Sustainable Cities and Society 50 (2019) 101681

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Sustainable Cities and Society

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A stakeholder perspective of social sustainability measurement in healthcare T

supply chain management
Faramarz Khosravi , Gokhan Izbirak
⁎

Department of Industrial Engineering, Eastern Mediterranean University, Famagusta 99628, Cyprus

ARTICLE INFO ABSTRACT

Keywords: Social sustainability is quickly becoming a measured threat to sustainability with human activities taking con-
Social sustainability tributing substantial causes. Despite of huge literature that has contributed, yet the dimension of social sus-
Sustainability fluctuation tainability seems to be extremly new in the service sector; the healthcare zone to be specified. This study de-
Performance measurement monstrates a stochastic exponential distribution model for measuring the social sustainability status of a supply
Exponentially distributed indicators
chain based on stakeholder theory. Iranian healthcare situated in Tehran is studied to illustrate the applicability
Stakeholder theory
of the proposed framework. In the results obtained, the sustainability index for Suppliers, Patients, Patient
relatives, Employees, and Government & Decision makers are 47%, 60%, 59%, 75%, and 56% respectively. The
proposed model can be applied as an extensive tool for measurement of the social sustainability level of any
supply chain system.

1. Introduction 2010). Emphasis has been laid on the assessment of environmental

business sustainability (Moreno, 2013). Meanwhile, the study of Ameer
The Sustainable Development Goals (SDG), founded by the United and Othman (2012) had reported additional challenges due to the
Nations for defining targets and indicators for the UN 2030 Agenda, emergence of the new business strategies ; and this has necessitated
attracted global attention (Reis Monteiro, Aparecida da Silva, & Moita corporate sustainability and sustainable management researches in all
Neto, 2019). However, lack of appropriate indicators was a major cri- facets of sustainability. Although the majority of research questions
ticism, as well as a model for measuring sustainability (Kapera, 2018). have been associated with financial objectives of organizations, studies
Currently, the definition of sustainable development is dealing with old of Carroll and Shabana (2010), Epstein and Roy (2014), Salzmann,
theories and developing new methods for evaluating the inter- Ionescu-somers, and Steger (2005), Schaltegger and Burritt (2018),
dependence between economic and social development to considering have been conducted to ascertain how a company could build-up lin-
the environment (Everard & Longhurst, 2017). The issues surrounding kages throughout environmental management and social features in a
sustainability are now becoming more germane than it was in the past manner that fosters corporate economic efficiency.
years. The Millennium Development Goals (MDG) as reported by Bird Rasouli & Kumarasuriyar, 2017 liken social sustainability to the
and Rowlands (2017) made it incumbent on all the countries of the capability to find reasons in creating and experiencing the value of
world to ameliorate some damages that fulfilled in terms of economies existence intellectually, emotionally, spiritually, and physically. This, if
and people. It has become necessary for everyone, either as a business achieved would be a true reflection of how people are responsive to-
owner, Government, and/or as major stakeholders to ensure improve- ward the societies business-wise or in another facet of the society (Reis
ment in all facets. Therefore, based on the studies of Wilcox, Nasiri, Monteiro et al., 2019). Invariably, it is absolutely proper to adopt the
Bell, and Rahaman (2016) and Dimond and Webb (2017), various theory discussed in Villeneuve, Tremblay, Riffon, Lanmafankpotin, and
concepts of sustainability based on three independent perspectives of Bouchard (2017), that social sustainability is the only tool for assessing
economic, environmental and social point of views have surfaced. the quality of life and could help in decision-making. This study will
However, it has been discovered that significant efforts on the appli- painstakingly and concisely expose how stakeholder theory can be used
cation of economic and the environmental dimensions in sustainability to appraise the social sustainability of a healthcare system. Huge le-
assessment have been abandoned, while the social aspect had been gitimacy has been given to social sustainability in the past decade due
mostly ignored (Ehrgott, Reimann, Kaufmann, & Carter, 2011; Pfeffer, to a significant change in perception that surfaced in both public and

⁎
Corresponding author at: Eastern Mediterranean University, Famagusta, North Cyprus, via Mersin 10, Cyprus.
E-mail addresses: Faramarz.khosravi@emu.edu.tr (F. Khosravi), gokhan.izbirak@emu.edu.tr (G. Izbirak).

https://doi.org/10.1016/j.scs.2019.101681
Received 8 April 2019; Received in revised form 6 June 2019; Accepted 22 June 2019
Available online 06 July 2019
2210-6707/ © 2019 Elsevier Ltd. All rights reserved.
F. Khosravi and G. Izbirak Sustainable Cities and Society 50 (2019) 101681

private settings. This is a result of various degrees of responsibilities environmental, and social. (Ashby, Leat, & Hudson-Smith, 2012). Singh
that have placed on them with the growing economy as well as an in- et al. (2019) have added the fourth dimension as stakeholders in those
crease in the utility requirements of both human and the society. These three areas and applied hierarchical pathway trading for finding vitality
have grabbed the attention of stakeholders and business owners and and magnitude of factors. Social sustainability is considered less im-
showed them the need to redesign the current clumsy-like configura- portant in supply chain management; (Klassen & Vereecke, 2012) pre-
tions in order to ensure optimal delivery, even in the face of the sented the three levels of social supply chain as (I) who – stakeholders,
dwindling economic and social preferences (Lamberton & Zhou, 2019; (II) which issues – social concerns influencing the organization and (III)
Singh, Sushil Kar, & Pamucar, 2019; Soma & Polman, 2018; Xian, Patel, how – the responsiveness of the management to these concerns in terms
Al-hussein, Yu, & Gül, 2018). of manipulating the attendant risks and enhancing the value added to
We propose the social sustainability of a healthcare due to its the customers. Mani, Gunasekaran, Papadopoulos, Hazen, and Dubey,
strategic influence on the quality of life, as we know the popular saying 2016; Mani, Childe et al. (2016) reported dimensions such as equity,
that “health is wealth”. The central focus of the healthcare supply chain safety, health and welfare, philanthropy, ethics, and human rights as
are the patients; however, this objective will be difficult to achieve if those highly germane for assessing the social sustainability supply
the social roles of other stakeholders are ignored. Synergy surrounded chain. More so, Mani et al. (2015), Sodhi and Tang (2018) all opined
by clients and providers must be put first above the mind of how to treat that this will be followed by customers’ needs, liquidity, and the social
the patients. According to Eizenberg and Jabareen (2017), researches in awareness level of the organization. Incorrect application of these social
the social facet of sustainability are scanty and grossly lacking, theo- features could lead to colossal losses for the organization (2016b, Mani,
retical and empirical outputs. Gunasekaran et al., 2016). Puska, Maksimović, and Stojanović (2018)
The enablers and barriers of various stakeholders within the have noticed the importance of sharing information for developing
healthcare system are yet to be deciphered technically and analytically organizational learning inside a supply chain. With the recent submis-
despite different views to adopt and emphasize social sustainability sion of Mani, Gunasekaran, and Delgado (2017) that social sustain-
(Ajmal, Khan, Hussain, & Helo, 2018; Karamat et al., 2019; ability has a high propensity to increase the efficiency of the supply
Maruthappu, Hasan, & Zeltner, 2015). According to the studies of Mani, chain, managers have deemed it necessary to integrate several dimen-
Agrawal, and Sharma (2015), it could be said that the nonchalant at- sions to the issues of sustainability in a supply chain (Marshall,
titude of the developing countries toward healthcare social sustain- McCarthy, McGrath, & Claudy, 2015). Business requires reporting some
ability is evidently shown in the high rate of maternal mortality, gender of their corporate social sustainability as suggested in Tate, Ellram, and
inequality and general health problems that have been ravaging the Kirchoff (2010). Unfortunately, few studies have been conducted to
quality of healthcare delivery in those countries. Most of these pro- report social sustainable supply chain (Badri Ahmadi, Kusi-Sarpong, &
blems are due to the ignorance and lip-service paying to the issues of Rezaei, 2017; Ehrgott et al., 2011; Pfeffer, 2010) and this has called for
social sustainability in the logistics supply chain of drugs and other proactive steps to further explore the supply chain in the social content
areas. Therefore, stakeholder theory found its way among prominent perspective (Morais & Silvestre, 2018).
and commonly used theoretical techniques by many researchers and Over the last decade, the healthcare system has witnessed stiffer
this theory led to important hedges in dimensioning sustainability (see competitions due to the huge influence of the patients and the quest to
Clark, Feiner, & Viehs, 2014; Baric, 2017; Alves, do, & Rodrigues, 2018; provide quality healthcare services (Castro, de, Mateus, & Bragança,
Carroll & Brown, 2018). 2017; Samuel, Gonapa, Chaudhary, & Mishra, 2010). Presently, the
The field of health care services has many potential for further system is faced with the emerging and evolving challenges of new
studies on the interactions between the environment and the human circumstances related to risks and twists in the known disease. It can be
factor. For this reason, the need to pay attention to this vital connection noted that the human element is sacrosanct at managing the healthcare
has been of interest to scientists and researchers (Daughton, 2014). process (Santilli & Randy Vogenberg, 2015). Roy, Adhinkari, Pamučar
This research has some original and new points. In fact, there are Kar, and Pamučar (2018) have developed a new model for measuring
several investigations related to the analysis of sustainability. Some of hospital service quality for finding priorities of internal and external
them are related to statistical methods, but little focus has been made factors; they realized that in this area, medical staff with professional
on the effect of statistical distributions on sustainability value. This abilities is the most important one. Previous studies (Griffith, Harvey, &
paper has tried to fill this gap by developing a novel model for mea- Lusch, 2006; Huibin & Yuan, 2014; Grembowski, Cook, Patrick, &
suring the social sustainability of involved stakeholders in a supply Roussel, 2002) have proven beyond doubt that interactions with ex-
chain. Different from the previous studies, the application and exten- ternal suppliers, inter-organizational, physicians, and their patients, as
sion of this model will allow to focus on the fit ability of statistically well as intro-organizational interactions, team members' relationships,
meaningful distributions to challenge and capacity indicators. supervisor-member relationships, and employee-organization relation-
Furthermore, this new vision (involving statistical distribution to sus- ships, are all necessary factors. No research has fully exposed or ex-
tainability measurement) makes this methodology flexible and applic- amined how these relationships are linked together in the framework of
able to different contexts. the service supply chain. Additionally, past research has also failed to
The remainder of this article after the introduction in Section 1 is examine the influence of enablers and barriers on social sustainability.
structured as follows. Section 2 presents a brief literature review. Sec- Ajmal et al. (2018) suggested that to implement social sustainability
tion 3 addresses the research methodology where the conceptual fra- across any supply chain, both the enablers and barriers of the social
mework for the proposed the exponential distributed sustainability aspect of the specific organization must be thoroughly considered. We
model with the rationales for the selection of enablers and barriers, the propose to employ this strategy in measuring the social sustainability
exponential model for the social sustainability of the healthcare system, supply chain of a healthcare system.
and the validation procedure for the exponential distribution is ex- As earlier stated, the stakeholder theory is the most formidable
posed. The numerical illustration of the model is presented in Section4. framework of sustainability measurements. The majority of researchers
Results and discussion are given in Section 5. Section 6 presents the supported the assertion that social sustainability and the stakeholder
conclusion. theory are consistent (Perrini & Tencati, 2006; Collier, Bates, Wood, &
Linkov, 2014; Bellantuono, Pontrandolfo, & Scozzi, 2016; Herazo &
2. Literature review Lizarralde, 2016). Therein are the criteria for identifying which of the
stakeholders to be engaged in a particular organization. Some schools
In the last few decades, the concept of sustainability has been dis- of thought Veralg. (2018) opined that the legal tendency, power, and
cussed in managing resources in different areas including economic, relevance to the issues pertaining to sustainability features of the

2
F. Khosravi and G. Izbirak Sustainable Cities and Society 50 (2019) 101681

stakeholders could be the criteria for selecting appropriate stake-

holders. Many other strategies, normative frameworks, guidelines and
standards for choosing stakeholders have been proposed by various
authors (see Roloff, 2008; Molteni & Pedrini, 2010; Konrad, Steurer,
Langer, & Martinuzzi, 2006). Recently, some authors (Gomes, Kneipp,
Kruglianskas, Barbieri Da Rosa, & Bichueti, 2015; O’Higgins, 2010)
gave a vivid and clear description of some frameworks by explaining
what the organizations do to reach the social sustainability.
In some frantic efforts made to achieve healthcare organizational
goals, rapt attention and strict priority are given to stakeholders
(Bulgacov, Ometto, & May, 2015). It is believed that proper cognizance
to the social exchange within the system is capable of reducing the
barriers toward attaining overall sustainability. Huge benefits are
availed healthcare practitioners through imbibing social interactions
within the others is the ability to gain peoples’ trust and credence and to
extend and deepen internal and external cooperation (Fawcett,
Fig. 1. Research conceptual framework.
Magnan, & McCarter, 2008). The stakeholder theory; Agudo-Valiente,
Garcés-Ayerbe, and Salvador-Figueras (2017) and Schaltegger, Hörisch,
and Freeman (2017) argued that contraction to the economic and other The contribution of this paper is to facilitate the measurement of the
resources are the bane and fundamental barriers to attendant risks and social sustainability in a healthcare system based on the stakeholder
enhancing the customers’ worth the sustainability. For Pagell and Wu theory and perspectives by establishing the statistical distribution of
(2009), the misassignment of those resources is the major reason for the those sustainability factors, against the previous studies where the as-
inadequate execution of social issues and techniques. The aforemen- sumption of a particular statistical distribution have been continuously
tioned drawbacks, prompted most organizations to force suppliers to used and reported.
reduce prices, for instance, as put by Wong et al. (2017), in spite of the
huge financial burdens of the healthcare system in China, the govern-
ment still keeps reducing its financial obligations to the system and 3. Research methodology
consequently, the citizens are made to pay more. Ludlow, Braithwaite,
Herkes, Lamprell, and Testa (2017) presented another dimension to the 3.1. Conceptual framework
barriers; the workplace culture as a serious hindrance to healthcare
sustainability. Therefore, misalignment in codes of conduct and other This study averred its concept on the social sustainability aggrega-
sundry local culture, as well as disagreements among the suppliers as a tion in each area of healthcare as highlight previously. Donaldson,
barrier to social issues toward sustainability has been reported (Walker Preston, and Preston (1995), Lambooij and Hummel (2013), and
& Jones, 2012). Leviton and Melichar (2016) have described stakeholder as an entity
Two dimensions to social sustainability have been utilized in lit- that can greatly influence or can be affected by the output of the
erature, both internal and external. Ahmad and Thaheem (2017), common organizational objectives. The recent report of Varsei, Soosay,
Gollan (2007), Kaminsky and Javernick-Will (2014), Pfeffer (2010) all Fahimnia, and Sarkis (2014) opined that despite of many existing social
described, internal social sustainability as an intention to manage and and environmental sustainability pieces of research based on the sta-
prioritize human resource, organizational design, and change man- keholders have been restricted to the supply chain manufacturing sec-
agement processes. In this sense, social sustainability refers to safe- tors. The current study proposes Fig. 1 as the conceptual framework on
guard and developing internal organization in terms of human and the basis of four mutually related stakeholders to evaluate the sus-
social capital. External aspects of the social sustainability deal with the tainability of a healthcare supply chain of Suppliers, Employees,
issues related mainly to strategic management processes and to public Community/Patients, and Owners/ Government as reported by Khan,
perception report (Popovic & Kraslawski, 2018). These two techniques Hussain, Ajmal, and Helo (2018) and one more element as Patient re-
have further explained social sustainability as a means to give back to latives. Stakeholder theory as advocated by Donaldson et al. (1995),
society rather than just exploiting the available resources (Docherty, Carter and Easton (2011) is employed with the view of exploring,
Kira, & (Rami) Shani, 2009). Summarizing the concepts, internal as- evaluating, and measuring the healthcare social sustainability from the
pects significantly deals in defining the possibility and finding ways to dimension of the participating stakeholders. These key areas of
secure and reproduce human and social capital within the organization. healthcare should be considered is driving decision with the process
External aspects see the relationships across organizational lines where according to previous studies: stakeholders/customers as discussed by
social resources and regeneration could be exchanged seamlessly and Phillips (2013), employees explained by Sarkis, Gonzalez-Torre, and
effortlessly. Adenso-Diaz (2010). So far, stakeholder theory has not been applied to
To assess and measure the sustainability of an organization (man- analyze healthcare social sustainability on the basis of all the stake-
ufacturer or service oriented) or to move towards sustainability, there is holders. This study seeks to integrate the social sustainability perspec-
a common concern about using measurable indicators among scientists, tive of all the stakeholders involved. A survey-based empirical data
decision makers, institutional and industrial managers (Peixoto et al., collection method is adopted to analyze the proposed framework.
2016). Indicators must be capable of focusing on the targets. Coin-
cidentally, for applicability of indicators, finding the appropriate
number of related indicators is a vital pattern in sustainability mea- 3.2. Rationales for enablers and barriers selection for the social
surement methods (Atanda, 2018). The importance of the need to de- sustainability evaluation
fine the appropriate indicators that can be measured at intervals is not
superficial. The areas that are to be covered by these indicators have Table 1 presents various rationales for selecting enablers and bar-
been discussed by practitioners and researchers (Fang et al., 2018). riers for appraising and measuring the social sustainability of a
Involving stakeholders in finding indicators and choosing the method of healthcare system guided by its identified supply chain elements of
sustainability assessment will increase the reliability of results (Collier suppliers, customers, employees, and government/owners.
et al., 2014).

3
 F. Khosravi and G. Izbirak

Table 1
Rationales for enablers and barriers selection for the social sustainability evaluation of a healthcare system.
S/N Supplier Patients Patient relatives Employee Government

1 Understanding of the cultural values and Ability to assess and decide on the activities Availability of a healthy workplace Availability of adequate resources, The commitment of the leadership to the
integrity of the hospital and its surrounding of the healthcare providers equipment, and technology-driven healthcare of the populace
healthcare gadgets
2 The rate performance of the supplier balance Available resources at their disposal for Ensuring effectiveness of comments Poor working conditions and terms of Poor management of socio-economic policies and
sheets and demand uncertainty healthcare service regulations
3 Ability to liaise with classified service High resistance to change Satisfaction with the behavior of Poor management and unreliable Diversity of the populace culturally and ethically
providers and partners medical staff with patients leadership support
4 Level of training and experience to cope with Healthcare quality and reliability concern Access to easy payment system during Ambiguous rules of engagement and Incoherent healthcare plans and structure on the
pressure from manufacturer and customers treatment and patient clearance empowerment basis of lack of consensus and agreement among
various arms

4
5 Capability to foster sustainability issues Patient-healthcare provider relationship Availability and easy access to facilities Work monotonous and capable conflict of The level of commitment to the Green supply
(entrance, lobby, staff assistance, and interests chain culture
services)
6 Adequate coordination, Collaboration, and Level of health Education and awareness Accessibility to meaningful information General organizational management Perceived image and reputation of the head of
management of its systems leadership
7 Adequate facilities for promoting healthy Ethno religion and cultural values –ego and Easy access to technological Capable of offering services that can Inadequate budgetary provisions to appropriate
Communication and up-to-date information beliefs components, including internet, enhance customers' Satisfaction various healthcare incentives
and Feedback television, computer
8 Sense of humor toward corporate social Inadequate communication between and Promoting caring connections between The flexibility of the workplace, equal Bad implementation of policies and regulations
obligations within various organs of the healthcare patients and relatives opportunity, and fairness
providers
9 The propensity for total quality management High concerns for safety and security of life The behavior of staff to reduce anxiety Reward in consonant with productivity Sponsoring of various health education and
and stress of patient relatives and output awareness programs
10 Awareness of the needs of the community and Issues related cost pressure and constraints Easy access to the patient in emergency Proper dispensation of policies and Perception, beliefs, and commitment to issues
the ability to measure success yet cases regulations relating to social sustainability
Sustainable Cities and Society 50 (2019) 101681
F. Khosravi and G. Izbirak Sustainable Cities and Society 50 (2019) 101681

Fig. 2. Progress charts of social sustainability values in stakeholders of the supply chain.

3.3. Model for exponential distribution of healthcare supply chain 0

1 2 2y dy
e
1 + 2
Sequel to the submission of Khosravi, Izbirak, and Adewale Adesina Sus= P(H< C) = +
(2019) that system’s factors can enable and also inhibit its progress, this 1 2 1y dy
e
study imbibing this concept poses enablers as those that improve the +
0 1 2 (5)
capacity of the healthcare system toward sustainability while its
struggle over some challenges and barriers as those negating the at- An exponentially distributed random variable deals with the time of an
tainment of social sustainability. The proposed exponentially dis- event or time between two events. Sustainability is defined as the
tributed healthcare sustainability model is built of the basic capacity, C probability that challenge factors can not surpass capacity factors and
is greater than the attendant challenges H, with the view of moving the In Eq. (1), we assumed variable Y is the difference between challenge
healthcare system toward sustainability. and capacity factors, so for calculating the value of sustainability we
Hence, from the aforementioned assertion, the probability of capa- should use the negative side of Y in Eq. (5).
city greater than the company’s challenges. Therefore, Eq. (1) is used to
express sustainability as follows:
3.4. Chi-square goodness of fit test for checking the fit ability of statistical
Sus= P(H< C) = P(H C< 0) = P( Y< 0) (1) distributions to data

The model further obtains the probability in Eq. (1) through a In many statistical models, we are interested in the testing cap-
probability density function for capacity and challenge factors as in Eq. ability of fitting one of the statistical distributions to the data related to
(2), where 1 and 2 as the exponential parameters; a process, which is extracted from the historical data of that process.
The goodness of fit test is a nonparametric method that shows the
1 h ability to perform this task well and accurately. We perform a Chi-
f (h, 1) = e 1

pdf= 1 square goodness of fit test for checking the fit ability of exponential
f (c, 2) =
1
e
c
2
distribution to challenge and capacity indicators corresponding Chi-
2 (2) square values.
This test is well-suited for continuous and categorized data. To find
Thus, Eq. (3) the Cumulative Density Function (CDF) of Y, FY (y) Is the number of intervals from the square root of observations and also to
piecewise, when find class interval, the range of data divided by the number of intervals
has been used.
y 0 or y> 0FY (y) = P(Y y) The goodness of fit test requires the analyst to state a null hypoth-
esis H0 , and an alternative hypothesis H1, the hypothesis is based in a
fH,C (h, c)dcdh = ( 1e 1h)( 2c)dcdh
2e
way that they are mutually exclusive. It means that accepting one of
0 h y 0 h y
hypothesis, makes it impossible to accept another; and conversely.
2y
1e Step 1: The first step is to state the null and alternative hypothesis to
= y 0
1 + 2 be tested clearly. Hypothesis are H0 =
h y
Distribution of indicators is exponential
= 1 fH,C (h, c)dcdh
y 0 H1 = Distribution of indicators is not exponential
h y
=1 ( 1e 1h)(
2e
2c)dcdh Step 2: After establishing the hypothesis, the decision about
y 0 choosing a level of significance must be taken. Confidence level with
2
which the null hypothesis is accepted or fail to accept. The standard
=1 e 1y y>0 value for α is 0.05.
1 + 2 (3)
Step 3: After the hypothesis are constructed, and the significance
By differentiating Equation 3 with respect to y, Eq. (4) as a prob- level is decided upon, the next step is to specify an appropriate test
ability density function is achieved as; statistic and its distribution and also finding the p-value (Asymp. Sig.)
Step 4:
1 2 2y
Making a decision about rejecting H0 or fail to reject H0 considering
e y<0
1 + 2 the p-value (Asymp. Sig.). According to the definition, the p-value
fY (y) =
1 2 1y
(Asymp. Sig.) is the smallest amount of probability that leads us to
e y>0
1 + 2 (4) reject H0 , it means that the null hypothesis H0 will be accepted for all
values of less than the p-value(Asymp. Sig.).
Finally, Eq. (3) can be used for finding the exact value of sustain- Step 5: Once all the steps are performed, the statistical conclusions
ability; can be drawn, and we can make our decision. If the result of the test,

5
F. Khosravi and G. Izbirak Sustainable Cities and Society 50 (2019) 101681

Table 3

unsatisfied employee to satisfy employee

1- Average time between invoice to stock
1- Time between two orders of category
. Mean value of capacity and challenging factors for measuring social sustain-

2- Time between two complaints from

3- Time between two complaints from

employees about working conditions

patients or fellows about expensive

ability of a healthcare provider (Hospital) in Tehran, Iran.

2- Time is taken for each checkout

Government & Decision Makers

3- Time between converting an

A drugs (in ABC analysis) Mean value of variables

Stakeholders Capacity Challenge Social Sustainability Value

Supplier 18.93 21.47 0.47
Patients 17.29 11.49 0.60
Patient relatives 15.29 10.33 0.59

sale`s money
healthcare Employee 22.62 7.71 0.75
Government 20.72 16.25 0.56

fails to reject H0 , this conveys that specific statistical distribution is fit

loan or advance payment of a portion of the

2- Time is taken for acceptance sampling of

3- Time between two lost working days, due

able to our data.

3- Time is taken for sorting & shelving of
1- Time between request and receipt of a

each batch with consideration of quality

each batch with consideration of quality

1- Time between two wrong perceptions

to occupational accidents, injuries and

2- Time between two complaints from
patients about employee’s conducts

4. Numerical illustration

To demonstrate the proposed model, general hospital in Tehran is

considered. This is the largest government hospital located within the
municipality of Tehran with an average population of 10,000,000.
Various wards of the hospital, which are male, female, accident and
emergency, surgical, children and maternity can accommodate 60, 60,
Employee

15, 20 and 80 patients respectively. The five (5) elements of the pro-
illness

salary

posed healthcare supply chain are shown in Fig. 2. The challenge and
capacity factors based on the social enablers and barriers evaluated for
each element are presented in Table 2. The value for each capacity and
1- Time between two complaints from

2- Time between two complaints from

3- Time between two complaints from

and nurses, according to preferences

3- 3-Waiting time to visiting doctors
relatives about the behavior of staff

challenge factor per element is determined and measured in time.

1- Waiting time in payment system
relatives about healthy workplace
relatives about the availability of

appointment in emergency cases

The SPSS results for the determination and validation of the ex-
2- Waiting time for taking an

ponential distribution are presented in Tables A1–A5. Worthy of note is

during the patient clearance

the significant level obtained for the capacity and challenging factors
for each element. The output reveals that the significance values of both
factors for all stakeholders are greater than the level of significance
Patient relatives

(α = 0.05); at 0.923, 0.814, 0.531, 0.270, 0.799, 0.372, 0.804, 0.644,

0.569 and 0.138 for Suppliers, Patients, Patient relatives, Employees,
internet
Challenge and capacity factors for the elements of the healthcare system from stakeholders’ perspectives.

and Government & Decision Makers respectively. It says that we fail to

reject null hypothesis to all factors and exponential distribution is fit
able.Therefore, Eq. (5) can be used to measure the social sustainability
fellows of patients about the long queue at

of the healthcare supply chain system. Applying the mean values of the
1- Waiting time for clinic appointments or

3- 3-Waiting time for operation in case of

(radiology, lab reports, and medication)

factors as given in Table 3, the sustainability values of the healthcare

1- Time between two complaints from

2- Time between two complaints from

3- Time between two complaints from

2- Waiting time for inpatient services

patients about cleaning and hygiene

system according to the perception of each stakeholders is calculated by

patients about the long lead time

using Eq. (5) as 47%, 60%, 59%, 75% and 56% for Suppliers, Patients,
Patient relatives, Employees, and Government &Decision Makers re-
spectively.
Utilizing the indicators in Tables 2 and Eq. (4), the sustainability of
specialist treatment

the supply chain stakeholders was obtained according to Eq. (5) as;
the pharmacy

0
Sustainability= 1 2
e 2y dy
emergency

1+ 2
Patients

For example,

Social sustainability of supplier=

0
( 21.47
1
) ( 18.93
1
)
e18.93y dy =
( 21.47 ) + ( 18.93 )
1 1
3- Time is taken between two deliveries on the
1- Time between two complaints from patients

difference between the requested delivery day

0.47 = 47%
customers about the packaging of drugs

Quantifying the contributions of each stakeholder toward the sus-

2- Time between two recalled products

3- Time between two complaints from

2- Delay, which reflects the difference

1- Response delay, which reflects the

between the actual delivery day and

tainability of the healthcare supply chain studied as advocated through

the stakeholder theory, a progress chart in Fig. 2 is presented.
about the quality of drugs

5. Results and discussion

confirmed delivery day
and the negotiated day

In sustainability measurement, there are two type of opposing fac-

tors:
agreed day
Supplier

• Capacity
• Challenge
Challenges

Each organization by empowering capacities to overcome chal-

Enablers
Table 2

lenges can increase the value of sustainability. From Table 3 and Fig. 2,
S/N

the sustainability of the stakeholders varies with the employee having

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F. Khosravi and G. Izbirak Sustainable Cities and Society 50 (2019) 101681

Table A1
Exponential distribution determination and validation of Supplier.
Capacity-Supplier Challenge-Supplier

Observed N Expected N Residual Observed N Expected N Residual

1 28 27.6 0.4 1 49 41.6 7.4

2 20 17.5 2.5 2 23 23.8 −0.8
3 8 10.9 −2.9 3 11 13.9 −2.9
4 8 6.5 1.5 4 6 7.9 −1.9
5 2 4.4 −2.4 5 5 5 0
6 2 2.2 −0.2 6 1 3 −2
7 2 1.5 0.5 7 1 2 −1
8 1 0.7 0.3 8 2 1 1
9 1 0.7 0.3 9 1 1 0
Total 72 10 1 1 0
Total 100

Test Statistics Test Statistics

Capacity-Supplier Challenge-Supplier
Chi-Square 3.18 Chi-Square 5.226
df 8 df 9
Asymp. Sig. 0.923 Asymp. Sig. 0.814

Table A2
Exponential distribution determination and validation of Patient.
Capacity-Patient Challenge-Patient

Observed N Expected N Residual Observed N Expected N Residual

1 30 31.3 −1.3 1 32 27 5
2 27 21.1 5.9 2 17 20 −3
3 13 13.8 −0.8 3 10 14 −4
4 4 9.2 −5.2 4 8 11 −3
5 8 5.5 2.5 5 12 8 4
6 2 3.7 −1.7 6 4 6 −2
7 2 2.8 −0.8 7 3 4 −1
8 2 1.8 0.2 8 4 3 1
9 1 0.9 0.1 9 5 2 3
10 2 0.9 1.1 10 2 2 0
Total 91 Total 97

Test Statistics Test Statistics

Capacity-Patient Challenge-Patient
Chi-Square 8.036 Chi-Square 11.087
df 9 df 9
Asymp. Sig. 0.531 Asymp. Sig. 0.27

Table A3
Exponential distribution determination and validation of Patient relatives.
Capacity-Patient relatives Challenge-Patient relatives

Observed N Expected N Residual Observed N Expected N Residual

1 31 29.7 1.3 1 37 29.6 7.4

2 18 20.1 −2.1 2 25 21.7 3.3
3 15 13.6 1.4 3 10 15.9 −5.9
4 10 9.2 0.8 4 8 11.7 −3.7
5 3 6.2 −3.2 5 9 8.6 0.4
6 7 4.2 2.8 6 3 6.3 −3.3
7 1 2.8 −1.8 7 3 4.6 −1.6
8 2 1.9 0.1 8 5 3.4 1.6
9 2 1.3 0.7 9 4 2.5 1.5
10 1 0.9 0.1 10 2 1.8 0.2
Total 90 Total 106

Test Statistics Test Statistics

Capacity-Patient relatives Challenge-Patient relatives
Chi-Square 5.601 Chi-Square 9.743
df 9 df 9
Asymp. Sig. 0.779 Asymp. Sig. 0.372

7
F. Khosravi and G. Izbirak Sustainable Cities and Society 50 (2019) 101681

Table A4
Exponential distribution determination and validation of Employees.
Capacity-Employees Challenge-Employees

Observed N Expected N Residual Observed N Expected N Residual

1 30 26.9 3.1 1 27 33.8 −6.8

2 14 17.2 −3.2 2 26 22.9 3.1
3 10 11.2 −1.2 3 19 15.5 3.5
4 8 6.7 1.3 4 11 10.5 0.5
5 7 4.5 2,5 5 7 7.1 0.1
6 1 3 −2,0 6 3 4.8 −1.8
7 1 1.5 -,5 7 2 3.2 −1.2
8 1 1.5 -,5 8 3 2.2 0.8
9 2 1.5 ,5 9 1 1.5 −0.5
Total 74 10 2 1 1
11 2 0.7 1.3
Total 103

Test Statistics Test Statistics

Capacity-Employee Challenge-Employee
Chi-Square 4.553 Chi-Square 7.845
df 8 df 10
Asymp. Sig. 0.804 Asymp. Sig. 0.644

Table A5
Exponential distribution determination and validation of Government & Decision Makers.
Capacity-Government Challenge-Government

Observed N Expected N Residual Observed N Expected N Residual

1 35 36 −1 1 58 54.1 3.9
2 24 24.4 −0.4 2 35 30.9 4.1
3 22 15.9 6.1 3 13 17.7 −4.7
4 12 10.6 1.4 4 8 10.1 −2.1
5 4 6.4 −2.4 5 4 5.8 −1.8
6 1 4.2 −3.2 6 1 3.3 −2.3
7 1 3.2 −2.2 7 2 1.9 0.1
8 3 2.1 0.9 8 1 1.1 −0.1
9 2 1.1 0.9 9 1 0.6 0.4
10 1 1.1 0 10 1 0.4 0.6
11 1 1.1 0 11 1 0.2 0.8
Total 106 12 1 0.1 0.9
Total 126
Test Statistics Test Statistics
Capacity-Government Challenge-Government
Chi-Square 8.613 Chi-Square 16.087
df 10 df 11
Asymp. Sig. 0.569 Asymp. Sig. 0.138

the highest value. This means the hospital under investigation is so- supplier’s side and delay in securing Local Purchase Order (LPO) from
cially sustainable according to the perception of the employees. Overall financial institution are capable of lowering the way the other two
the hospital is meeting the social yearnings of the employees. For the stakeholders perceived the supplier. Therefore, an unsatisfactory social
patients, a higher value equally indicates how patients, Patient relatives incentives and supports from other stakeholders especially the
and other visitors appreciate the level of the social incentives and Government could be a serious clog in the wheel of the suppliers toward
various supports provided to the patients and their relatives. The gov- attaining social sustainability goals. It could be deduced that the huge
ernment assumed the fourth higher level of social sustainability. This impact of social activities cut across all the participating parties (sta-
nececiates the evaluation of the same governmental interventions or keholders) irrespective of the projected sustainability value obtained
incentives toward the hospitalphysicians, patients and the employees. for each of them. This implies adjusting just a factor from any stake-
Certainly, these values scored by the Government might be elusive if holder would produce a ripple impact on all other factors thereby
environmental and economic issues have been sacrificed for the de- shifting the sustainability value of all the system. Therefore, holistic
velopment of social facet in a hospital. Obviously, the yearnings of both maneuvering or improvement of the overall sustainability index of the
the employees and patients must have met by the Government to a system is necessary. Another inference could be deducted a positive
reasonable extent. Intuitively, Governmental allocations must have perception of all and sundry in the issues related to sustainability and
been dissipated and influence the social ability of these two stake- also should learn to integrate social sustainability objectives within
holders. their mission and value statements. Depending on the prevailing con-
On the aspect of the supplier, a lower sustainability value is ob- ditions, it could be that mere scrutiny of a factor would lead to the
tained. Reasons not limited to bottlenecks from the hospital, reduction in the challenge loads resulting in an enhanced social sus-
Government and even the suppliers’ staff could be a bane hindering the tainability trait.
perceptions and low social traits within the supplier circle. Hindrances
like bureaucracy within the Government functionaries toward ap-
praising and selecting the adequate supplier, logistics issues from the

8
F. Khosravi and G. Izbirak Sustainable Cities and Society 50 (2019) 101681

6. Conclusions and challenge of those areas could easily be expanded as;

The proposed conceptual framework is designed based on properties -

of exponential distribution and applied to measure the social sustain- - Planning for cutting-edge standards to care for the patient, diag-
ability for the majority of the stakeholders involved in a healthcare nosis and surgical procedures, medicine-management and hy-
supply chain. In this way, challenge and capacity factors that sum- gienic food supply.
marized in Table 2 selected and measured based on efficiency and the - Using strict social criteria to firstly select suppliers.
importance of the factors. - Reducing the ethical decadent and pushing for more transparent
This is the first model to measure the social sustainability of a and all-inclusive governance that will make the Government be
supply chain in the presence of exponentially distributed factors that more accountable to their stakeholders.
can be applied in measuring the sustainability of supply chains in - Encouraging the employee to freely express how they should be
various domains. Hence, areas of priorities as identified by all stake- engaged in training that could enhance innovative thinking.
holders can be well focused. The onus is now on individual hospitals to
rejuvenate their strategies in order to decipher which factors to be in- For future studies, issues such as the following should be in-
cluded and those that should be jettisoned. This will go a long way vestigated.
toward attaining high effectiveness of the model.
- Developing a model for indicators with other types of meaningful
6.1. Implications statistical distributions.
- The applicability of the identified capacity and challenge factors
This proposed social sustainability exponentially distributed model should be tested with applying methods of finding indicators
is flexible, which could form a rigid framework for appraising and priority.
measuring the sustainability of today’s organizations from different - Various dimensions to compare and contrast with respect to the
backgrounds. The special and easiest way to enhance the social ability identified factors with other healthcare centers (hospital) in other
and inclination of all stakeholders within the healthcare supply chain is localities is essential to generalize the applicability of the proposed
to present them for training and restraining at all times. No doubt this framework.
study will assist the manager in taking an informed decision in ac-
cordance with the provisions of the prevailing supply chain. Another
way to go is the advocate and foster diligent, equity, fairness and good Declaration of Competing Interest
cultural values among all the participating stakeholders with a view to
better assist them to coordinate efficiently. The scope of the capacity None declared.

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