key: cord-0849848-pupu4bv1
authors: Gedam, Vidyadhar; Raut, Rakesh; Inamdar, Zeeshan; Narkhede, Balkrishna; Dharaskar, Swapnil; Narvane, Vaibhav
title: COVID‐19 critical success factors in Indian healthcare industry—A DEMATEL approach
date: 2021-08-05
journal: Journal of Multi-Criteria Decision Analysis
DOI: 10.1002/mcda.1763
sha: 24813690bfa399c02b3cd15901b7c0b9354c1368
doc_id: 849848
cord_uid: pupu4bv1

The prosed study aims to provide COVID‐19 critical success factors (CSF) associated with pandemic circumstances in the Indian healthcare industry (HCI). The CSF was identified via expert team inputs and a detailed literature review. The Decision‐Making Trial and Evaluation Laboratory (DEMATEL) method is used to determine the causal relationship between identified CSF. The methodology was supported by the case study of the Indian HCI. A total of 15 CSF in the Indian HCI during COVID‐19 are identified and prioritized using the DEMATEL method. The findings indicate that the high‐quality personal protective equipment (PPEs; LC8) and testing laboratories/facilities, centres, and kits (LC15) are the significant cause, and appropriate healthcare laws (LC13) are the least effect group. The study shows that policy and decision‐makers need to emphasize on LC8 and LC15 CSF in the Indian HCI and act accordingly to win the battle against post‐COVID‐19 circumstance. The policy/decision‐makers and healthcare administrations can identify the CSF and focus on that particular CSF. The identified CSF will help policy and decision‐makers swiftly build up the HCI to cope with the future pandemic.

The first unknown aetiological pneumonia cases are identified in Wuhan City, and the Chinese Centre for Disease Control and Prevention named it Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2; Rowan & Laffey, 2020) . The World Health Organization (WHO) renamed the SARS-CoV-2 as COVID-19. Because of high health concern and health system vulnerability, the pandemic outbreak was declared public health emergency of an international nature on 30 January 2020 (WHO, 2020a) . The COVID-19 pandemic in India is far better than other affected countries as there are only 6.59% active cases, and the recovery rate is 92.11% as of 7 April 2021, 08:00 IST (GMT + 5:30; MoHFW, 2020a).

The COVID-19 pandemic has placed a significant burden on the world's healthcare industry (HCI). This industry is an essential and front leading sector during COVID-19 in Indian and the world over.

During the fight against COVID-19, the HCI and the healthcare staff (HCS) were the front lines defence providing patient care by ensuring COVID-19 infection prevention and control . However, the outbreak was a clinical threat to HCS working in the HCI as they and their dear ones are becoming susceptible to the COVID-19 (Misra, 2020) . During the pandemic's initial phase, the Indian HCI faced a critical care crisis and lacked enough medical support. The COVID-19 difficulties faced by HCI include quality and quantity of PPEs, ventilators and PPEs supply, medical infrastructure, testing facility, drug/vaccinations, and so on (Godlee, 2020;  Ñamendys-Silva, 2020; Rowan & Laffey, 2020; Tanne et al., 2020) .

Earlier studies also discussed HCI issues related to scarce medical resources, fair allocation, allocation of monetary funds, and effective crisis management (Lee et al., 2020; Xie et al., 2020) . Indeed, healthcare availability mismatch may result in COVID-19 exposure and infection to the HCS (Misra, 2020) . The insights about capacity and supply scarcity in the Indian HCI is highlighted in earlier literature Rajagopalan & Choutagunta, 2020) . Indeed, in the combat against the COVID-19 pandemic, it is crucial to have an effective strategy for crisis management and healthcare resource management (Krishnakumar & Rana, 2020) . The past studies have highlighted the approaches, emergent preventive strategy, planning/ guidelines, and recommendations to be taken by HCI in confining COVID-19 spread Ehrlich et al., 2020; Huh et al., 2020; Yang et al., 2020) .

Further, different psychological, ergonomic, organizational, technological, and working conditional factors requiring focus attention on improving the condition of HCS as pointed by Rathore and Gupta (2021) .

Irrespective of scarce medical and other resources, the spread of the COVID-19 pandemic in India was appropriately contained, and several cases eventually started to decrease (MoHFW, 2020a) . To cease the damage associated with COVID-19, the Indian HCI took adequate measures on an urgent basis. Thus, it is paramount to study and understand the COVID-19 critical success factors (CSF) in Indian HCI and understand the cause-effect relationship among identified CSFs.

There was a shortage of published literature and reports related to COVID-19 CSF endure by the HCI in detail during the research work. Identifying the CSF experienced by the HCI will help to put accelerated efforts in the post-COVID-19 scenario. More importantly, the study will help reduce the COVID-19 further transmission, increase positive cases, and improve the service offered by HCI. It The structure of the proposed study covers the literature review in Section 2. The research methodology is covered in Section 3. The case study, data collection, and demographic details are covered in Section 4.

The result and discussion are covered in Section 5. The conclusion, future scope, and limitations are covered in Sections 6 and 7.

The HCI during the COVID-19 pandemic has faced several challenges involving multiple perceptions. The complexity and various perceptions ensure that the strategies and planning are appropriately intertwined, multi-structural, which later help implement. The COVID-19 successful mitigation broadly depends on healthcare, economic, social aspects, efficiency, effectiveness, and healthcare delivery reliability (Haleem et al., 2020) . Prominent healthcare CSF includes (i) identification, treatment, and quarantine of patients, (ii) responsive medical system, (iii) availability of HCS and medical facilities, (iv) safety and protection of HCS, and (v) healthcare resources supply chain, and so on. There is a plethora of literature highlighting COVID-19 impact on HCI. For instance, Ivanov (2020) studied the effect of COVID-19 on the global supply chain of China, Europe, and the USA and investigated the impact of different supply chain performance parameters. Govindan et al. (2020) studied a decision support system for managing the demand in the healthcare supply chain to mitigate the healthcare supply chain disruptions during a pandemic. Rowan and Laffey (2020) studied the scarcity of personal protective equipment (PPE) in Ireland during the COVID-19 pandemic. Chen et al. (2020) proposed a citizen and social media theoretical model to promote citizen engagement through social media during the COVID-19 crisis. Pamučar et al. (2020) explored the selection of sustainable strategies to reorganize the HCI during the COVID-19 pandemic. Manupati et al. (2020) and Bharsakade et al. (2020) propose an assessment framework for selecting the best healthcare waste disposal technique generated during COVID-19 and a lean approach to managing healthcare waste. However, scanty literature is available on CSF in HCI, particularly in the developing economy. The subsequent section provides insight into different CSF identified in the proposed study.

Along with medical readiness, the legal provisions play a crucial role in controlling the further spread of COVID-19. To contain the COVID-19 pandemic requires urgent and strict legal action from government authorities (Gowd et al., 2020) . To address the COVID-19 emergency, the Government of India (GoI) invoked the Disaster Management Act (DMA), 2005, Epidemic Disease Act (EDA), 1897 and made subsequent amendment in Epidemic Diseases Act 1897 (EDA, 1897; DMA, 2005; Nomani & Tahreem, 2020) . The standard operating procedures (SOPs) are also crucial documents to refer to avoid further transmissions of an outbreak (Dhahri et al., 2020) . These SOPs include guidelines related to personal protective equipment (PPEs), personal hygiene, delivery of healthcare, healthcare facility, preventive measures for the community and public, etc. Indeed, during pandemic circumstances, the guidelines, rules, policies, strategies, and action plans to contain pandemic spreads need continuous updates and strict follow-up (Khalid & Ali, 2020) . In a time-bound manner, GoI, Ministry of Health and Family Welfare (MoHFW), came up with different SOPs, guidelines, rules, policies, strategies, and action plans related to controlling COVID-19 and made sure that these SOPs are appropriately followed (MoHFW, 2020a).

The main concern during the COVID-19 pandemic was that the pandemic might exhaust available healthcare resources, infrastructure, and HCS. Even in developed nations, there was a concern that these facilities may get overwhelmed due to the sudden surge of COVID-19 patients. Further, the scarcity of healthcare resources, infrastructure, and HCS in developing countries may lead to deterioration in the quality of health support and increased workload on HCS (Alhalaseh et al., 2020) . There was a global shortage of medical resources during the pandemic, and global supply chains of necessary medical equipment, PPEs, ventilators, masks, and so on was at strain (Rowan & Laffey, 2020) . Mainly there was an acute shortage of high-quality PPE worldwide due to irrational use, panic-buying, rise in demand, and so on (WHO, 2020b) . To cope with the demand and supply gap of medical resources, the strategic approach and adequate in-house planning, local manufacturing, and increasing procurement and stockpiling are necessary. The GoI took appropriate steps on a war footing basis and imported high-quality PPE conforming to national, international standards and restricted the export of ventilators, breathing devices, diagnostic kits, PPE, masks, etc. The shortage of ventilators during the COVID-19 pandemic was also taken care of by exploring alternative options, developing indigenous ventilators, and so on Rayasam & Mande, 2020; Tempe et al., 2020) . The launch of the Aarogya Setu and other specialized apps were also developed to have real-time monitoring of healthcare resources (Tempe et al., 2020) .

Further, to avoid the rapid depletion of medical resources and their potential reuse, it is crucial to have in-house cleaning and disinfection facilities. The appropriate in-house pre-cleaning and disinfection facility such as microwave steam, hydrogen peroxide, ultraviolet light, warm air/steam, dry heat processing, autoclaving, and so on, was developed ensure safe material functionality even after effective COVID-19 treatments. Such in-house facility availability will reduce the burden on the supply of medical equipment, PPEs, ventilators, masks, and so on (Czubryt et al., 2020) .

The continuous influx of COVID-19 patients and the demandsupply gap of healthcare resources require rapid expansion of existing healthcare infrastructure and sensible use of healthcare resources.

The earlier available literature and guidelines emphasize the careful use of healthcare resources and adequate stockpiling to take care of the demand and supply gap (CDC, 2020a; CDC, 2020b; WHO, 2020c; MoHFW, 2020a) . Along with available guidelines, the HCS must ensure that the available resources are wisely allocated to patients requiring critical care. The HCI and public health administration can implement coping strategies for improving the supply, rational use, appropriate sharing, and allocation of healthcare resources (Devereaux et al., 2020; Sharma et al., 2020) .

The widespread use of PPEs, syringes, and other healthcare resources during the pandemic also created huge downstream healthcare waste disposal problems (Singh et al., 2021) . Thus, it is necessary to have proper management of healthcare waste and increase healthcare waste handling to avoid further spread of the virus (WHO, 2020d; Das et al., 2021) . Thus, to take care of healthcare waste disposal, strict waste disposal policy guidelines need to be followed. Further, healthcare waste management requires appropriate identification, collection, segregation, and storage in color-coded bins, transportation, treatment, and disposal, followed by disinfection, personnel protection, and training (Hantoko et al., 2021; Manupati et al., 2020) . The healthcare waste generated in Indian HCI has been managed appropriately as per the GoI and WHO guidelines (CPCB, 2020; WHO, 2020d) .

Due to the sudden surge in COVID-19 patients, there was an acute shortage of sufficient and trained HCS. Thus, to cope with the situation, the deployment of additional dedicated HCS in HCI is necessary. Besides, training related to COVID-19 precautionary measures to HCS is also vital. Earlier authors argue that the HCS needs an education and training program related to sample collection, using PPE and their safe disposal, ventilatory management, and so on (Sri et al., 2020; Tempe et al., 2020) . These adequate education and training programs impart skills and awareness regarding precautionary measures and appropriate management of healthcare resources among HCS (Ojha et al., 2020) . The GoI took initiatives related to an online training program for HCS under the aegis of MoHFW (MoHFW, 2020a). The health authorities also explored an option of young and retired HCS joining the fight against COVID-19 (Alhalaseh et al., 2020) . However, to take care of COVID-19 patients, the HCS spends hours with bulky PPEs leading to stress and fatigue during healthcare delivery. Therefore, it is crucial to have a reasonable working hour for HCS to discharge their duties effectively. A dedicated team of HCS can look after COVID-19 patients with a periodic rotation and adequate rest in between (Chandra & Vanjare, 2020) . Further, to ensure the safety of HCS, high-quality PPEs can be provided, such as goggles, shoes, head cover, face shield, face mask, gloves, apron, and so on (Goel et al., 2021) .

The HCS was widely praised as a COVID-19 warrior by government leaders and media across the globe. However, there were few instances of stigmatization of HCS (Ramaci et al., 2020) . These instances lead to an unwanted burden on HCS, leading to ineffectiveness in their healthcare delivery (Taylor et al., 2020) . The HCS requires support and collaboration from government authorities, society, and zero tolerance to any violence against HSC (Padubidri et al., 2020) .

And the communities at large need to behave responsibly towards HCS to discharge their duties efficiently. The supportive, collaborative working atmosphere with trust and professional unity can help HCS discharge their COVID-19 duties more effectively (George et al., 2020) . Indeed, to boost the morale of HCS and take their active support during the COVID-19 fight, policymakers and managers need to give attention to appropriate insurance/monetary incentives to HCS. To ensure decent working conditions for HCS, governments and policymakers need to develop policies related to compensation and benefits (Williams et al., 2020) . The GoI provided a unique insurance scheme to HCS covering all HCI and wellness centres across pan India. Further, the central and state government provided incentive funds, insurance coverage, encouragement allowance, monthly cash benefits, and so on, to HCS (ILO, 2020).

To flatten the growth curve of COVID-19 essentially depends upon early, accurate detection of the COVID-19 patients, isolating them, and providing effective drug/vaccines. The availability of scientific COVID-19 laboratory testing/facility and kits helps in widespread community testing, patient care, subsequent contract-tracing, and minimizes the mortality rates (Kumar et al., 2021) . The efforts were To control the spread of COVID-19 within and outside of healthcare facility, and to provide safe COVID-19 patient care, adherence to SOPs is essential. The SOPs and guidelines related to personal protective equipment (PPEs) and personal hygiene need to be appropriately followed by the healthcare staff (HCS). Adhering to SOPs and guidelines during the use and removal of appropriate PPEs, personal hygiene, and precautions by HCS is paramount to prevent COVID-19 infection Xie et al., 2020; MoHFW, 2020a; Dhahri et al., 2020; Khalid & Ali, 20,201 LC2 Appropriate inhouse precleaning and disinfection facility Suitable in-house facilities to clean, reprocess, disinfect, or decontaminate the medical equipment, and one-time use of PPE, masks, gloves, and so on, is essential in HCI, specifically during the pandemic scenario. Such a facility helps to ensure safe material functionality even after effective COVID-19 treatments and reduces the burden on the supply chain of medical equipment, PPEs, ventilators, masks, and so on In the event of a national pandemic and outbreak situation, the information about the requirement and frequency of the use of valuable healthcare resources such as PPEs, antiviral drugs, ventilators, and or healthcare facilities is crucial. It is imperative to utilize, wisely allocate, and conserve resources during the COVID-19 pandemic. The information about the required quantity, rate of use of these resources, and contingency planning during stock shortage will help to have adequate stockpiling in pandemic situations Rowan & Laffey, 2020; Yang et al., 2020; Ehrlich et al., 2020; Ojha et al., 2020; Alhalaseh et al., 2020; Sharma et al., 2020; WHO, 2020c; CDC, 2020a; CDC, 2020b; Devereaux et al., 2020 LC8 High-quality personal protective equipment (PPEs)

The lack of PPEs was of concern during the COVID-19 pandemic. However, the availability of high-quality PPEs in the Indian HCI has managed appropriately. The COVID-19 pandemic circumstances call to have PPEs in adequate quantity. In extraordinary times, due to amid and a severe shortage of PPEs, the HCS may be forced to used tailor-made low-cost PPEs as a measure against pandemic exposure. Thus, the availability of high-quality PPEs will contain COVID-19 infection more effectively and prevent its further spread to HCS 

A multi-criteria decision-making (MCDM) tool is highly preferred (Abrantes et al., 2020; Devarakonda et al., 2021) . Among all the MCDM methods, the DEMATEL method attracts a great deal of attention due to a simplified analysis of complex problems. The DEMATEL method is employed when the analysis of qualitative criteria requires degree of relationships and a robust weighting tool that can consider an interdependent relationship between the criteria. The technique considers interrelationships between the evaluation criteria and analyses their importance along with cause-effect relationships (Perçin, 2019) . Further, the criteria divided into cause-effect relationship helps in better understanding of the relationship among identified criteria. The DEMATEL methodology offers numerous benefits to decision and policymakers in complex decision-making scenarios. The method provides a solution to a complex problem and helps policymakers examine interrelationships and the influence between criteria or factors. The DEMATEL process also helps in gathering groups of ideas and analysing the structural issues. The method further helps in providing a simple hierarchical approach irrespective of the complexity of criteria or factors. 'zero influence' is 0; moderately low influence is '1'; moderately high influence is '2'; high influence is '3'; and very high influence is '4'. 

Second step: The normalized direct-relationship matrix 'N' calculation-

The initial matrix shown in Equation (1) and obtained via 1st step is normalized. The normalization of the matrix is done via Equations (2) and (3).

Third step: The total influence matrix 'I' calculation-During this method, the matrix 'I' is calculated. The matrix 'I' is obtained from the second step using Equation (1), where 'M' implies as identity matrix.

where

Then I = N (M À N) À1 , when h!∞.

Fourth step: The sum of rows and column calculations-During this step, the sum of rows and columns is calculated. The 'a' and 'b' shows the sum of rows and column and can be obtained using Equations (5) and (6). 

The study fills the literature gap related to COVID-19 CSF in the Indian HCI using the DEMATEL method. The final results and causeeffect calculations are shown in Table 7 .

The (B-A) values are calculated to know the cause-effect relationship among CSF, and from this result, the causal influence diagram ( Figure 2 ) is plotted.

When the value of (B-A) is positive, the factors are categorized in the cause group. The Table 7 there is an international concern regarding the supply chain of PPEs and testing laboratories/facility/kits (Godlee, 2020; Rowan & Laffey, 2020) . Developed countries are increasingly focusing on an adequate supply of PPE and other medical support. The HCI can effectively discharge its duties with adequate PPEs and testing laboratory /facility/kits . The earlier studies highlighted that during the COVID-19 pandemic, the focus was on manufacturing, logistics, supply chain, appropriate use, reuse of PPEs, and testing laboratory/facility/kits (Huh et al., 2020; Xie et al., 2020; Yang et al., 2020 

There was an increasing health concern during the COVID-19 outbreak, which spread to most countries worldwide, including India. The outbreak has placed unprecedented challenges on the world HCI. Additionally, during pandemic outbreaks, to ensure optimal utilization of healthcare resources. The policymakers need to classify the healthcare facility into different types, such as temporary patient facilities outside the hospitals, standard hospitals, Jambo COVID-19 hospitals, and so on. In these hospitals, to conserve the healthcare resources, appropriate pre-treatment and disinfection facilities for extended use and or limited reuse can be provided (CDC, 2020a;

CDC, 2020b). The government and health administration need to ensure the timely supply of healthcare resources in COVID-19 highly affected areas and in sufficient quantity. The state, local, and healthcare administration can further double-check that the healthcare resources are being distributed based on an actual need . The policymakers must further rope as many private labs and hospitals to provide care and testing facilities by providing them proper support. The government can also involve big and small industry players to cope with HCI's healthcare resource security during the pandemic circumstance. The government can formulate the rapid response team to coordinate the post-COVID-19 pandemic healthcare emergency and tackle the supply and demand of healthcare resources in states, districts, villages, or clusters.

Compared to developed nations, India lacked healthcare resources; however, India's fight against COVID-19 is international.

Indeed, India had the upper hand against COVID-19 because of the strategic approach, taking into account different possible scenarios, providing all necessary facilities and protection to HCS. The identified CSF can further help the Indian HCI contain the COVID-19 second wave and future pandemics. The policymakers have imposed smart lockdowns based on clusters and permitted industrial, commercial, and essential economic activities to sustain economic growth. The CSF identified in the proposed study will help mitigate future pandemics and healthcare challenges and an economic downfall arising from such pandemic.

In summary, the COVID-19 pandemic has placed a mammoth burden on the HCI. However, the help of CSF, as identified in Table 1, can help the HCI to mitigate pandemic challenges. The identified CSF certainly has the utmost importance, and sharing the Indian HCI experiences can help to mitigate the post-COVID-19 pandemic is paramount. The identified CSF will help policy and decision-makers swiftly build up the HCI to cope with the COVID-19 second waves and future pandemic.

One of the few limitations of this study is that the expert team's sample size is not significant. The expert team's inputs could be of biased nature, leading to influence in finding and the DEMATEL method's reliability. Future studies can be performed using more advanced and sophisticated MCDM methods such as fuzzy DEMATEL, ISM-DEMATEL, and so on, to get more exciting results.

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Rakesh Raut https://orcid.org/0000-0002-0469-1326

Vaibhav Narvane https://orcid.org/0000-0003-3923-2805

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