1. Introduction
There is a major discrepancy in the global economic market; private-sector companies continually seek to reach economically well-off consumers, while simultaneously ignoring a vast majority of the world population, estimated to be over four billion [
1]. The base of the pyramid (BOP) concept, first theorized by Prahalad and Hart [
2], argues that top-of-the-pyramid (TOP) consumers are the targets for most products and services offered by corporates, while a large part of the BOP population does not have access to goods and services. In its early conceptualization, BOP was defined as the basis of consumers living with a per capita annual income of less than 1500 United States dollars (USD), while TOP consumers (estimated around 75–100 million) live with more than 20,000 USD per capita annual income [
2]. Currently, BOP includes approximately four billion people living with less than
$9.05 per day, of which around 2.6 billion individuals earn up to
$2.00 per day [
3,
4,
5]. However, it should be noted that, while numerical thresholds vary with contextual conditions and with the idiosyncratic definitions of poverty, BOP commonly identifies those individuals that rely on informal economies and are generally excluded from the capitalistic systems and relevant decision-making processes [
3,
6].
BOP proponents argue that private-sector involvement in the BOP market would lead to poverty eradication and improvement in the quality of life [
1,
2,
7]. This view gained momentum in the last few years, particularly after the United Nations’ (UN) release of the 17 Sustainable Development Goals (SDGs) in support of the development agenda 2015–2030. The SDG framework emphasizes how (private) organizations can—and should—contribute to addressing complex societal issues or grand challenges [
8], which are rooted at multiple societal levels—social, organizational, and individual. Particularly at the organizational level, the sustainability view redefined performance as a balance between financial, societal, and environmental objectives, also known as the triple-bottom-line (TBL) framework [
9,
10,
11], which is recognized as providing an alternative to the neoliberal, profit-maximizing paradigm [
12].
Promoting health and well-being of disadvantaged communities living at the BOP holds a prominent role in the UN’s sustainable development agenda as SDG 3 (Good Health and Well-Being) and is closely related to SDG1 (No Poverty), SDG2 (Zero Hunger), SDG4 (Quality Education), and SDG8 (Decent Work and Economic Growth). Hunger and living in poverty are often due to a lack of formal or appropriate employment, which is associated with low educational levels. Poverty, in turn, is argued to lead to ill health because it prevents people from obtaining the necessary means to ensure good health [
13,
14]. Ill health further adversely affects the financial conditions of the poor, owing to high healthcare costs, loss of wages, and a greater vulnerability to catastrophic illnesses [
15]. It is estimated that excessive healthcare payments are one of the main contributors to poverty [
16]. Hence, providing access to healthcare directly translates into greater welfare for the BOP population [
7]. As a result of the circular relationship between poverty and ill health, the initiative of private healthcare providers in resource-constrained areas could result in a positive change by improving access to healthcare, thereby improving the overall well-being of the deprived population [
17]. Private business initiatives in the healthcare sector targeting disadvantaged communities provide ideal examples of TBL organizations or social enterprises, in the sense that they pursue financial sustainability while at the same time improving the socio-economic conditions of the target communities [
18].
However, to be able to generate such outcomes, private healthcare providers aiming at targeting BOP patients need innovative, socio-culturally sensitive business models. The health-seeking behavior of BOP consumers presents unique dynamics and is depicted as a complex nexus of, among others, gender, marital status, socio-economic conditions, type of illness, type of available healthcare facility, age, and social role [
19,
20]. The institutional divide, i.e., the distance in social norms, cognitive frames, and normative values between service providers and recipients, is high in the case of BOP consumers [
21,
22] and particularly exacerbated in the case of healthcare services [
23]. Among the BOP population, healthcare needs are often not recognized or ignored because of poor health literacy and fear of social stigma [
24,
25]. Hence, interventions which can educate the BOP population to recognize their health needs, become aware of accessible and affordable solutions, and improve their illness disclosure and health-seeking behavior are needed. Prior work documented how business models that succeed at reaching BOP consumers often display co-creation approaches [
26,
27], which become even more salient in the healthcare domain [
23]. Business models of private healthcare providers need to stem from an in-depth understanding of the health-seeking behavior of target groups, and need to leverage a vital phase of value discovery, which is defined as a “co-creation process through which the healthcare need is identified by the patient and by the organization together” [
14,
23].
In line with this thread, the present study explores the determinants of BOP patients’ choice of public vs. private hospitals in an Indian setting, with the primary aim of providing deeper insight into BOP health-seeking behavior and, hence, promote a co-creation approach to the development of new business models aimed at inclusive healthcare delivery. While prior quantitative studies highlighted the relevance of specific provider attributes within BOP individuals’ choice of public vs. private providers (e.g., Reference [
28]), this study is particularly interested in unveiling the decision-making process leading to specific choices, and the relative balance of socio-cultural and socio-economic factors underpinning health-related decision-making in slum settings. By comparing the perception of BOP consumers toward private and public health providers, this research intends to shed more light on which of the two healthcare delivery models is most appropriate because of its higher match with the socio-cultural expectations of BOP patients, in turn, related to their idiosyncratic conditions. The current study, therefore, pursues an answer to the following question: How do BOP patients choose between public and private healthcare providers?
The research setting of the present study is particularly relevant. The Indian healthcare market is composed of a mix of private and public healthcare providers [
29,
30], although the private sector is predominant. Public health expenditure in India is among the lowest in the world, with only 1.4% of the GDP [
31], while out-of-pocket expenditure takes up 62.4% of the total expenditure on health [
32]. There is a large need for investments in healthcare, as the current healthcare facilities are deemed insufficient [
33]. It was argued that Indian patients prefer private over public healthcare, despite the downsides of high costs and, at times, sub-optimal quality. Peters et al. [
34] found that 39% of private-sector hospitalizations are accounted for by the population in the lowest income quintile, despite their limited financial resources. This choice arguably has the potential to push BOP households further below the poverty line. Therefore, understanding the reasons behind BOP patients’ hospital choice is critical to help public healthcare providers improve the perceived quality of their services and, in general, better attract BOP patients to more affordable healthcare providers.
This research aims at advancing existing knowledge about BOP and social entrepreneurship in healthcare, particularly examining the gap between patients’ socio-cultural expectations and the organizational models in place. Although a few studies were conducted so far on specific companies delivering healthcare products or services to the BOP [
23,
35], there was little research on the customers’ perspective in relation to the available healthcare providers in BOP settings. This perspective is especially relevant as it can contribute to a better understanding of the needs and health-seeking behavior of the BOP consumers, thus helping bridge the socio-cultural gap between available models and patients’ expectations, and inform new, more culturally sensitive and acceptable business models based on co-creation approaches.
The remainder of the article proceeds as follows:
Section 2 addresses the theoretical background of the study, by providing an overview of the academic literature related to health-seeking behavior at the BOP, to consumer choice at the BOP, and to recent developments of the BOP managerial paradigm.
Section 3 describes the methodological design and the techniques for data collection and analysis used for the qualitative and quantitative phases of this research.
Section 4 presents the results and distinguishes between quantitative findings—in the forms of tables and quantitative tests—and qualitative findings—shown using interviewees’ quotes and coding process.
Section 5 discusses the results in light of previous work and presents the grounded theory model of BOP patients’ health-seeking behavior that emerged from our qualitative work.
Section 6 illustrates the contribution of our study, together with its academic, managerial, and policy implications.
Section 6 also presents the limitations of this research, along with the directions for future research. Finally,
Section 7 provides conclusion of our paper.