Introduction
The healthcare supply chain, particularly in public hospitals, plays a critical role in delivering medical services to patients, especially during disasters. In recent years, health-related disasters such as the COVID-19 pandemic, economic sanctions, and natural disasters have severely disrupted the healthcare supply chain, leading to shortages of essential medical equipment, drugs, and other necessary resources for providing medical services. These disruptions have also resulted in abnormal increases in demand for medical services and have caused social crises. Healthcare supply chain resilience, defined as the system’s ability to quickly recover from disruptions and maintain sustainable services, is a key factor in national and international healthcare management. 
Public hospitals play a crucial role in providing services to vulnerable people and, therefore, have a significant role in the healthcare system. These hospitals primarily rely on government support and are more vulnerable to supply chain disruptions. Hence, identifying the enablers of healthcare supply chain resilience in these hospitals is essential for improving the efficiency and sustainability of healthcare services. To our knowledge, no research has specifically analyzed the enablers of healthcare supply chain resilience in public hospitals in Iran. In this regard, this study aims to identify and rank the enablers of healthcare supply chain resilience in public hospitals in Isfahan, Iran. 

Methods
This is a descriptive mixed-method study that was conducted in 2024. The study was carried out in three phases, with the first phase being a qualitative study and the second and third phases being quantitative studies. The first phase included the identification of the enablers of resilience in the healthcare supply chain of public hospitals. In the second phase, we employed the analytic hierarchy process (AHP) method, a well-known multi-criteria decision-making technique, and the third phase included the use of the cross-impact matrix multiplication (MICMAC) approach. 
In the first phase, a search was conducted using the keywords “healthcare supply chain resilience” and “resilient healthcare supply chain” in international and national databases to find the enablers. To screen the identified enablers, they were presented to 20 experts in the healthcare sector to rate them using a Likert scale (ranging from 1 to 5). They were selected from public hospitals in Isfahan using a judgmental sampling method. They were senior hospital managers, medical specialists, and professionals with at least eight years of relevant experience. To determine the weight or rank of the enablers, the AHP method was used in the second phase. In this regard, the paired comparison kernel was used. The inconsistency ratio of the paired comparison matrices was less than 0.1, indicating the consistency of experts’ judgments in ranking the enablers. The ranking was done using Expert Choice v.11 software. Finally, the MICMAC method was employed to identify the cross-impact between the enablers and analyze their direct and indirect effects using MICMAC software version 5.3.0.

Results 
Based on the literature review, 12 healthcare supply chain resilience enablers were identified. After screening, 11 enablers were finally selected, which included agility, IT capabilities, supply chain risk management, flexibility, speed, collaboration, sustainability, awareness/sensitivity, security, supply chain network design, and robustness. The agility, IT capabilities, and supply chain risk management were identified as the most important enablers, while supply chain network design and robustness had the lowest priority. Based on the MICMAC analysis, the enablers were classified into four categories: independent, autonomous, dependent, and linkage (key enablers). Agility, flexibility, and speed were placed in the linkage category, indicating their strong influence and high level of dependence. Autonomous variables included sustainability and security which have low influence and dependence and do not cause significant changes in the system when altered. Dependent variables included awareness/sensitivity, collaboration, and robustness, which have high dependency but low influence on the system. Independent variables included IT capabilities, supply chain risk management, and supply chain network design, which have high influence but low dependency. According to the direct impact matrix, flexibility had a very strong influence on agility. Additionally, supply chain risk management strongly affected awareness/sensitivity and speed. There was also a strong mutual relationship between awareness/sensitivity, collaboration, and speed. Furthermore, according to the indirect impact of the enablers, supply chain risk management had a strong indirect influence on robustness and awareness/sensitivity. Additionally, collaboration had a relatively strong indirect impact on agility, while speed indirectly affected awareness/sensitivity. The final enablers were classified into four main groups: elastic capabilities (Agility, flexibility), reporting capabilities (sustainability, security, supply chain network design, robustness), cognitive capabilities (supply chain risk management, awareness/sensitivity), and operational features (IT capabilities, speed, collaboration).

Conclusion
To enhance healthcare supply chain resilience in Iran, particularly in public hospitals, hospital managers should focus on strengthening elastic capabilities (with an emphasis on agility) and reporting capabilities (with an emphasis on IT). Industry 4.0 technologies such as artificial intelligence, big data, the Internet of Things (IoT), and blockchain play a significant role in improving IT capabilities and fostering collaboration among supply chain partners. Hospital managers should also place significant emphasis on risk management and employ innovative approaches in this area. Moreover, enhancing flexibility should be considered. Flexibility has a strong impact on agility. The more flexible the healthcare supply chain is, the greater its ability to quickly and efficiently respond to changes and disruptions, allowing for rapid shifts in strategies, sourcing of various equipment, and optimizing treatment processes. The results of this research can help policymakers and healthcare managers in Iran design and implement better operational plans to improve the healthcare supply chain resilience of public hospitals.

Ethical Considerations

Compliance with ethical guidelines
All ethical principles were considered. Informed consent was obtained from all participants.

Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Conflicts of interest
The authors declared no conflict of interest.

Acknowledgments
The authors would like to thank all participants for their cooperation.



 

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