RESEARCH PROPOSALPROPOSED TOPIC:TOWARDS A SUSTAINABLE HEALTH SUPPLY CHAIN IN GHANA: AN ASSESSMENT OF THE UPSTREAMS AND DOWNSTREAMS OPERATIONS1. Background of the StudyFor even and effective flow and availability of drugs and other health resources for quality healthcare delivery in the hospitals, there must be an effective and efficient supply chain system that ensures that health commodities and related resources are evenly distributed in the service chain for quality healthcare delivery to ultimately satisfy the customers (Bossert, 2004).According to the Chartered Institute of Procurement and Supply (CIPS, 2013), the supply chain process involves how organizations plan the order of operations of the functions and activities of the entire supply chain to operate together to allow the flow of materials, information and the financials, right from when the customer places a request through to when the final product or service is delivered to the customer (Raturi et al., (2005).Stevenson, (2012) further explained that, creating an effective and efficient supply chain requires bringing together all aspects of the supply chain of which Rajgopal, (2014) and Laudon & Laudon (2013) also agree, and thoroughly analyze them to do away with those aspects that do not add value to the supply chain operations to help increase supply chain total profits, reduce risk and enhance suppliers and customer relationship management and performance. Effective supply chains involves planning, sourcing, make or buy decisions, deliver and manage defective and excess products returns from customers (Stevenson, 2012).According to Sotiris (2000), Caplice (2006), MOH, (2012), and Dowling (2011), for health institutions that provides healthcare delivery to patients, their logistics and supply chain functions will include the selection, forecasting, procurement, storage, inventory management, distribution, logistics management information system (LMIS), performance monitoring, customer service, and the coordination of medicines and non-medicines supplies to ensure the smooth flow of healthcare commodities, information and financials to ensure the provision of quality healthcare.Bossert et al., (2004) opined that the health commodity supply chain network of the public sector in Ghana is a tier push structure of which drugs and consumables and other health commodities are distributed through, comprising of the central medical stores (CMC) which receives and store all procurements from the ministry of health and other donor agencies and distribute to the all the ten (10) regional medical stores (RMS) from which all the district medical stores (DMS) or service distribution points (SDP) and health facilities get their supplies from for healthcare delivery. There exist transportation component in this network connecting these distribution facilities within the entire Ghana health services.Achieving total quality healthcare delivery for patients by the health systems demands some availability of health commodities and other equipment to support the quality healthcare delivery. The issue really is about how these activities of care provision are undertaken with recognition of preserving the environment, economy and socially responsible for their operations. This brings the concept of Sustainability to the fore for discussion which underpins the need for further research to appreciate how the Ghana health supply chain handles and manage sustainability issues in their supply chain.In recent years, companies and by extension, the health sector, are under increasing pressure from consumers, grassroots and community organizations, governments, and shareholders to develop and practice sustainable business practices. While individual companies’ sustainability efforts are important, a true sustainability can be achieved only if all members of a supply chain participate in sustainable practices (Xun and Dogan, 2015).Whiteing (2011), opined that, supply chains will not be sustainable if they are subject to levels of risk that cannot be managed or mitigated effectively. Accordingly, Wittstruck and Teuteberg, (2010) concluded that, companies must tackle multiple new challenges: rapid climate changes, face the negative impact of the financial crisis and the prices, deal with the growing public interest in ecology, and ensure environmental sustainability and energy efficiency in their operations.Health facilities procure and consume a wide variety of products, including pharmaceuticals, medical and building supplies, and foods. Procurement activities that promote the use of efficient materials, reduce waste, and prioritize products with low carbon footprints can create cost savings and environmental and health benefits (World health Organization, 2019) which promotes sustainability in the health supply chain.According to the UN Global Compact and Business and Social responsibility (2010), supply chain sustainability is the management of environmental, social and economic impacts, and the encouragement of good governance practices, throughout the lifecycles of goods and services with objective to create, protect and grow long-term environmental, social and economic value for all stakeholders involved in bringing products and services to market and integrate the UN Global compact principles into supply chain relationships, health institutions and companies can advance corporate sustainability and promote broader sustainable development objectives.According to the Sustainable Supply Chain Foundation, (SSCF), sustainable supply chain management involves integrating environmentally and financially viable practices into the complete supply chain lifecycle, from product design and development, to material selection, (including raw material extraction or agricultural production), manufacturing, packaging, transportation, warehousing, distribution, consumption, return and disposal to environmentally sustainable supply chain management and practices and assist organizations in not only reducing their total carbon footprint, but also in optimizing their end-to-end operations to achieve greater cost savings and profitability.Anne and Rob (2017) in their reviews of papers on relevant practices on how to implement sustainable supply chain management suggest that this question can best be organized by focusing on ensuring the organization determination for with sustainability regulations, ensuring that its internal processes and procedures are aligned with sustainability practices regulations, and external alignment in respect of buyer–supplier relationship perspective on sustainability.2. Problem StatementSustainability management practices in Ghana is an evolving area with very limited research suggesting how Ghana should transition its supply chains to be more sustainable to deliver value to its customer without any negative impact on future needs, the three dimensions of sustainability: environment, social and economic perspectives (Anne and Rob (2017).Compounding these challenges is the copious relegation and neglect of sustainability concepts and management of the health supply chain of Ghana. A cursory look at the main source document, the public procurement law of Ghana, Act 663 of 2003, as amended, Act 914 of 2016, which are supposed to provide the framework for integrating sustainability management into the already ineffective health supply chain, have very inadequate regulations and framework on how sustainability issues should be handled when conducting procurement, transportation, storage and distribution, disposal and reverse logistics of health commodities. Further to this point, Mensah and Amoyaw (2012), in their research on sustainable procurement management in Ghana, found out that, among the procurement and supply chain practitioners, very few understand Sustainable Procurement as the kind that encompasses the environmental, economic and social aspects of sustainability. These issues, which are the main concerns for SP, have not been harmonized into a policy for use in the Ghana. This poses a challenge to the practice of SP. It was further established from Mensah and Amoyaw, (2012) that the lack of understanding of the SP Concept and the higher initial costs associated with SP were identified as the major challenges that face SP practice in the Ghanaian procurement landscape. Their research could not address the health specific sustainability management leaving a GAP in that regard worth researching.  In a related research by Mathew, (2012), on sustainable procurement in developing countries, it was noted that there is no clear understanding of the concept of sustainability and how it is related to the procurement process. A review of research that has been carried on this subject depicts that sustainable procurement has been studied more in the manufacturing sector, and less in the public and service sectors like health. It is also crystal clear that studies on sustainable procurement have been evident in the developed countries (including UK, USA, German, Spain, etc) and this success is largely because of the well-designed regulatory framework and enforcement. Mathew concluded by suggesting future research should consider sustainable procurement practices in the perspective of developing countries since these have had less representation in literature that exists on the subject. Mathew, (2012) research only looked at the procurement process which is just a component of the health supply chain which much have an end to end assessment of sustainability practices.Ghana’s sustainable procurement and supply chain management has been without challenges ranging from funding, human resources capacity, regulations, and political will to prosecute the sustainability agenda in all government procurement and supply chain operations. This challenge saw the support of the Swiss-Ghana Sustainable Public Procurement Project, is a three year project being implemented by the Public Procurement Authority and financed by the Swiss Government with a $2.7 million grant. The project’s aim is to improve the public procurement practices of the Government of Ghana by introducing sustainable public procurement. The project will achieve its aim through: The establishment of the Ghana Task Force on Sustainable Public Procurement-a multi-stakeholder group to lead the process of introducing sustainable public procurement. Ghana Task Force on Sustainable Public Procurement, Development of Government Policy on SPP, Awareness creation programmes for public organizations, procurement officers and procurement boards on SPP, Training of procurement officers, practitioners, consultants on SPP, Re-design of Standard Tender documents, Training private sector on SPP (SPP.PPA Ghana, 2012).Furthermore, Mingu et al., (2018) in their research also validated the problem of sustainability management in supply chains to include poor sustainability management practices in the supply chains of organizations which lead to disappointing sustainability performance, and there opined the importance of ensuring that there are adequate measures to effectively implement sustainability management practices that will achieve the desired overall sustainability performance in a supply chain. It is worth tackling sustainability practices from intra-organizational or institutional and inter-organizational or institutional perspectives such that, the combined efforts will deliver an end to end sustainability management practices in the supply chains.Gimenez and Tachizawa (2012) suggested that both internal and external factors enabled firms to facilitate sustainability practices. They defined enablers as the factors that assist firms in achieving sustainability practices. Internal enablers include but are not limited to the firm’s environmental commitment, top management support, resource availability, purchasing personnel’s supply management capability and proper performance measurement systems. External enablers include supply chain-related capabilities such as trust, national culture and logistical and technological integration. However, an assessment of the Ghanaian context of sustainability management practices indicates that Ghana is far from these sustainability management practices.It is against this background this research is proposed on the topic: towards a sustainable health supply chain in Ghana: an assessment of the upstream and downstream operations. This is intended to comprehensively assess the upstream and downstream operations of the health supply chain actors: from manufactures and importers of drugs and non-drugs commodities to the final users, that is the hospitals, customers and those customers that receive the prescription to understand how each of these functions of supply chain handles sustainability aspects of the supply chain.     Conceptual Framework Proposed Research ObjectivesSource: Researcher’s own construct3. Research ObjectivesThe main objective of the research work is to conduct a comprehensive assessment of the upstream and downstream operations of Ghana health supply chain towards a sustainable health supply chain. The research sought to achieve the following specific research objectives proposed to realize the general objective stated above.To examine the operations of the health supply chain of Ghana.To identify the key stakeholders operating in the Ghana health supply chain and their sustainability practices in their operations.To assess the sustainability compliance of the downstream and upstream operations of the key stakeholders in the Ghana health supply chain.To assess the moderating effect of internal and external regulations, procedures and on achieving sustainable health supply chain in Ghana.4. Research Questions ProposedHow is the health supply chain of Ghana operated?Who are the key stakeholders operating in the Ghana health supply chain?Are the downstream and upstream operations of the key stakeholders in the Ghana health supply chain sustainability compliant?Does internal and external procedures, regulations and laws have any effect on sustainability compliance? 5. Significance of the StudyThis study is very significant as it seeks to unearth more knowledge and insight into the subject of sustainability management in the health supply chain of Ghana, and contribute to the Sustainable development goals of the united nations of which Ghana and Norway are advocates for the implementation.The findings of the study will be of relevance to academia; especially those who may wish to carry out further research on sustainability management in public and health sector in Ghana and Africa as most of the current research in sustainability skewed to the developed world.More so, the study will contribute to the body of knowledge in sustainability research.The anticipated findings of this research will make recommendations to specific management implications on the enforcement and compliance to sustainability issues in the health supply chain in Ghana and the benefits of such compliance leading to an improved standard of living of the citizens of Ghana.The findings to objectives of examining the moderating effect of compliance to internal and external procedures, regulations and laws will promote sustainability performance of most private and public health organizations in Ghana.6. MethodologyMulti-research design will be applied in this research. Survey and Case study are to be used in the design of the research where appropriate to ensure a well-balanced and quality data is obtained for the research. A survey research encompasses any measurement procedures that involves asking questions of respondent to solicit their views on the phenomenon being studied. They are usually quantitative in nature, systematic, impartial, representative, theory-based and replicable (Lynda, 2007). The case study design is to be used in this research to enable the researcher to use multiple sources of data and a variety of research methods to explore the research questions which, in turn, foster the validation of data through triangulation. This ensures that the issue is not explored through one lens, but rather a variety of lenses which allows for multiple facets of the phenomenon to be revealed and understood. The study will, where appropriate, Descriptive studies to focus on describing the characteristics of the phenomenon understudied while and Explanatory studies to address cause-and-effects relationships between variables. 7. Study Population, and Sampling MethodsThe Study population proposed, will cover the manufacturers, importers distributors/wholesalers of drugs and non-drugs consumables, Central and regional medical stores, selected regional and district hospitals incorporating private faith based health institutions in Ghana. A mix approach will be adopted in the sampling of the respondents for the research. The researcher will employ convenience or purposive sampling techniques in sampling the respondents where appropriate. The reason being that, most of the targeted respondents to be elected from the population have some specialty and expertise in their respective fields and the population have heterogeneous features. A random sampling approach will also be used where appropriate should the research needs change in that regard.8. Data Collection Methods Primary sources and secondary sources will be the main source of data to be used for the study. Questionnaire (where appropriate, electronic or mail questionnaire and telephone interviews) will be used to collect the primary data. Secondary data on the research topic and associated variables will be gathered through the reviews and analysis of published research articles, journals and other print and electronic sources that may be relevant for the study.The questionnaire will cover the key variables to be measured to be able to obtain the relevant data for the analysis to establish the key relationship between the variables. The questionnaire will be designed using the appropriate 5 point Likert scaling with key variables, constructs and sub-constructs for the respondents to choose from.A combination of mixed approaches (field visit face-to-face self-administration of the questionnaire, electronic or mailed questionnaire to the targeted respondents) will be used for the questionnaire administration. Some research assistants will be recruited to aid in the distribution of the questionnaire where appropriate.The questionnaires for each respondent group will be self-administered. Those to be administered to the patients will be done on one-to-one basis to the respondents willing to fill or provide answers to the questionnaire at the entities premises with the help of a field assistant to be recruited. In the case of the staff, the researcher will distribute the questionnaires to them and collect them back at a later date to be agreed in line with the research time line set for data collection. The questionnaires will be pre-tested to ascertain their validity and reliability when deployed for the main research. The findings from the pretest will help in amending where appropriate, areas that does not guarantee validity and reliability of the variables being measured.9. Data Analysis and PresentationIn analyzing the data to be collected for the study, quantitative data analytical techniques and procedures will be employed. Prior to analyzing the data, the questionnaires to be received from the field will be examined, cleaned and edited before they are entered into the statistical packages to be used in the study. Both descriptive and inferential statistical tools will be used. The basic descriptive statistical tools to be employed will be frequencies, means, and standard deviations. Due to the large nature of the sample size being envisaged, Structural Equation Modeling (SEM), will be used for the analysis to explore deeper into the relationship between the variables. In estimating the study’s theoretical framework, exploratory factor analysis, correlational analysis, and ordinary least square regression analysis will be employed. The results of the analysis will be reported in tables and figures where appropriate. SEM, SPSS and Microsoft Excel, where appropriate will be used to aid in the data analysis.11. Limitation of the StudyA number of limitations have been noted regarding this study:The first limitation for this research work will be that, sustainable supply chain management areas are broad and covers several topical issues of business life, but this study will be limited to health aspects of sustainability management of supply chain operations. The research will cover the relevant literature that deals with how sustainability issues should be incorporate in every facet of the health supply chain covering the upstream and downstream of the supply chain. It will assess sustainability issues based on the upstream and downstream supply chain of the stakeholders in health supply chain in Ghana. It will also cover the regulations and legal frameworks compliance assessment which are moderating the application and implementation of sustainability in supply chains. Time limitation will be a constraints which will make it impossible to cover many institutions and stakeholders which would have given a broad exploration and analysis of the research variables. Financial and other related resources constraints are also factors that will limit this research work. Research works comes with cost and other needs hence the limitation of the research.12. Organization of the ResearchThis Research Work will be divided in to five chapters. Each chapter will be dedicated to a specific issue. Chapter one will be the introduction. It will deal with the background of the study, the statement of the problem, the objectives of the study, the research questions, significance of the study, scope of the study, methodology, among others.Chapter two will deal with the Literature Review. In this chapter, the researcher will look at or examine the views of other authorities on the subject of health supply chain and sustainability issues. It will cover the views of other writers of the subject in relation to the research objectives. The hypothesis will equally be dealt with the relevant literature to support them.Chapter three will discuss in detail, the design of the research work. It will discuss the research population, samples and size, the data collection methods, sampling methods to be employed for the study, data analysis methods and applicable tools and software.Chapter four will present the details of the data to be collected. This chapter will set out the decision rule for accepting or rejecting the outcomes from the questionnaires. It will provide the discussions on the findings of the research and hypothesis reporting.Chapter five which will be the final part of this study will provide a summary of the findings and conclusions of the study. 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