Journal of Macromarketing

http://jmk.sagepub.com Rising Markets and Failing Health: An Inquiry into Subaltern Health Care Consumption under Neoliberalism
Rohit Varman and Ram Manohar Vikas Journal of Macromarketing 2007; 27; 162 DOI: 10.1177/0276146707301333 The online version of this article can be found at: http://jmk.sagepub.com/cgi/content/abstract/27/2/162

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Rising Markets and Failing Health: An Inquiry into Subaltern Health Care Consumption under Neoliberalism
Rohit Varman and Ram Manohar Vikas

This research highlights some of the fundamental weaknesses in the market-based economic approach for a developing society. This study of health care consumption by subaltern groups in India reveals that consumers believe that greater reliance on a market-based system has contributed to a decline in the state health institutions, proliferation of private clinics, and a close physicianpharmaceutical firm nexus. Accordingly, instead of creating a more efficient system of health care delivery, market forces are instrumental in marginalization of the subaltern sections of the population. Ramifications of these findings include a suggested expansion in quality of life marketing framework to include the concept of consumer empowerment with specific emphases on dimensions of control and exclusion. Keywords: health care; development; quality of life; subaltern consumers; neoliberalism

focused on specifically. In concurrence with the interpretation of hegemony by de Certeau (1988) and Scott (1990), this research demonstrates a high level of consumer consciousness. However, this consciousness does not translate into consumer empowerment. Utilizing the framework developed by Lukes (1974), this article illustrates the significance of the dimensions of control and exclusion under neoliberalism in the consumer disempowerment process. This interpretation has possibilities for the expansion of the quality of life (QOL) marketing framework.

THEORETICAL CONSIDERATIONS Health Care, Markets, and Development Over the years an impressive body of literature has accumulated about the effects of health on development and the linkage between health and economic development (Barro 1997; Fogel 1994). It can be safely said that health is a productive asset that significantly influences economic growth (Sen 1999). We live in a world of ubiquitous markets, which negotiate most aspects of modern-day consumption. Increasingly, consumption of health care is no exception. It is necessary to understand the emphasis placed on the growth of the market-based health care delivery system because traditionally welfare state mechanisms attempted to perform the role of health care provider. The marketbased governance of health care institutions is a relatively recent phenomenon in many countries across the world, including India. This shift is a part of the general nature of global capitalism, which has witnessed a rise in neoliberalism in the last two decades (Kilbourne 2004)essentially the belief in markets to optimize societal welfare (Kurien 1994; Stiglitz 2003). More fundamentally, this trend may be seen as an attempt to render human existence as part of
Journal of Macromarketing, Vol. 27 No. 2, June 2007 162-172 DOI: 10.1177/0276146707301333 2007 Sage Publications

t this moment, the notion of market occupies a particularly important space in social discourse. Markets, largely without institutional intervention and operating in an unfettered global order, are theorized to lead to the most efficient distribution of resources. In this research, by examining subaltern consumption of health care in India, the efficiency myth of the markets perpetrated by some development theories is systematically questioned (Etzioni 1988; Polanyi 1947; cf. Stiglitz 2000, 2003). Through this case study, it can be suggested that subaltern consumers believe that market forces can have a devastating impact on the health care system. This research furthermore shows that the current emphasis on privatization in the Indian economy is leading to a structural shift in the direction of a profitbased health care system. In the process, subaltern consumers experience marginalization and exhibit serious reservations about this shift. In this examination of the impact of neoliberalism on health care consumption, the issue of disempowerment is

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markets, with every social act an act of instrumental exchange (Becker 1991). This research specifically examines the impact of neoliberalism on health care consumption of the subaltern population. Subaltern population is defined as a socially subordinate group (Gramsci 1971). It is important to note that although the role of economic classes is not being denied here, the usage of the term subaltern in this article attempts to transcend a rigid economistic class analysis (Lal 2001). It can be argued that in any society there are several organizing principles, such as race, caste, gender, age, capital, etc., and it is simplistic to examine subaltern groups narrowly from only the economic perspective. Comparatively, the delineation of the concept of capital into the categories of economic, social, and cultural offers a richer and more nuanced understanding of the coordinates of differentiation and subordination (Bourdieu 1986). Quality of Life, Health Care, and Markets Several macromarketing scholars have questioned the efficacy of markets, controlled by private enterprise, in ensuring consumer well-being (e.g., Belk 2000; Kilbourne 2004). Theoretical developments in the domain of QOL are partly a result of this concern (Sirgy 1996, 1998). Assessing quality of life indicators, Sirgy et al. (1991) have established a positive relationship between overall satisfaction and life and health care satisfaction. Good health as an indicator of quality of life is recognized as an end in itself, valued by those who own it and considered a significant dimension of modern civilized societies. Extending this concept to the level of national well-being, Hagerty et al. (2001) argue that QOL encompasses the domains of relationships with family and friends, emotional well-being, material well-being, health, work and productive activity, feeling part of ones local community, and personal safety. Similarly, making an attempt to put a standardized framework of assessment on international progress, Estes (2000) has developed ten subindexes of education, health status, women status, defense effort, economic, demographic, geography, political participation, cultural diversity, and welfare effort. These works are of relevance for this articles theorization because of the importance attached to the dimension of health care consumption and its linkages with the concepts of individual and societal well-being. Given the critical nature of health care consumption, the framework of QOL marketing with its concern for enhancement of consumer well-being is particularly significant (Lee and Sirgy 2004). It is emphasized that among the environmental factors, social consciousness related to consumer well-being is an important antecedent

for QOL marketing (Lee and Sirgy 2004). Here, Lee and Sirgy (2004, 52) describe social consciousness as the degree of a societys sensitivity to the well-being of consumers. Accordingly, high consciousness translates into stronger norms for business conduct and safeguards for consumer welfare. In other words, a socially conscious society does not allow firms to generate unfair profits. Conversely, low consciousness results in higher tolerance for compromise with consumer well-being and unfair profits (Lee and Sirgy 2004). Although the description of antecedents and consequences of QOL marketing is an insightful framework, the concept of social consciousness requires a deeper analysis. Social consciousness can be interpreted as awareness about socioeconomic reality and the ability to make informed decisions by consumers. Conceptually, consciousness in this form extends from individual consumer awareness to collective social norms and societal regulations. Here, ability or power to influence market behavior is implicit in the approach towards consciousness suggested by Lee and Sirgy (2004). Thus, a richer understanding of underlying ideas of norms, consciousness, and power is necessary to further this conceptualization. It is noteworthy that several scholars have emphasized the importance of norms in shaping and controlling any social or economic interaction (e.g. Elster 1989; Macaulay 1963; Sherif 1936). The authors of this article follow Macneils definition of norms as A principle of right action binding on the members of a group and serving to guide, control, or regulate proper and acceptable behavior (1980, 38). Theorists have identified a close relationship between norms and consciousness in any society. Here the assertion by Lee and Sirgy (2004, 5253) that A society characterized as high on social consciousness is one that has strong norms regarding how business should be conducted is partly covering the relationship that exists between the two concepts. Norms and consciousness are characterized by interpenetration of each other with ontological priority of one over the other difficult to determine. This interpenetrative relationship implies that individual consciousness leads to formation of norms, which in turn shape the consciousness of consumers. A significant part of this relationship is the concept of power that influences the interaction between norms and consciousness. One part of this interplay among consciousness, norms and power is captured by the conflict school on the origin of norms. The conflict school views norms as reflecting the historical or present power of a group (Gibbs 1968). Axelrod (1986) suggests that dominance plays a significant role in formation of group norms. Accordingly, a dominant group, wielding power, can impose certain desirable behavioral characteristics on a larger group.

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The other part of this interplay is captured by the three underlying dimensions of powercontrol, exclusion, and hegemony (Lukes 1974). Control implies that consumers or marketers have the ability to direct markets for their benefits. This entails observable forms of conflict and overt bias in favor of one over the other. The second dimension works on the principle of exclusion of issues or barriers to participation in the decision-making process by those wielding power. This dimension features not only a bias for the exclusion of the weaker sections, but also a control of their agenda. The first two dimensions can involve overt use of power and ability to control decisions through use of force (Lukes 1974). The third dimension of hegemony involves internalization of power structures and influence at the level of consciousness to resist other actors. Theoretically the concept of social consciousness is closely linked to the third dimension of hegemony with its rich history of debate about the true or false nature in the subaltern context (de Certeau 1988; Gramsci 1971; Scott 1990). In this study we place special emphasis on the role of control and exclusion in influencing QOL marketing in health care markets. Here, it has to be understood that consciousness does not necessarily translate into the power to shape markets. In other words, from consumers perspective the first two dimensions of exclusion and control are also necessary to shape markets for their well-being. It is particularly relevant to understand the role of these dimensions and their structural relationship with markets in the context of health care and QOL studies. Market as a system of exchange essentially responds to buyers with purchasing power. Marketers in their quest for greater profits primarily reach out to consumer segments with greater resources, excluding poorer consumers in the process. This imbalance is controlled through legal structures and is legitimized through the discourse of neoliberalism (Chossudovsky 1997; Stiglitz 2003). Kurien adequately draws linkages between markets and capitalism describing this relationship as follows:
Capitalism does not recognize consumers or their need to consume. Its concern is with purchasers, precisely because their power to purchase is what keeps the system going . . . The critical role played by the market under capitalism is to provide the arenas where those who seek profits realize them. (1994, 7; emphasis in original)

of consumers to overtly restrict and exclude unfair profit seeking behavior of these players. Several theorists have argued that the dominance of markets under the neoliberal phase of capitalism restricts consumer power because of limited participation of state institutions in governing exchanges (Chossudovsky 1997; Kurien 1994; Stiglitz 2003). States with investments in welfare programs and health care infrastructure traditionally provided a safeguard and an alternative to a profit-based market system. In the neoliberal era this alternative arguably has been systematically eroded under the aegis of the World Bank and the International Monetary Fund (IMF) in most of the less developed world and particularly in India (Kurien 1994). Based on the review of extant theory, it appears that clearer understanding of the antecedents for QOL marketing requires an appreciation of the role of consumer empowerment and its systemic linkages with a market-based system of governance. In summary, the neoliberal doctrines profess a consumerfriendly nature of global market system. Considerable emphasis is placed on efficient functioning of markets in this paradigm. Health care is one of the critical determinants of quality of life and requires high levels of social consciousness for markets to be effective for the subaltern consumer groups. Consumer empowerment for creation and adherence to appropriate norms is necessary for QOL marketing to be effective. Examination of extant theorization on empowerment suggests that consciousness has to be supplemented with the dimensions of control and exclusion for a better understanding of the phenomena.

RESEARCH SETTING In India nearly 26 percent of the people live below the poverty line (Deaton 2003). A recent study by the National Council of Applied Economic Research reveals that the richest 20 percent enjoy three times the share of public subsidy for health compared with the poorest quintile. The poorest 20 percent of Indians have double the mortality rate as compared to the richest 20 percent (Misra, Chatterjee, and Rao 2003). In spite of the appalling standards, the Indian government spends 0.9 percent of the gross domestic product on health care. On an average, the subaltern population spends 12 percent of its income on health care, as opposed to 2 percent spent by the rich (Misra, Chatterjee, and Rao 2003). As a result of this, research findings show that more than 40 percent of the hospitalized patients in India borrow money or sell assets to cover expenses, and in the process, 35 percent fall below the poverty line (World Bank 2001). In a society with such high levels of poverty, the role of the state in guaranteeing adequate health care for the subaltern population is critical. This concern has gained particular significance in light of the structural adjustment program initiated by the Indian government in the early 1990s under the

This issue is important because of the relationship between poverty and ill health. Evidence from across the world indicates that ill health disproportionately afflicts the subaltern groups, especially because of their lack of insurance against medical emergencies and their inability to access health care markets (World Bank 1993; see also World Bank 2006). Thus, to make health care accessible, civil society and consumers should have the ability to control the profit orientation of pharmaceutical firms and physicians. This requires empowerment

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guidance of International Monetary Fund and the World Bank. Similarly, to many other parts of the third world, the structural adjustment program has meant reduction in the expenditure on welfare by the state and increase in the dominance of private enterprise and market forces in the country (Kurien 1994). The India Health Report prepared by Misra, Chatterjee, and Rao (2003) is a strong indictment of the state and the forces of privatization. Accordingly, in the last two decades, with the dominance of the neoliberal agenda, state expenditures on health care has declined from 67 percent to 5 percent of total government spending. This decrease has happened at a time when treatment costs measured through average episodic expenditure have gone up from $20 to $35 in rural and $24 to $42 in urban India. This increasing cost is primarily borne by consumers, and around 87 percent of expenses are met through private financing. As a result of these rising costs, the proportion of poor who do not seek any health care has gone up from 15 percent to 24 percent in rural and from 10 percent to 21 percent in urban India in the last two decades. This study was conducted in the North Indian city of Kanpur, which is a part of the state of Uttar Pradesh. This region is one of the poorest regions of the country, with nearly 50 percent of the population living below the poverty line. Despite high levels of poverty per capita, state expenditures on health care at Rs. 18.10 (around US 40 cents) is one of the lowest in the country (Misra, Chatterjee, and Rao 2003). The state has a poor health infrastructure, with hospital beds per 100,000 population ratio of 34, one of the lowest in the country (Misra, Chatterjee, and Rao 2003). A few decades back, the city of Kanpur was one of the most industrialized and prosperous cities in the region. It had several industries such as textiles, automobiles, chemicals, and leather to name a few. However, the last few decades have witnessed flight of capital and substantial deindustrialization of the city. This has led to an increase in urban poverty and high levels of unemployment in the city.

TABLE 1 PROFILE OF PARTICIPANTSCONSUMERS

Pseudonym
Kavita Radha Sarita Sandhya Neeru Raju Raghvendra Ramesh Kamlesh Vipin Mahesh Satinder Mahendra Vivek Vikas

Gender
Female Female Female Female Female Male Male Male Male Male Male Male Male Male Male

Age
45 33 25 31 33 28 50 52 55 23 30 40 45 30 35

Occupation
Works in a laundry Homemaker Sweeper Domestic worker Domestic worker Janitor Janitor Peon Peon Works in a laundry Sweeper Sweeper Construction worker Construction worker Construction worker

TABLE 2 PROFILE OF PARTICIPANTSPHYSICIANS AND SALES REPRESENTATIVES

Pseudonym
Rajan Amit Harish Kabir Amolak Sharad Kalpana Rahul Amalan Neeraj

Gender
Male Male Male Male Male Male Female Male Male Male

Age
30 27 27 32 30 45 40 38 47 40

Occupation
Sales representative Sales representative Sales representative Sales representative Sales representative Physician Physician Physician Untrained physician Untrained physician

METHOD A qualitative study was conducted to understand the role of markets in consumption of health care by subaltern consumers. The approach involved extended fieldwork and theorization that helped researchers to arrive at a deep level of understanding of a particular geographically and culturally bound setting. The fieldwork primarily consisted of participant observation and formal/informal interviews, which were conducted over a period of one year in the city of Kanpur, India. Fifteen adult consumers participated in the in-depth interviews. Additionally, ten interviews were conducted with physicians and sales representatives of pharmaceutical firms. A participant profile is presented in tables 1 and 2.

Following qualitative research conventions, the sample plan was purposeful. As suggested by Miles and Huberman (1984), for in-depth understanding, within-case sampling and a nested approach were utilized, looking at various relevant actors in the market. The objective was not to attain a statistically representative sample; rather variance on the extent of their immersion in the health care market was sought (Thompson and Troester 2002). To achieve the target of covering the gender- and age-based variations within the market, a mix of young and old and of males and females among subaltern participants was captured. These respondents were recruited through contacts at hospitals, referrals by other participants, and personal acquaintances that researchers made during the course of the study. All participants resided in the city of Kanpur or the neighboring rural areas. Data collection followed the conventions of qualitative in-depth interviewing (McCracken 1998). The consumer respondents were primarily questioned about their experiences with health care provided by the government

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and private hospitals. Physicians and sales representatives were primarily questioned about their activities that included emphases on how pharmaceutical firms sell their products and incentive systems for prescribing medicines. In the spirit of a naturalistic inquiry, the participant observation method was actively employed with hospitals and clinics as the research sites (Lincoln and Guba 1985). Interpretation of the interview texts and the field notes was conducted through a hermeneutical process that involved a continuous movement between individual notes and transcripts and the emerging understanding of the entire data set (Thompson 1997; Thompson and Troester 2002). In the process, the theoretical understanding presented here reflects the final stages of the analysis in which linkages are developed between participant meanings and a broader set of theoretical questions. As recommended by Erlandson et al (1993), the following techniques for establishing trustworthiness were followed: prolonged engagement, persistent observation, triangulation, peer debriefing, thick description, and purposive sampling.

Patient-Hospital Interactions An examination of the biggest state-owned hospital in the city, which was traditionally an important source of health care for the subaltern groups, revealed that despite having an excellent infrastructure, the hospital was dogged by the apathy of physicians and support staff toward servicing the needs of the subaltern consumers. Patients repeatedly complained that the physicians and the paramedical staff did not provide proper care to the subaltern groups because of their enfeebled socioeconomic position. The following description by a working-class respondent conveys this sentiment about the state-run hospital:
The physicians in the hospital do not care for the patients. Most of the time paramedical staff diagnoses patients. Most of the patients who go there die. The physicians do not talk to us properly. They talk to people who are neatly dressed. . . . Responsibility of patients health does not lie with the doctor. (Male, 33)

FINDINGS In this section, a description of the state of health care as experienced by the studys subaltern participants is provided. The theme of receding state, rising market influence, and profit imperative as a dimension that explains disempowerment of subaltern consumers is presented. The second theme of consumer marginalization and alternate care delineates the impact of powerlessness on subaltern health care consumption. The data illustrate high levels of consciousness among subaltern consumers about the exploitative role played by private physicians, hospitals, and pharmaceutical firms. However, consumers find themselves helplessor more appropriately, powerlessto change a health care system increasingly governed by market forces. This marginalization is further exacerbated by the dominance of the norm of profit that strongly influences the socioeconomic setting. Receding State, Rising Market Influence, and Profit Imperative In this theme, the process of disempowerment for subaltern consumers in the health care system is examined at two levels. In the first part, the patient-hospital interactions are considered. This section particularly highlights the decline in the government health care facility in the city, which forces subaltern consumers to buy private health care. The second part focuses on the physician and pharmaceutical firm nexus. This analysis provides further insights into disempowerment of subaltern consumers in the health care market, which is governed primarily by profit norms.

Respondents asserted that the government hospital neglected patients. As the above quote illustrates, these respondents complained to researchers that patients with greater buying power, better clothing, or superior references were given preferential treatment in the hospital. This was a big concern area for these subaltern consumers because of their greater dependence on this low-cost health care facility. Another subaltern participant informed researchers that
we are also scared of going to the [government] hospital. . . . My sisters son was taken to the hospital, and he was completely neglected there. In the hospital, if you are asked for some money and if you cannot manage it, then they give you wrong medicines and injections. (Female, 33)

These informants were particularly appalled by the deterioration in the government hospital in the last few years. Researchers observations of dead bodies and littered biological waste in patients wards further illustrate the poor nature of services provided by the support staff in cleaning and maintaining proper hygiene in these hospitals.
Field note: The [general] ward was full of patients lying on beds in the room. On the last bed of this ward a woman was lying with her face covered. She appeared to be very thin and there was no perceivable movement of the chest. The slow moving fan blew a portion of her sari . . . the arm got exposed with multiple needle marks and dried blood stains. The stains of blood and plasma appeared to be fresh. The patient on the bed next to her informed me that she was dead.

This description of a general ward, which is used by poorer patients, strongly supports the consumer narrations about the appalling state of the government facility. In the last decade and a half, the structural adjustment program in

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the country has particularly encouraged private enterprise. Respondents were of the view that the rise in market forces in health care has been accompanied by a decline in the quality of patient care offered by the state. Several respondents informed researchers that their earlier experiences with the hospital were much more satisfactory. These consumers explained to researchers that the primary reason for the neglect of the state facilities was the dominance of private clinics in the city. A respondent informed researchers that
physicians ask you to come to their private clinics. They dont treat you properly in the government hospital. Physicians also ask us to buy medicines from outside stores. These medicines are provided by the government and should be given free to the patients. But corrupt physician and hospital staff sell them in the open market. (Male, 52)

A number of sales representatives informed researchers that physicians often overprescribed expensive drugs and medical tests to fulfill this requirement. The following response by a sales representative summarizes this problem:
Dr. Agarwal took a gift from us and started prescribing the drug twice daily instead of once in a day, which was adequate medication. . . . In another instance, Dr. Gupta instead of prescribing 400 mg of one brand of salt prescribed 100 mg of the same salt from four different manufacturers to keep them all happy. (Male, 30)

Accordingly, physicians discouraged patients from visiting state hospitals. Instead the physicians, who were also in charge of administration in these hospitals, wanted patients to visit private hospitals and clinics. A large majority of the government physicians in the city spent most of their time practicing in these clinics, which offered substantially higher remunerations. These private clinics were governed by the market logic of profit and essentially cater to consumers with higher resource power. PhysicianPharmaceutical Firm Nexus The profit imperative was further revealed in the close nexus between pharmaceutical companies and physicians. Interviews with the local sales representatives of several big pharmaceutical companies in the region, some of which are large multinational firms, revealed that physicians actively accepted incentives in the form of gifts and prescribed their medicines in return. This has become an entrenched norm that governs the behavior of these actors. Incentives such as cars, air conditioners, and DVD players were not unusual for successful physicians in the city. Pharmaceutical companies extracted higher sales of their medicines in return for these incentives. According to a sales representative (Male, 30) of a multinational pharmaceutical firm, The number of visits and the value of gifts determine prescriptions. Only 12 percent of physicians do not accept gifts and are sincere about their profession. Commenting on this aspect, another sales representative (Male, 32) told researchers that, a physician even went to the extent of asking me to finance the rituals following the death of his mother. He told me to take care of the ceremony by paying for the venue and food. Interviews with physicians further confirmed this relationship. A physician (Male, 38) informed researchers that gifts such as gold chains, television, and refrigerators are commonly given. In return the physician is expected to prescribe their medicines.

These pharmaceutical companies also maintained a very tight system of accountability and expected a return of around ten times the amount invested in these gifts. This control was maintained by closely monitoring the sales records of the local pharmacies, which kept an account of physicians prescriptions. In summary, the state-run hospitals in the city are characterized by their neglect of patient care. The rise in profit orientation and a market-based fee system has particularly contributed to the deterioration in the state facilities. Similarly, physicians and pharmaceutical firms work closely with each other to maximize profits. In the process, consumers are left with restricted space and are forced to participate in this system as buyers with limited ability to voice their dissent. Marginalized Consumers and Alternate Care Declining state facilities, the high cost of private health care, and the pharma-physician nexus have led to marginalization of the subaltern consumers by the formal medical care system. The following field note from a private clinic offers a vivid description of this phenomenon:
Field Note: As I was talking to the assistant, I noticed a man who appeared to be from a working-class background. . . . He had a very sad expression on his face and was talking to another assistant at the clinic. After some time he took out some money from his pocket and gave it to the assistant of Dr. Pandey. The assistant threw away the money and said You stayed with your child in this hospital for four days. Now your child is doing fine, but you are not paying the full money. With folded hands and with tears in his eyes, the worker pleaded Sir, you are like God; you saved my child. I am grateful to you but please keep this money. I do not have more money at the moment. The assistant shrugged his shoulders and pushed the worker away. The worker started touching the feet of the assistant and was almost on the verge of crying.

Most of the subaltern respondents informed researchers that they find it exceedingly difficult to access private health care because of much higher costs. The restricted access translated into a widespread neglect of health, frequent diseases, and chronic ailments, often with fatal consequences.

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Corroborating the evidence provided by Misra, Chatterjee, and Rao (2003), patients took loans with high interest rates to pay their health care bills in private hospitals. These debts further push subaltern consumers into the vortex of poverty. This marginalization forces subaltern consumers to look for alternate health care systems. As a result of the demandsupply gap, untrained medical practitioners or quacks have proliferated in both urban and surrounding rural areas. These quacks lack formal training in allopathic medicine but actively prescribe this medication to hapless patients. An interview with one of the quacks revealed that
the conditions are conducive for my type of doctors. They [qualified private physicians] charge high fee in private nursing homes. Multigency [a big private hospital] will charge no less than Rs 300/-($ 6). A General Physician can charge somewhere around Rs 50Rs 150/-($13). Tell me, how can a person who pulls rickshaw whole day or works on a construction site and earns less than 80 rupees ($2) at the end of day can afford to seek private consultation? I charge Rs 10 (20 cents) and many a times I allow credit too. (Male, 47)

Although these physicians provide much needed health care service for the poorer consumers, their inadequate training often results in wrong prescriptions and faulty diagnoses. This approach frequently leads to disastrous consequences for patients, with serious side effects of drugs and the lack of timely medical intervention. Quacks informed researchers that despite these problems, subaltern consumers sought their services because the high cost of private medical care and the lack of proper care in the state-run hospitals did not leave consumers with many alternatives. This view was actively supported by consumer respondents. Corroborating the above claim made by an untrained medical practitioner, a consumer informed researchers that
I have two daughters and if I spend too much of money on my medication, how will I get them married? My husband and I earn around Rs. 5000 (approximately US $110) in a month, and it will be difficult to pay their dowry if we dont save money. Therefore, even if quacks are not good, I will still go because they are the cheapest, which is the most critical issue for me. (Female, 45 years)

follow the dictates of market forces. A respondent (Male, 28), whose three-year-old son had died because of his inability to take him to a physician, informed researchers that physicians prescribe expensive tests and medicines because they get money from these sources. But we dont have a choice because everyone is doing it. In summary, the decline in the government health care facility has been accompanied by greater emphasis on privatization. This structural shift has also strengthened profit norms and provided legitimacy to market forces. The structural shift is also accompanied by physicians and pharmaceutical firm nexus to maximize their profits. The findings here show that these developments are viewed critically by subaltern consumers. Accordingly, the rise of market forces and marginalization of subaltern consumers in Kanpur are interrelated processes. This marginalization has created a need gap for consumers, which is being actively plugged by untrained service providers. The subaltern participants further display a high level of consciousness about the detrimental role of physicians, private hospitals, and pharmaceutical firms. However, these consumers expressed inability to change the reality because of the increase in their powerlessness in a system increasingly governed by market forces.

DISCUSSION AND CONCLUSIONS While markets are being increasingly celebrated as guarantors of human welfare and development, this studys findings serve to question these assumptions. This research shows that subaltern consumers believe that markets are contributing to their marginalization by having a detrimental influence on their ability to access health care products and services. The authors perspective is critical of the neoliberal discourse, which this research shows to be flawed in both its conceptualization and manifestation. Unfortunately, the neoliberal discourse continues largely unabated, despite scathing attacks on its theoretical weaknesses and practical limitations (George 1992; Milonovic 2003; Polanyi 1944). Institutions such as the World Bank and International Monetary Fund, which systematically force many countries in the South to conform to their structural adjustment programs, have particularly legitimized the discourse in recent times. As a result, increasingly, many societies are manipulated and reduced to being appendages of the corporate order, often with disastrous consequences for some populations, as this research suggests. In examining the health care system in the city of Kanpur, the myth of efficiency perpetrated by supporters of the neoliberal agenda can be questioned (refer to figure 1). This research illustrates the limitations of the market-based orthodoxy in which subaltern consumers are systematically sidelined because of their lack of resource power. Given the context of health care consumption and the criticality for development, this trend is particularly alarming. The research demonstrates that subaltern consumers believe that

Interestingly, subaltern consumers display a high level of consciousness about the factors contributing to their disempowerment. As illustrated in the earlier section, these consumers exhibit a remarkable understanding of the privatization process and attributed the decline in the state facility to market forces. Subaltern consumers are also conscious about the limitations of the untrained practitioners as the above narration by a female consumer illustrates. They demonstrated a high level of awareness of the physicianpharmaceutical firm nexus as well. However, the critical nature of the health care system has left them vulnerable with little choice but to

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Q. O. L.

Healthcare

Support for subaltern population

Q.O.L. Marketing

Socially accountable health delivery system High Consumer Empowerment Low Strengthens Welfare State Control, Exclusion, and Consciousness Weakens Privatization

Profit Orientation

Untrained Medical Care

FIGURE 1 SUBALTERN HEALTH CARE UNDER NEOLIBERALISM Note: QOL = Quality of life.

market forces driven by the profit motive have contributed to the decline of state health care institutions. On the one hand, this development has forced consumers to rely on private physicians and hospitals, which are closely controlled by big pharmaceutical firms through a lucrative system of incentives. On the other hand, subaltern consumers believe that without resource power they are forced to operate in alternate health care markets managed by untrained medical practitioners, who frequently fail to provide adequate service. This research provides strong support for arguments of Chossudovsky (1997), Kurien (1994), and Stiglitz (2003), and their criticisms of the neoliberal agenda. In highlighting the issue of empowerment, this research extends the framework for understanding the antecedents of QOL marketing suggested by Lee and Sirgy (2004). The

findings here demonstrate that despite high social consciousness, a restriction on the generation of unfair profits is a limited reality. Profit norms are considered legal and legitimate within the existing sociopolitical framework, leaving subaltern consumers to fend for themselves. In highlighting the dimensions of control and exclusion, it can be argued that consciousness in itself is inadequate unless consumers have power to determine the role of market forces (figure 1). Traditionally, the welfare state represented this sentiment of the population and acted on behalf of these consumers in controlling the agenda of providing health care and excluding or limiting the role of a profit-based market system. However, neoliberalism has led to a systematic erosion of these public institutions and has contributed to the dominance of profit seeking agendas.

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Here, marginalization of subaltern consumers is particularly of a serious social consequence. Most of the consumer participants are dalits or belong to the lowest caste group. Dalits are traditionally the untouchables who are at the bottom of the social hierarchy. Historically, these groups have faced high levels of discrimination and exploitation in the Indian context (Limbale 2003; Omvedt 2004). Several theorists argue that because of affirmative actions of the government, the caste-based system of discrimination is on a decline in urban India (Beteille 2002; Srinivas 2003). This also finds partial confirmation in this studys data which show that none of the participants mentioned caste as a reason for their marginalization. However, the findings here show that vestiges of the system are still evident in the lives of participants. This traditional system of exploitation has not only resulted in economic marginalization which is historical in nature, but has also contributed to low levels of social and cultural capital for this group (Bourdieu 1986). It was also found that this consumer group believes that the onset of the structural adjustment program and a gradual erosion of the state institutions have left them disempowered and in a more vulnerable condition. The structural shift in the direction of privatization and the dominance of profit norms in the health sector have also resulted in a sharper conflict of interests among the stakeholders. On the one hand, privatization has allowed the physicians with superior economic and social capital to draw from a bigger and deregulated pool of finances and international technology. This has allowed these physicians to build a more specialized, elitist, and profitable system of health care with the support of private pharmaceutical firms. On the other hand, these proliferations of specialized facilities and technologies result in a greater pressure for their utilization. This, in turn, escalates the total cost of health care and has a particularly detrimental impact on subaltern consumers with limited resource power. These findings concur with the following observation made by Misra, Chatterjee, and Rao:
Usually technology advances are associated with a lowering of costs. But the reverse is true of the medical sector, with capital intensive technological development increasing health expenses . . . Hospital managers have also admitted that they are forced to recover the investment on hightechnology equipment through excessive referrals . . . making health care unaffordable and a major drain on the resources of the poor. (2001, 109)

A ramification of the capital-intensive health care system is that non-specialists and untrained medical practitioners or quacks primarily cater to the lower end of the market. This results in a neatly segmented market being in place for the health care industry. Subaltern consumers operate at the lower end of the market and are forced to rely on the cheapest and in the process, often the lowest quality health care service providers. Only in the event of crises do these

consumers use services provided by the specialized and more expensive physicians and hospitals. Subaltern consumers consistently narrated to researchers their inability to exercise free choice in the absence of resource power. A high level of dissatisfaction with the state of health care for subaltern consumers also renders into a constant concern about their state of well-being. Although the relationship between objective and subjective QOL parameters is not formally tested here, the study demonstrates a fundamental convergence of these dimensions for the population group under study. This finding is in concurrence with the contention of Cummins (2000, 63) that, the inter-correlation of QOL measures between O and S dimensions will increase as objective life quality decreases to low levels. It is quite evident from the discursive and subjective analysis of health care consumption that for these subaltern consumers, the objective conditions of subordination also translate into a state of dissatisfaction with their well-being. This state of crisis in the health care system should be a cause for serious concern for the policy makers in India. The data here strongly support the declining trends in the development process in India, as indicated by the Index of Social Progress (Estes 2003). Accordingly, India dropped 26 ranks to 111th from the year 1980 to 2000; the stagnation in the decade of nineties is particularly alarming with health care along with a host of other parameters of social progress such as status of women, political participation, and economy showing a decline (University of Pennsylvania News Bureau 2003; Estes 2003). Based on this study, the authors agree with the observation made by Richard Estes (as quoted in University of Pennsylvania News Bureau 2003, 3) that Indias formula for developmenthigh military spending in combination with pervasive povertyis one that predicts disaster. These findings also raise some serious ethical issues, which are also central to the QOL marketing framework. From the stakeholder perspective, it is quite obvious that business practices of private hospitals, physicians, and pharmaceutical firms are unethical (Evan and Freeman 1988; Gibson 2000). It is evident from this studys findings that a heavy price is being paid by subaltern consumers for the profits being generated by the triad of private hospitals, physicians, and pharmaceutical firms. Clearly, from the normative or deontological perspective, interests of the patient stakeholder group are being overlooked (Donaldson and Preston 1995; Evan and Freeman 1988). The three principles of stakeholder enablement, director responsibility, and stakeholder recourse suggested by Freeman (2002) can be important steps within the current system of health care to support subaltern consumers. However, for this to be possible, this studys findings show that subaltern consumers and the civil society should have the power to reign in the forces of unfair profit. This study is limited in its scope and perhaps is confined to the impact of privatization of a health care system affecting a small set of informants in a less developed country. The

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ubiquity of privatization under the neoliberal agenda nevertheless requires a careful analysis in the various domains of social progress and QOL as delineated, for example, by Estes (2000) and Hagerty et al. (2001). Specifically, the linkages among these domains and their relationship with social progress require continuous monitoring. Additionally, some of the macro and statistical descriptions should be further substantiated with deeper subjective analyses of these domains, as this study has attempted. Future scholarship in the area of QOL studies should systematically and comprehensively work toward understanding consumer empowerment and its possible alternatives. The role of the state as an institutional watchdog and as a mechanism for countervailing market forces requires further emphasis. Proposals such as voice systems suggested by Mehrotra and Jarret (2002) in the form Grass Root Organizations (GROs) need a closer examination. Similarly, wider possibilities of applying the alternate health care models developed in Cuba (Waitzkin et al.1997) and in the Indian state of Kerala (Franke and Chasin 1989; Panikar 1979) merit further investigation. Specifically, the processes of consumer empowerment in the domains of hegemony, control, and exclusion in these alternate health care models require a deeper understanding. Finally, QOL theorists should work toward creation of a framework that will help the civil society in exercising control and in excluding unfair practices of private firms. This will constitute an important step forward in the direction of meeting the goals of fairness and justice, which are central to macromarketing scholarship. REFERENCES
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Rohit Varman is an assistant professor in the Department of Industrial and Management Engineering at Indian Institute of Technology, Kanpur. He has a PhD in Marketing from University of Utah, an MBA from McGill University, and a Bachelor of Engineering degree from Mangalore University. Ram Manohar Vikas is a doctoral candidate in the Department of Industrial and Management Engineering at Indian Institute of Technology, Kanpur. He has completed an MBA from Indian Institute of Technology, Kanpur and a Bachelor of Engineering degree from Calicut University.

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