**1. Introduction**

In recent decades, the service sector's have made a significant contribution to gross domestic product (GDP) and affects the global economy [1]. This phenomenon has driven the development of the service supply chain (SSC) concept [2–4]. Methods of supply chain and performance measurement can be used to develop healthcare performance [5]. The healthcare supply chain (HSC) is an implementation of the SSC into healthcare businesses. HSC implementation stimulates healthcare service providers to collaborate with supply chain actors to ensure customer and/or stakeholder satisfaction [2] and cost reduction [6]. The HSC performance measurement (HSCPM) can be used to measure the success of the collaboration between healthcare service providers with other HSC actors.

In 2013, the service business contribution to Indonesia's GDP was 39.87% [7]. In the period from 2012 - 2015, the service business contribution to the Product Domestic Regional Brute (PDRB) of the East Java Province was an average of 71.11%. The service contributions show increasing trends in: tourism, hotels and restaurants, professional services, banking and insurance, and healthcare [8]. On the other hand, pressure from globalization and stakeholders requires the HSC operation to give attention to the environment, community, economic, and intangible assets [9]. Implementation of sustainable service supply chain could minimize the negative effects of operation on the environment and society and maximize profits [10]. Based on the contribution to GDP and/or the PDRB and as well as globalization and stakeholder pressure, healthcare businesses need a sustainable healthcare supply chain (SHSC), especially in the Province of East Java, Indonesia. SHSC implementation is expected to be able to improve the performance of healthcare businesses. Besides, the development of SHSC is feasible because healthcare businesses are concerned with improving public health and wellbeing.

The SHSC performance requires a performance measurement system. Sustainable supply chain performance is defined as a company's capacity to reduce the use of materials, energy, or water and to find more eco-efficient solutions by improving the supply chain [11]. Performance measurement of the SHSC can be adapted from the sustainable service supply chain performance measurement models. The performance of sustainability aspects in the supply chain are often difficult to measure [12]. The scope of sustainable service supply chain performance measurement (SSSCPM) includes environmental management, social responsibility, management of health, safety and risk, and customer management [13]. SSSCPM is still dominated by economic and environmental aspects, and less by social aspects [14]. SHSC performance measurement (SHSCPM) is also still oriented toward economic and environmental (green) aspects, such as the environmental supply chain performance measurement [15], life cycle assessment, and life cost assessment [16]. The social aspect of SHSC is important and is becoming a key objective within the SHSC because healing patients is the primary outcome of the HSC, and the social aspect of the SHSC is concerned with human aspects [17]. Social aspects are similar to intangible assets and are the main characteristic of the services sector [18]. Thus, SHSCPM implementation must consider both intangible assets and sustainability aspects.

The concept of the SHSCPM has been developed and reported. There has been is littleness integration between economic, environmental, and social aspects simultaneously. Furthermore, SHSCPM research is suitable for development in East Java Province, Indonesia. This study aims to propose an SHSCPM by combining the balanced scorecard (BSC) with the decision-making trial and evaluation laboratory (DEMATEL) and the analytical network process (ANP), while with simultaneously considering to the intangibility characteristics and sustainability aspects. The BSC will be combined with DEMATEL to design a strategy map that represents the relationships between perspectives and indicators. The relationships are designed based on the level of importance and influence by DEMATEL. Finally, the BSC strategy map will be used as input in the design of the ANP structure model. The ANP structure model will determine the weights of the performance indicators, performance perspectives, and sustainability aspects.

Integration of the BSC with DEMATEL and ANP for SHSCPM can improve previous SHSCPM models, which SHSCPM has designed by integrating of the BSC and DEMATEL [9]. This study aims to add the ANP method into the SHSCPM model, along with BSC and DEMATEL, where the ANP output is the weight of the performance indicators based on the BSC strategy map. Finally, integration of the BSC with DEMATEL and ANP for SHSCPM can enrich the SHSCPM literature based on BSC.

This article is organized as follows. This study discusses the BSC and DEMATEL in the SHSCPM, including a strategy map framework from a previous study in Section 2. Section 3 presents the DEMATEL and ANP for performance measurement, especially SHSC. Then, the methodology that describes the research stages and the structural model are presented in Section 4. Section 5 discusses data from an expert preference questionnaire survey of professionals in the healthcare business; this questionnaire is used in the processes of the ANP, and in weighting the performance indicators, performance perspectives, and sustainability aspects. Next, the limitations of this study are discussed in Section 6. The last section presents conclusions that describe the phenomenon of SHSCPM and future research opportunities.

#### **2. BSC and DEMATEL on SHSCPM**

The actors in the healthcare supply chain consist of a producer, suppliers, healthcare service providers, and patients [19,20]. The orientation of HSCPM comprises eleven elements, i.e.: continuous improvement and customer satisfaction [21], demand, customer relationship, supplier relationship, capacity and resources, information technology [5], trust, knowledge exchange, IT integration between the supplier and service provider [22], and costs and benefit [23].

The BSC is a model of performance measurement that describes the relationship between the performance of perspectives and indicators as a strategy map. The strategy map is a business strategy that is related with financial and non-financial execution [24]. Besides that, BSC can be used simultaneously by several organizations that are collaborating together [25]. The BSC has been used to measure the performance of sustainable SCPM [26]. Finally, the BSC can be adapted to measure supply chain performance because a supply chain is a reflection of the collaboration between producers, suppliers, providers and customers.

The BSC is dynamic and innovative because it can integrate with other methods [27] for the design of sustainable or green SCPM practices. Examples include BSC and AHP (analytical hierarcy process) –PGP (pre-emptive goal programming) [28], BSC and game theory [29], BSC and a fuzzy analytical networking process (ANP) [30], BSC and data envelopment analysis (DEA) [31], and BSC and DEMATEL [9]. Based on this, the design of the SHSCPM can integrate the BSC with another method.

The DEMATEL is a multi-attribute decision-making (MADM) method that can be used as a tool to help in decision-making processes [32]. The DEMATEL has used to analyse the component structures from decision variables. It can analyse the direct or indirect relationships between variables [33]. It is used to determine the relationship between the impact of the performance of perspectives and indicators on the performance measurement, including on BSC [33]. Furthermore, the DEMATEL can describe both the level of importance and the level of influence of an attribute or a variable in a system and then use a matrix system to determine all the causal relationships between the attributes and variables [33]. Finally, the DEMATEL can be used to determine the level of importance, level of influence, and supplier selection on the sustainable supply chain [34,35].

Integration of the BSC and DEMATEL for SHSCPM has been published. This past research shows that the SHSCPM orientation has similarities with the perspectives used in services sector performance: finance, customers, operational, information, and innovation & growth [9]. The relationship between perspectives is shown in Figure 1.

**Figure 1.** Strategy map of a sustainable healthcare supply chain performance measurement (SHSCPM).


**1.** Relationship between performance indicators and perspectives performance based on sustainability aspects.

**Table** 

Once the strategy map has been determined, the performance indicators of the SHSCPM can be identified. The identification of the performance indicators was based on a literature review, and in this paper, twenty nine indicators are used [9]. Furthermore, the performance indicators have been classified into the sustainability aspects and performance perspectives that are show in Table 1.

Figure 1 and Table 1 still do not show the weights of the performance perspectives and indicators of the SHSCPM, which indicate their contribution to performance. More study is still needed to determine the performance weights of indicators and perspectives based on the relationships between them, and these aspects can be done by using the ANP.

#### **3. DEMATEL and ANP for Performance Measurement**

The ANP is a general theory of relative measurement used to derive a composite priority ratio from an individual ratio that represents the relative measurement of the influence of elements that interact with control criteria [36]. For the performance measurement, ANP is usually combined with the DEMATEL [32], where the DEMATEL is used to relate of indicators and perspectives, and then the relationships created are used to make the ANP model. Finally, the ANP model can determine the weights of perspectives and indicators based on inner and outer dependence.

The ANP can improve the limitation of AHP, especially for accommodating the relationships between criteria and alternative [36]. There are two relationships in ANP, namely inner and outer dependence. Inner dependence is the relationship between indicators within a cluster, and outer dependence is the relationship between indicators in different clusters.

The ANP provides a way to input judgment and measurements to derive the ratio of a priorities scale for the distribution of influence among the criteria and groups of criteria in the decision process [33]. ANP is a qualitative multi-attribute decision-making approach that provides structured communication to address the business model [30]. The weight of an indicator on performance measurement can be determined by the ANP. The ANP can help decision-makers to determine a strategy for improving performance based on the strategy map.

This section may be divided by subheadings. It should provide a concise and precise description of the experimental results, their interpretation, as well as the experimental conclusions that can be drawn. Figure 1 and Table 1 still do not show the weights of the performance perspectives and indicators of the SHSCPM, which can indicate their contribution to performance. More study is still needed to determine the performance weights of indicators and perspectives based on the relationships between them, and these relationships can be processed using the ANP.

#### **4. Research Methodology**

The healthcare business in the Province of East Java, Indonesia was used for the design of the SHSCPM. The healthcare business consists of producers, suppliers (distributors), health clinics, and hospitals. In this study, the BSC will be combined with DEMATEL to design a strategy map that represents relationships between perspectives and indicators. The relationships are designed based on the level of importance and influence by DEMATEL. Furthermore, the BSC strategy map will be used as an input for design of the ANP structure model. Finally, the ANP structure model can be determine the weights of the performance indicators, performance perspectives, and sustainability aspects as final output of this study.

#### *4.1. Data Collection*

The development of the SHSCPM model in this study was based on a survey with in-depth interviews with seven expert respondents for data collection. The respondents were representatives of the healthcare business as supply chain actors. The respondents consisted of: one pharmaceutical industry manager, one supplier owner, two private hospital professional managers, one public hospital professional manager, and two clinical professional managers. All of the respondents had more than 10 years of experience in their profession. The surveys were obtained for the period from March 2018 to December 2018. Respondents were asked about pair-wise comparisons between perspectives and indicators based on their perceptions.
