Data analysis included 792 initial codes that after a continuous comparison of these codes and the raw data considering similarity and differences, the similar codes were categorized and labeled in a category. 209 categories were created and after integration they were summarized in 30 subthemes and 8 themes (Table 1). The present results have led to “wasting” of the pharmaceuticals and consumable medical equipment during natural disasters as the main phenomenon of the research (Fig. 2).
Disaster management structure
Disaster management structure is considered as an important determinant in managing pharmaceuticals and consumable medical equipment supply chain during disasters. This main theme contains 5 subthemes of infrastructure standards, health system potentials, appropriate designing of the structures, supply chain stewardship, unique command and initial actions.
About the structure standards, one of the participants declared that:
“If the health centers encountered the earthquake, they would not have enough consistency. In the experience of Sarpol-e Zahab earthquake those governmental buildings of the health centers had sufficient consistency against those of private or charity sectors that do not have so much solidity” [P3].
About utilization of the health system potentialities, another participant added:
“One strength point in our country is the existence of healthcare centers and hospitals with near distances, because of this, we always have amount of medicine and medical equipment even for the consumption of several months according to the condition and numbers of referees” [P7].
Appropriate designing as another subtheme was mentioned here:
“Right at the earthquake night a comprehensive team of medical university and drug and food deputy was attended as a disaster in governors’ office but the promptitude was not enough. It seems that the present structure does not have enough efficiency and should be redesigned” [P23].
Kermanshah earthquake has implied the importance of unique command and stewardship of pharmaceutical and consumable medical equipment during disasters. In this regard, a participant said:
“In early 24 h the needed structures were made and food and drug deputy was assigned as the steward of medicine and medical equipment’s distribution to the damaged areas” [P17].
Information in disasters can help to identify the local condition and problems in order to assess the needs and better management of supply chain. The related subthemes in this regard were: comprehensive information of the managers, appropriate need assessment and creating an integrated information system.
Comprehensive information of the managers considers very important during disasters and should be reached via training the managers with principles of disasters and consistency of the management. One participant declared that:
“A person should be responsible of a supply chain that has enough experience and is aware of the process. Such a person can act more rapidly than those who do not have necessary experience and specialty” [P5].
According to the present results, inefficient structure of need assessment was an obvious problem in Kermanshah earthquake. A participant said:
“During disasters, food and drug deputy as an agent of Ministry of health should assess the pharmaceutical needs and allocate local and national resources to these requirements, but unfortunately this is not happened in reality” [P7].
An integrated information system is among the most significant information management principles during disasters. A participant clarified:
“There was lack of integrated information system and unique management. The only thing that we really required was a management unit that can integrate the information with online monitoring, assess daily needs and plan for them…” [P12].
Supply chain supervision
The need of supply chain supervision is obvious during disasters because of preventing probable abuse and readiness for encountering the contagious outbreaks. The related subthemes were as follows: pharmaceutical distributors’ offending, controlling the probable outbreaks, controlling of the local condition and respecting safety principles. Regarding the conflict of interest toward the pharmaceuticals and medical equipment suppliers and distributors, the possibility of corruption and offending during disasters is not unexpected. In this regard, one of the participants clarified his experience:
“If we do not check the delivered packages, the distributors may send whatever they want to the damaged areas without considering our needs. This condition may include fake recipients of the items, sending expired medicines or those with only a short shelf life” [P3].
Controlling the epidemics in damaged areas regarding the geographical and critical circumstances of the field should be sped up. One participant declared:
“The needs may become different second by second according to the condition. In Sarpol-e- Zahab we have experienced epidemic crisis the same as prevalence of Cutaneous Leishmaniasis that needs extra requirements to be controlled the same as environmental interventions, poison spraying, etc.” [P25].
Management and control of the local condition during crisis was among other important subthemes. One of the participants stated:
“According to the climate and seasonal needs, the condition became different. The requirements of the damaged areas were greatly related to the type of crisis, severity of the disaster, the volume of collapse, the population and geographical conditions. All these variables can affect the management of the supply chain” [P29].
Finally, health care workforces’ respect of the safety principles during service delivery was among other subthemes. This subtheme becomes more considerable knowing the psychological problems affect the personnel during disasters. One participant remembered his experiences as follows:
“In such a condition many of the healthcare workers may attempt to do some think because of their empathy and emotional forces, in this regard, if a shortage is occurred or a new problem is emerged, they may forget about the safety procedures and try to help under any circumstances” [P11].
Cultural and social factors
One of the other determinant factors affecting the resilience of pharmaceutical and medical equipment supply chain is the sociocultural characteristics of the damaged areas that can affect the improvement of resource allocation and relief process or worsen the condition. According to the present results, level of literacy, employment, age, religion and the expectations and requests of the damaged people from the healthcare system are among the important sociocultural factors. In this regard, one of the participants added:
“The cultural of the people in damaged areas is a determinant factor in disaster management. For example, if they have ever experienced similar condition or the level of expectations. Of course in rural and retrieved areas, it becomes manageable easier than the metropolitans with higher expectations of the citizens and their resistance to change” [P19].
Planning was a key determinant that was considered in all the interviews. The participants indicate lack of planning in pharmaceutical and consumable medical equipment supply chain. The related subthemes were: non-integrated service delivery, importance of decision-making and necessity of planning.
The participants have claimed that healthcare system may experience a shock caused by the disaster. This shock can affect the potential of resilience of the system and may lead to non-integration and disorder. One participant said:
“In many disasters as well as Bam, Bushehr, Azerbaijan and Kermanshah earthquakes, we have faced anarchy particularly in 2–3 initial days. This chaos can lead to the system’s shock. So in this way we cannot have an integrated information system about the real needs, exact estimation of the damages and the affected population as well. All of these may cause lack of integrated services by different organizations during disasters” [P4].
The necessity of urgent and significant decisions is among main characteristics of critical conditions. But the present results indicate the wrong, delayed and arbitrary decisions in many situations. One participant noted:
“unfortunately we always postpone the decision-making to the disaster condition rather than predicting and preparing before that. So in such an emergency condition we are forced to decide promptly and in a hurry” [P21].
The participants have indicated the inefficiency and inappropriateness of their organizations’ action plans for real crisis. One participant added:
“we do not have a systematic national plan for disasters. We may conduct workshops and meetings but an executive plan is missing always. As a result, in disasters, the organizations act separately and according to their local instructions” [P9].
The present results have emphasized the importance of financial and manpower resources during natural disasters. The main subthemes here are as follows: resource shortage, supply chain management, donation management and workforce management. According to the participants, the access to health services may decrease regarding the type and severity of the crisis and shortages may be highlighted. One participant exemplified:
“pharmaceutical system among all other health care sections allocate a considerable amount of costs so during disasters, the consumption of medicines and consumable medical equipment may increase and the shortages will be occurred” [P16].
The participants have mentioned supply chain management as a determinant factor in resource management during disasters. A participant affiliated in a military organization clarified:
“as an allied organization, we can help the healthcare organizations during disaster but our main responsibility is not health service delivery and we cannot procure all pharmaceuticals and medical equipment requirements” [P13].
Another finding was donations. Some part of these gifts delivered from all over the country was not practical and necessary and some of them were over the needs. A participant said:
“many of the donated items were out of our control and cannot be organized. For example, 20 packages of gloves were sent that we did not really need. Many other items that were donated from all over the country also were not needed and we did not even have the condition for their storage” [P20].
About another subtheme, human resource management through supply chain, we should point to two sections of specialists’ management and the management of the volunteers. A participant added:
“If there was a documented plan for the actions along with the trained workforces, the problems could better be managed. We needed trained volunteers with adequate familiarity with the condition of damaged areas and their culture and even language” [P31].
Health service coverage
Health service coverage was divided to four related subthemes as follows: supply chain restrictions, health insurance coverage, healthcare system efficiency and access to health cares. According to the participants, supply chain restrictions included distributive restrictions and legal requirements. A participant said:
“when we had 2 or 3 destinations for medicines, our logistic potentiality was decreased for appropriate distribution” [P13].
Increasing the costs of services during disasters requires a rapid intervention of insurance organizations. In this regard, another participant added:
“We had all the services freely in the first month after earthquake, but in the second month, we tried to relate the population needs with their insurance coverage. Many of the injured people had an insurance coverage but unfortunately their needs were not reimbursed by the insurers and the Ministry of Health had to pay” [P8].
Inefficiency of the healthcare system was among another subtheme that was made because of increasing in load of services and unneeded referrals. A participant pointed out:
“the volume of patients was great during the earthquake and the other provinces helped us a lot. At the same time, collapse of health infrastructures imposed a great load of actions to our governmental and even private centers. All the surgeons were on call 24 hours… all of these along with the emotional and psychological dimensions led to system’s inefficiency” [P11].
Transportation problems also had led to barriers in physical access to pharmaceuticals and medical equipment supply chain. One participant stated his experience as follows:
“that night when we were on a way to deliver medicines and medical equipment to Sarpol-e-Zahab, the landside was happened and the rural ways were chocked. This collapsed the process of relief and unfortunately we missed that vital hours” [P10].
Wasting was the main and core determinant in the study. This was the most intellectual theme that joins all the other themes to each other. According to the participants, wasting includes all the waste and overuse that occurred in human resources, financial resources and time. In this regard, one of the participants emphasized on the wasting of financial and human resources as follows:
“we had a good access to workforces and volunteers with high level of energy but unfortunately we could not utilize and manage these valuable sources” [P5].
About financial wasting, another participant added:
“although we have a rich country, we are not able and trained to save. In Kermanshah earthquake we really did not have serious resource shortages but the main problems were appeared in resource allocation” [P17].
And finally, time wasting was among the other subthemes. A participant declared that:
“we always act and decide in a hurry so we waist out main capital, time, if we were ready before disaster, we never behaved in a try and error way that caused wasting our golden time” [P11].
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