a new concept that needs further definition. The lack of papers applying
Industry 4.0 techniques to healthcare organisations makes it difficult to measure the benefits (or hazards); therefore, it needs
empirical validation. Concerning HCSC automation, is it always
viable? Which processes can be automated, and which ones
should remain strictly made by humans? What is the human
factor role in a hospital 4.0? These questions still require validation. There is also the possibility of medical impacts on
patients; therefore, a multidisciplinary team should include
engineers and doctors to measure the impacts for the treatment that the patient must deal with a machine. Which risks a
fully automated SC could mitigate and which risks may be generated is still unclear. Many papers converge to a framework
that include Identification, Assessment and Mitigation as a way
of building SCRM; nevertheless, what is the importance of each
phase and the importance of the variables that build
the constructs?
Papers usually do not formally highlight integration in the
identification, assessment and mitigation framew…